Health Net
Benlysta (belimumab)
Drugs for Pain and Fever : Arthritis and Pain Drugs
  • Prior Authorization: Lupus Nephritis:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Systemic Lupus Erythematosus (SLE):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: ST Single Generic

  • Lupus Nephritis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Nephrologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)

    Systemic Lupus Erythematosus (SLE):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Positive Autoantibody Test Required: Unspecified
    SELENA-SLEDAI Score Required: N/A
    Reauthorization SELENA-SLEDAI Score Required: N/A
    Reauthorization Requirements Documented in Policy: 3 of Adherence to product and standard of care therapy;Meet Initial Criteria;Shows positive clinical response
    Does Policy Include Excluded Indications: No
    Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests