J0490, Injection, belimumab, 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For initial therapy: documentation of diagnosis of active systemic lupus erythematosus OR documentation of diagnosis of active lupus nephritis (as applicable).
- Documentation that severe active central nervous system lupus is absent (policy: 'without severe active central nervous system lupus').
- Documentation that the patient is currently receiving at least one standard of care treatment for active systemic lupus erythematosus (examples provided in policy: antimalarials, corticosteroids, or immunosuppressants) that is not a biologic.
- For continuation of therapy: documentation that the patient has previously received Benlysta injection for intravenous infusion.
Key Coverage Criteria
- This policy refers only to Benlysta (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN).
- Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus when all of the following criteria are met: For initial therapy: Diagnosis of active systemic lupus erythematosus, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combi [...]
- Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not [...]
- Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis when all of the following criteria are met: For initial therapy: Diagnosis of active lupus nephritis, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combination with Lupkyni [...]
- Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiv [...]
- FDA indication (informational): Benlysta is indicated for the treatment of patients aged 5 years of age and older with active systemic lupus erythematosus who are receiving standard therapy and patients aged 5 years and older with active lupus nephritis who are receiving standard therapy.
14 Active Policies
UHC-POL-benlysta-belimumab, Benlysta (Belimumab)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
RX501.116, Belimumab
BCBSIL-RX501.116, Belimumab
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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