Subject: Specialty Quantity Limit Benlysta 3027-H P2022
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most
common uses of the medication. If the member’s plan allows a quantity
limit exception review for the requested medication, coverage of an
additional quantity may be provided up to the exception limit with prior
authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
Exception Limit*
|
FDA-Recommended
Dosing
|
|
Benlysta
(belimumab) 200
mg/mL single-dose
prefilled autoinjector or
single-dose prefilled
syringe
|
4 syringes per 28
days
|
8 syringes per 28
days
|
Systemic lupus
erythematosus (SLE):
• 200 mg
subcutaneous
injection once
weekly
Lupus nephritis:
• 400 mg
subcutaneous
injection once
weekly for 4 doses,
then 200 mg once
weekly thereafter
|
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Benlysta [package insert]. Philadelphia, PA: GlaxoSmithKline LLC; March 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
April 16, 2022
