Subject: Specialty Quantity Limit Benlysta 3027-H P2023

Drug

BENLYSTA  (belimumab)

Note:

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:

1. 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.

June 18, 2023