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Benlysta (belimumab)


Billing

Code: J0490

Description: Belimumab injection

Unit: 10 mg

Payment: $50.927

Pay quarter: Q3 2023


Medicare history

Dosage and Frequency

Systemic Lupus Erythematosus (SLE)

Induction:
• 10mg/kg IV every 2 weeks for the first 3 doses

Maintenance:
• 10mg/kg IV every 4 weeks

OR

• 200mg SQ every 1 week

Lupus Nephritis

Induction:
• 10mg/kg IV every 2 weeks for the first 3 doses

Maintenance:
• 10mg/kg IV every 4 weeks

OR

Induction:
• 400mg SQ every 2 weeks for the first 4 doses

Maintenance:
• 200mg SQ every 1 week

Calculate drug reimbursement


Total Reimbursement:

$4,318.61

(ASP: $4,074.16, Margin: $244.45)


Code:

J0490

# Units to bill:

80

Prior Authorization

Prior auth criteria for Benlysta may include but is not limited to:


1. The patient must have a diagnosis of systemic lupus erythematosus (SLE) for at least 6 months.

2. The patient must be at least 18 years of age.

3. The patient must have active, autoantibody-positive (anti-double stranded DNA or anti-Smith antibody) lupus and 4 or more of the 11 American College of Rheumatology (ACR) criteria for SLE.

4. The patient must have a history of inadequate response to antimalarial and/or glucocorticoid therapy.

5. The patient must have had a stable dose of glucocorticoid therapy for at least 4 weeks prior to initiation of Benlysta.

6. The patient must have had a stable dose of antimalarial therapy for at least 4 weeks prior to initiation of Benlysta.

7. The patient must have no active, serious infections.

8. The patient must have adequate organ function.

9. The patient must have a negative pregnancy test for women of childbearing potential.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

49401-0101-01

BENLYSTA (GLAXOSMITHKLINE)

120 MG


49401-0102-01

BENLYSTA (GLAXOSMITHKLINE)

400 MG



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