Benlysta (belimumab)
Billing
Code: J0490
Description: Belimumab injection
Unit: 10 mg
Payment: $50.199
Pay quarter: Q1 2023
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
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
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:
$4,256.88(ASP: $4,015.92, Margin: $240.96)
Code:
J0490# Units to bill:
80Prior 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:
Billable NDCs
49401-0101-01
BENLYSTA (GLAXOSMITHKLINE)
120 MG
49401-0102-01
BENLYSTA (GLAXOSMITHKLINE)
400 MG
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