Prior Authorization Criteria for Benlysta (J0490)

Date: January 14, 2022 Attention: Oncology Providers Effective Date: March 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Beginning March 1, 2022, Benlysta (procedure code J0490) will be available for Medicaid members as a medical benefit. Benlysta (belimumab) is indicated to treat active, autoantibody-positive, systemic lupus erythematosus (SLE) in clients 5 years of age and older who are receiving standard SLE therapy. Benlysta is also indicated to treat lupus nephritis in adult clients, 18 years of age and older who are on standard therapy. How this impacts providers: There are no prior authorization criteria, but there are age/diagnosis restrictions for Benlysta (belimumab) J0490 infusion therapy: For systemic lupus erythematosus:

• The client is 5 years of age and older.
• The client has a confirmed diagnosis of systemic lupus erythematosus (diagnosis codes: M3210, M3211, M3212, M3213, M3214, M3215, M3219, M328, M329).

For active lupus nephritis:

• The client is 18 years of age and older.
• The client has a diagnosis of active lupus nephritis

Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff. If you have any questions, please email TCHP Department at: TCHPPharmacy@texaschildrens.org. For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.