Clinical Policy: Belimumab (Benlysta)

Reference Number: CP.PHAR.88
Effective Date: 10.01.11
Last Review Date: 05.26
Line of Business: Commercial, HIM/ICHRA, Medicaid

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

Belimumab (Benlysta®) is B-lymphocyte stimulator specific inhibitor.

FDA Approved Indication(s)

Benlysta is indicated for the treatment of:

• Patients aged 5 years and older with active systemic lupus erythematosus (SLE) who are receiving standard therapy.
• Patients aged 5 years and older with active lupus nephritis (LN) who are receiving standard therapy.

Limitation(s) of use: The efficacy of Benlysta has not been evaluated in patients with severe active central nervous system lupus. Use of Benlysta is not recommended in this situation.

Policy/Criteria

a. IV: Dose does not exceed 10 mg/kg per dose every 2 weeks for the first 3 doses and every 4 weeks thereafter;
b. SC (i or ii):

  i. For pediatric members weighing ≥ 40 kg and adults: Dose does not exceed 200 mg once weekly;  
  ii. For pediatric members weighing 15 kg to < 40 kg: Dose does not exceed 200 mg once every 2 weeks.

Approval duration:
Medicaid/HIM/ICHRA – 12 months
Commercial – 6 months or to member’s renewal date, whichever is longer

B. Lupus Nephritis (must meet all):

a. IV: Dose does not exceed 10 mg/kg per dose every 2 weeks for the first 3 doses and every 4 weeks thereafter;
b. SC (i or ii):

  i. For pediatric members weighing ≥ 40 kg and adults: Dose does not exceed 400 mg per week for the first 4 doses*, then 200 mg once weekly;  
  ii. For pediatric members weighing 15 kg to < 40 kg: Dose does not exceed 200 mg per week for the first 4 doses*, then 200 mg once every 2 weeks.  
  *Loading doses not permitted if previously receiving Benlysta for treatment of SLE

Approval duration:
Medicaid/HIM/ICHRA – 12 months
Commercial – 6 months or to member’s renewal date, whichever is longer

C. Other diagnoses/indications (must meet 1 or 2):

1. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b):
   a. For drugs on the formulary (commercial, health insurance marketplace/ICHRA) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace/ICHRA, and CP.PMN.255 for Medicaid; or
   b. For drugs NOT on the formulary (commercial, health insurance marketplace/ICHRA) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace/ICHRA, and CP.PMN.16 for Medicaid; or
2. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace/ICHRA, and CP.PMN.53 for Medicaid.

Clinical Policy

Belimumab

B. Other diagnoses/indications (must meet 1 or 2):

1. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b):
   a. For drugs on the formulary (commercial, health insurance marketplace/ICHRA) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace/ICHRA, and CP.PMN.255 for Medicaid; or
   b. For drugs NOT on the formulary (commercial, health insurance marketplace/ICHRA) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace/ICHRA, and CP.PMN.16 for Medicaid; or
2. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace/ICHRA, and CP.PMN.53 for Medicaid.

III. Diagnoses/Indications for which coverage is NOT authorized:

A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policies – CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace/ICHRA, and CP.PMN.53 for Medicaid, or evidence of coverage documents.

B. Autoantibody negative SLE.

IV. Appendices/General Information

Appendix A: Abbreviation/Acronym Key

ANA: anti-nuclear antibody
Anti-dsDNA: anti-double-stranded DNA
Anti-Sm: anti-Smith
DNA: deoxyribonucleic acid
FDA: Food and Drug Administration
LN: lupus nephritis
SC: subcutaneous
SLE: systemic lupus erythematosus

Appendix B: Therapeutic Alternatives

Not applicable

Appendix C: Contraindications/Boxed Warnings

• Contraindication(s): previous anaphylaxis to belimumab
• Boxed warning(s): none reported

Appendix D: Autoantibody Positive Versus Negative SLE

Only one of the five Benlysta pivotal trials included patients with autoantibody negative SLE; no significant differences between any of the Benlysta groups and the placebo group were observed. However, on further analysis Benlysta appeared to offer benefit to a subgroup of autoantibody positive patients. Benlysta’s efficacy was confirmed in the remaining four trials which included only autoantibody positive patients. Because of the apparent lack of

Clinical Policy

Belimumab

efficacy in autoantibody negative patients, Benlysta coverage will not be authorized for patients with autoantibody negative SLE.

V. Dosage and Administration

VI. Product Availability

• Single-dose vial: 120 mg and 400 mg lyophilized powder for reconstitution

• Single-dose prefilled autoinjector/syringe: 200 mg/mL

Coding Implications

Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Reviews, Revisions, and Approvals

Clinical Policy

Belimumab

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents(s) (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

Clinical Policy

Belimumab

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

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