ND Committee Review
Internal Medical Policy Committee 1-22-2020
- Decrease
in age from 18 to 5 years of age.
Internal Medical Policy Committee 9-21-2020
- Added
language that self-administered Belimumab (Benlysta) injection is a pharmacy benefit;
and
- Added
reauthorization criteria.
Internal Medical Policy Committee 3-17-2021
- Added
active lupus nephritis indication,
and
- Updated
SLE criteria
Internal Medical Policy Committee 3-23-2022
- Added
'is currently treated with' standard therapy in addition to continue standard therapy 'in combination with belimumab (Benlysta) intravenous infusion';
and
- Added
Zeposia as a contraindicated drug;
and
- Added
list of agents contraindicated as concomitant therapy.
Internal Medical Policy Committee 3-23-2023
Effective May 01, 2023
- Added
another FDA labeled indication criteria;
and
- Updated
age criteria;
and
- Updated
the concomitantly statement;
and
- Removed
FDA labeled contraindications criteria;
and
- Updated
Agents NOT to be used Concomitantly list.
Internal Medical Policy Committee 3-19-2024
Effective May 01, 2024
- Updated
initial and reauthorization criteria wording;
and
- Updated
Agents NOT to be used Concomitantly list.
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024