CurrentUnitedHealthcarePolicy CSIND0046.08

Benlysta (belimumab) — IV injection (Indiana)

Defines UnitedHealthcare Community Plan medical benefit coverage for intravenous belimumab (Benlysta) for systemic lupus erythematosus and active lupus nephritis in Indiana; self‑administered subcutaneous Benlysta is covered under the pharmacy benefit.

Policy Summary

PayerUnitedHealthcare

PolicyBenlysta (belimumab) — IV injection (Indiana)

Policy CodePolicy CSIND0046.08

Change TypeRoutine reviewno content changes

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionProviders must meet the current InterQual criteria for IV belimumab to establish medical necessity for coverage.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1state this policy applies to

J0490HCPCS code listed for belimumab IV

InterQualexternal clinical criteria referenced

Coverage Criteria for Intravenous Belimumab (Benlysta)

Medical Benefit Coverage — InterQual criteria

Covered when the InterQual criteria for Benlysta are met

Policy Summary

PayerUnitedHealthcare

PolicyBenlysta (belimumab) — IV injection (Indiana)

Policy CodePolicy CSIND0046.08

Change TypeRoutine reviewno content changes

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionProviders must meet the current InterQual criteria for IV belimumab to establish medical necessity for coverage.

SourceLink

On This Page

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The presence of a procedure or billing code in this policy is for reference only and does not imply coverage for the service described. Benefit coverage for health services is determined by applicable federal, state, and contractual requirements and laws, which may mandate or restrict coverage for a specific service. The inclusion of a code in this document does not guarantee reimbursement or claim payment, and other policies or plan terms may apply when determining coverage.

Provider Actions and Billing Guidance

Prior Authorization

InterQual criteria required for medical benefit coverage

Providers must meet the current InterQual® guideline for Benlysta (belimumab) IV to support medical benefit coverage determinations. For medical necessity clinical coverage criteria, refer to the current release of the InterQual® guideline: Benlysta: CP: Specialty Rx Non‑Oncology, Belimumab (Benlysta).

InterQual criteria are required for prior authorization and medical necessity review.
Providers should reference the specific InterQual release in effect at the time of the request.

Step Therapy

Step therapy

This policy does not impose any additional step therapy requirements beyond the criteria outlined in InterQual. Coverage decisions will follow the InterQual criteria where applicable; check plan-specific step therapy programs if implemented separately under the member's benefit.

If the member’s plan sponsor or state/federal rules has a separate step-therapy program, that program may apply.
Contact the payer or review the member’s benefit plan to confirm whether an external step therapy policy applies.

Billing Rule

Coverage determined by plan terms

Benefit coverage for belimumab is determined by the terms of the member’s federal, state, or contractual benefit plan. Inclusion of a code or mention in this policy does not guarantee coverage or payment.

The presence of HCPCS code J0490 in this policy is for reference only and does not indicate coverage.
Always verify member benefits, eligibility, and any applicable limits or exclusions prior to service.

Note

Reference plan terms

Consult the member’s federal, state, or contractual benefit requirements before relying on this policy. This document is intended to assist interpretation of standard UnitedHealthcare benefit plans and does not override specific contract, state, or federal obligations.

In case of conflict, the federal, state, or contractual requirements govern.
UnitedHealthcare policies are informational and may be modified; verify current contractual obligations and applicable laws.

Benefit Placement and Product Definitions

Subcutaneous Benlysta — pharmacy benefit

ProductBenlysta (belimumab) — subcutaneous formulation

Benefit channelPharmacy benefit (self‑administered subcutaneous injection)

Indications (per policy)Systemic lupus erythematosus (SLE) and active lupus nephritis (LN)

Intravenous Benlysta — medical benefit

ProductBenlysta (belimumab) — intravenous injection

Benefit channelMedical benefit (intravenous infusion)

Indications (per policy)Treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN)

Coverage determinationMedical necessity for IV belimumab is determined by current InterQual criteria referenced in the policy

OpenPayer

Benlysta (belimumab) — IV injection (Indiana)

Coverage Criteria for Intravenous Belimumab (Benlysta)

Relevant Procedure and Billing Codes

Provider Actions and Billing Guidance

Benefit Placement and Product Definitions

Background

Policy Revision History