CurrentUnitedHealthcarePolicy CSOH2026D0046.C

Benlysta® (Belimumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

UnitedHealthcare Community Plan medical benefit drug policy for belimumab (Benlysta) intravenous injection applicable only to Ohio; references InterQual criteria for medical necessity and covers treatment of systemic lupus erythematosus and active lupus nephritis per those criteria. Subcutaneous benlysta is via pharmacy benefit and not governed by this medical benefit policy.

Policy Summary

PayerUnitedHealthcare

PolicyBenlysta® (Belimumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

Policy CodePolicy CSOH2026D0046.C

Change TypeRoutine review (no content changes)

Effective DateApr 1, 2026

Next Review Date

Key ActionProviders must document that the member meets current InterQual CP: Specialty Rx Non-Oncology, Belimumab (Benlysta) criteria for initiation and continuation of IV belimumab; coverage decisions are based on that guideline and Ohio Administrative Code when applicable.

SourceLink

POLICY UPDATE CHANGES

Routine review conducted with no content changes.

2Indications referenced (SLE, active lupus nephritis)

1HCPCS codes listed

1State-specific applicability (Ohio only)

Coverage Summary

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UnitedHealthcare Community Plan medical benefit drug policy for belimumab (Benlysta) intravenous injection applicable only to Ohio; this policy is covered_with_criteria and references the current InterQual criteria to define medical necessity for treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Note: self-administered subcutaneous (SC) belimumab is managed under the pharmacy benefit and is not evaluated under this medical benefit policy. Any services stated as unproven or subject to coverage/quantity limits will be evaluated per Ohio Administrative Code 5160-1-01.

Medical Necessity Coverage

Coverage is determined by meeting the current InterQual guideline for Belimumab (Benlysta) under CP: Specialty Rx Non-Oncology, Belimumab (Benlysta).

Place of Service/Benefit Pathway: Request is for belimumab injection for intravenous infusion (medical benefit) for treatment of systemic lupus erythematosus (SLE) or active lupus nephritis (LN).
Policy refers only to IV formulation for medical benefit; SC is via pharmacy benefit.
Clinical Criteria Reference: Member meets the InterQual criteria for Benlysta (Belimumab) CP: Specialty Rx Non-Oncology, Belimumab (Benlysta) in the current InterQual release.
Policy refers to current InterQual guideline; users must reference InterQual for the specific clinical entry criteria, exclusions, and continuation criteria.
Benefit Routing for SC Formulation: Requests for self-administered subcutaneous belimumab are processed under the pharmacy benefit and are not evaluated under this medical benefit policy.
Different benefit pathway; do not apply medical-benefit InterQual criteria to SC preparations.
State-specific Evaluation: Any services stated as unproven or subject to coverage/quantity limits will be evaluated per Ohio Administrative Code 5160-1-01.
Applies only to Ohio members.

Provider Actions & Requirements

Prior Authorization

Medical necessity evaluation per InterQual required

Obtain and document that the member meets the current InterQual CP: Specialty Rx Non-Oncology, Belimumab (Benlysta) criteria for initiation and continuation of intravenous belimumab; coverage decisions for the medical benefit IV injection are based on that guideline and state requirements.

J0490

Documentation Required

Benefit pathway for SC vs IV formulations

Document whether the requested formulation is IV or SC because subcutaneous belimumab is processed under the pharmacy benefit and is not evaluated under this medical benefit policy.

Coverage decisions are based on the current InterQual release for Benlysta (Belimumab) CP: Specialty Rx Non-Oncology, Belimumab (Benlysta) and UnitedHealthcare’s use of that guideline to determine medical necessity. Where applicable for Ohio members, evaluations of unproven services or those with coverage/quantity limits follow Ohio Administrative Code 5160-1-01.

Background & Definitions

This Medical Benefit Drug Policy applies only to belimumab (Benlysta) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN) and relies on InterQual criteria to define medical necessity. Self-administered subcutaneous belimumab is covered under the pharmacy benefit and is not governed by this medical benefit policy. Any services noted as unproven or with coverage/quantity limits will be evaluated per Ohio Administrative Code 5160-1-01.

Term	Definition
InterQual	A third-party clinical decision-support guideline used by UnitedHealthcare to evaluate medical necessity for belimumab (Benlysta).
Medical benefit	Coverage pathway for provider-administered intravenous belimumab; differs from pharmacy benefit which covers self-administered subcutaneous belimumab.