CurrentUnitedHealthcarePolicy CSIND0046.08

Benlysta (Belimumab) (for Indiana Only)

UnitedHealthcare Indiana-specific medical benefit drug policy for belimumab injection (intravenous) covering use for systemic lupus erythematosus and active lupus nephritis when meeting InterQual criteria; subcutaneous benlysta is via pharmacy benefit and not covered by this medical benefit policy.

Policy Summary

PayerUnitedHealthcare

PolicyBenlysta (Belimumab) (for Indiana Only)

Policy CodePolicy CSIND0046.08

Change TypeRoutine review; no content changes

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must document clinical information demonstrating that the member meets the current InterQual guideline criteria for belimumab (Benlysta) IV; the policy references InterQual as the medical necessity standard.

POLICY UPDATE CHANGES

Routine review; no content changes.

1Referenced HCPCS code

IndianaState scope

InterQualClinical criteria source

Coverage Summary

UnitedHealthcare Indiana-specific medical benefit drug policy for belimumab (Benlysta) intravenous injection covering use for systemic lupus erythematosus (SLE) and active lupus nephritis (LN) when the member meets the current InterQual criteria. The policy applies only to members in the state of Indiana.

Medical Necessity / Coverage Criteria (per InterQual)

Covered when ALL of the following are met per the current InterQual guideline:

ALL of the following

Patient has diagnosis of systemic lupus erythematosus (SLE) or active lupus nephritis (LN)
Use of benlysta (belimumab) intravenous injection is consistent with the criteria in the current InterQual guideline 'Benlysta: CP: Specialty Rx Non-Oncology, Belimumab (Benlysta)'
Provider must refer to the current release of InterQual for specific clinical details (e.g., prior therapy, disease activity thresholds, laboratory or clinical findings).
Policy applies only to members in the state of Indiana

Provider Actions & Billing Rules

Documentation Required

Use InterQual documentation

Providers must document clinical information demonstrating that the member meets the current InterQual guideline criteria for belimumab (Benlysta) IV. The policy references the InterQual guideline Benlysta: CP: Specialty Rx Non-Oncology, Belimumab (Benlysta) as the medical necessity standard and requires use of that current InterQual release when determining coverage for IV belimumab.

Affected medical benefit code: J0490

Billing Rule

Subcutaneous formulation billed through pharmacy benefit

Benlysta for self-administered subcutaneous injection is obtained under the pharmacy benefit and is not covered under this medical benefit policy. This policy applies only to intravenous belimumab; subcutaneous formulation should be billed and managed through the pharmacy benefit.

Bill intravenous belimumab under the medical benefit using HCPCS code J0490 only

Background & Definitions

This policy applies only to the state of Indiana and addresses Benlysta (belimumab) for intravenous infusion for the treatment of SLE and active lupus nephritis when the member meets the current InterQual criteria.

Benlysta for self-administered subcutaneous injection is obtained under the pharmacy benefit and is not covered under this medical benefit policy.

InterQual is a third-party clinical criteria tool referenced by UnitedHealthcare to determine medical necessity for benlysta; providers must refer to the current InterQual guideline (Benlysta: CP: Specialty Rx Non-Oncology, Belimumab (Benlysta)) for specific clinical details such as prior therapy, disease activity thresholds, and required laboratory or clinical findings.

Term	Definition
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