CurrentUnitedHealthcarePolicy CSOH2026D0046.C

Benlysta (Belimumab) — Intravenous (Ohio Only)

Medical benefit drug policy governing intravenous belimumab (Benlysta) for treatment of systemic lupus erythematosus and active lupus nephritis for UnitedHealthcare Community Plan members in Ohio.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBenlysta (Belimumab) IV — Medical Benefit (Ohio only)

Policy CodePolicy CSOH2026D0046.C

Change TypeRoutine review — no content changes

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization; medical necessity for IV belimumab is evaluated using the current InterQual Belimumab criteria.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1Applicable HCPCS code listed

OhioState-specific applicability

InterQualExternal clinical criteria referenced

Coverage Criteria

Medical Necessity (InterQual referenced)

Covered when ALL of the following are met per InterQual guideline

InterQual-based medical necessity: Member meets the InterQual CP: Specialty Rx Non-Oncology Belimumab (Benlysta) criteria for IV belimumab for systemic lupus erythematosus (SLE) or active lupus nephritis (LN).see InterQual

Provider must follow the current InterQual criteria as referenced in this policy

This medical benefit policy applies only to the intravenous (IV) formulation of Benlysta (belimumab) for infusion. The subcutaneous (SC) formulation is obtained and covered under the pharmacy benefit and is not covered by this medical benefit policy.

The list of procedure and diagnosis codes in this policy is provided for reference only. Listing a code does not imply the service described by the code is a covered service or guarantee payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws.

Coding and Billing

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBenlysta (Belimumab) IV — Medical Benefit (Ohio only)

Policy CodePolicy CSOH2026D0046.C

Change TypeRoutine review — no content changes

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization; medical necessity for IV belimumab is evaluated using the current InterQual Belimumab criteria.

SourceLink

On This Page

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Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for IV belimumab and medical necessity determinations follow the InterQual® guideline for Belimumab (Benlysta®). Prior authorization requests will be evaluated against the current InterQual criteria; approval is contingent on meeting those medical necessity requirements.

Prior authorization tied to InterQual criteria
Use current InterQual release when submitting requests

Billing Rule

Coverage Not Guaranteed by Coding

Inclusion of a procedure or diagnosis code in this policy is for reference only. Listing a code does not imply that the service is a covered benefit, guarantee payment, or confer a right to reimbursement. Benefit coverage is determined by federal, state, or contractual requirements and applicable law.

Codes provided are informational only
Coverage and payment depend on member's benefit plan and governing requirements

Documentation Required

Documentation and Governing Rules

Documentation supporting medical necessity must be maintained and submitted as requested. Providers should reference and comply with federal, state (Ohio Administrative Code), and contractual requirements governing benefit coverage when submitting requests or appeals.

Retain clinical records that justify InterQual criteria-driven decisions
Provide complete documentation with prior authorization and appeals

Note

Provider Action Required

Providers must take action to ensure prior authorization requests reference InterQual criteria and include required supporting documentation; failure to follow these steps may delay or result in denial of coverage.

Verify applicable benefit plan terms and any state or federal mandates before submission
Include diagnostic information, prior therapies, and rationale mapped to InterQual criteria

Definitions

Benlysta (belimumab) IV

DefinitionIntravenous belimumab (Benlysta) injection for infusion indicated for treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN).

Coverage settingCovered under the medical benefit when medical necessity is met per the current InterQual guideline for Belimumab (CP: Specialty Rx Non-Oncology).

Prior authorizationMedical necessity determinations and prior authorization for IV belimumab are evaluated against the current InterQual criteria.

Relevant HCPCSJ0490 — Injection, belimumab, 10 mg.

Benlysta (belimumab) SC

DefinitionSubcutaneous belimumab (Benlysta) for self-administration; indicated for systemic lupus erythematosus and active lupus nephritis.

Coverage settingCovered under the pharmacy benefit and is NOT covered under this medical benefit policy.

Access noteProviders should obtain SC belimumab through pharmacy benefit processes rather than medical prior authorization for IV formulation.

OpenPayer

Benlysta (Belimumab) — Intravenous (Ohio Only)

Coverage Criteria

Coding and Billing

Provider Actions and Authorization

Background

Definitions