Site of service changes and new coverage option for Benlysta® now in effect

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Site of service changes and new coverage option for Benlysta^® now in effect

June 1, 2018

The U.S. Food and Drug Administration (FDA) recently approved a subcutaneous formulation of Benlysta (belimumab) for the treatment of active, autoantibody-positive systemic lupus erythematosus. This is the second formulation of Benlysta to receive FDA approval; the infusible formulation was approved in 2011. The subcutaneous formulation allows members to self-administer the drug at home rather than go to a hospital outpatient facility for infusion.

As of June 1, 2018, AmeriHealth added the infusible formulation of Benlysta to our Most Cost-Effective Setting Program for AmeriHealth members. This formulation remains eligible for coverage under the medical benefit, but the following changes occurred:

New requests for infusible Benlysta now require review for setting, as well as medical necessity, during the precertification process.
Members who have received precertification approval for infusible Benlysta in a hospital outpatient facility may continue treatment in this setting until their current precertification approval expires. However, at the next precertification review, AmeriHealth will evaluate the requested setting and make a coverage determination.

Appropriate setting review

During precertification review, each member?s medical needs and clinical history are evaluated to determine if the drug requested by the provider is appropriate. As part of our Most Cost-Effective Setting Program, AmeriHealth also reviews the requested treatment setting for certain drugs covered under the medical benefit to ensure that they are administered in settings that are both safe and cost-effective.

Covered settings for infusible Benlysta include:

a physician's office;
the member?s home, where the infusion is administered by an in-network home infusion provider;
an ambulatory (freestanding) infusion suite that is not owned by a hospital or health system in our network.

A hospital outpatient facility setting will primarily be considered for members who are receiving an initial dose of Benlysta or if there is a clinical rationale that requires the member to receive treatment in that setting. The provider must submit documentation to AmeriHealth to support the request for coverage in the hospital outpatient facility. This information will be reviewed and a coverage determination on setting will be made.

Coverage for subcutaneous Benlysta under the pharmacy benefit

Covering infusible Benlysta under the medical benefit and subcutaneous Benlysta under the pharmacy benefit gives our members more treatment options. Members whose pharmacy benefits are managed by FutureScripts^®, a pharmacy benefits manager, can choose to receive subcutaneous Benlysta under their pharmacy benefit. Providers are encouraged to consider the subcutaneous formulation for patients who may be interested in self-administering the drug. Providers will need to write new prescriptions for members who choose to receive subcutaneous Benlysta. Note: The subcutaneous formulation of Benlysta is not covered under the medical benefit.