Belimumab (Benlysta) (CPB 0818, reviewed 2026-06-10)

IMMEDIATELY (Policy effective 2026-06-10): 1) PRECERTIFICATION REQUIREMENT: Billing team must establish mandatory precertification workflow for ALL Belimumab (J0490) claims. Contact Aetna at (866) 752-7021 or fax (888) 267-3277 for precertification. Obtain Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification before claim submission. 2) PRESCRIBER VALIDATION: Verify that prescribers are rheumatologists, lupus specialists, or nephrologists (for lupus nephritis) before processing claims. Reject claims from non-approved specialties. 3) CLINICAL CRITERIA VERIFICATION: Prior to billing, confirm member meets ALL approval criteria: (a) For SLE: positive autoantibodies (ANA, anti-dsDNA, anti-Sm, or antiphospholipid antibodies) AND concurrent standard SLE therapy (glucocorticoids, antimalarials, or immunosuppressants); (b) For Lupus Nephritis: kidney biopsy confirmation OR positive SLE autoantibodies AND standard therapy regimen. 4) EXCLUSION SCREENING: Flag and DENY claims for: severe active CNS lupus requiring intervention before therapy initiation, or Benlysta combined with other biologics. 5) SITE OF CARE REVIEW: Apply Aetna's Site of Care Utilization Management Policy for infusion location before approving. 6) UPDATE BILLING SYSTEM: Configure system to require prior authorization flag for J0490; add clinical criteria checklist to encounter documentation; block claims missing precertification or failing exclusion criteria. 7) PROVIDER EDUCATION: Notify in-network rheumatologists and nephrologists of precertification requirement and approval criteria. CONSEQUENCE: Claims submitted without precertification or failing to meet clinical criteria will be denied.