Does J0490 require prior authorization?

Yes, J0490 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0490?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0490`, Injection, belimumab, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For initial therapy: documentation of diagnosis of active systemic lupus erythematosus OR documentation of diagnosis of active lupus nephritis (as applicable).
Documentation that severe active central nervous system lupus is absent (policy: 'without severe active central nervous system lupus').
Documentation that the patient is currently receiving at least one standard of care treatment for active systemic lupus erythematosus (examples provided in policy: antimalarials, corticosteroids, or immunosuppressants) that is not a biologic.
For continuation of therapy: documentation that the patient has previously received Benlysta injection for intravenous infusion.
For continuation of therapy: documentation of positive clinical response to prior Benlysta treatment.
Documentation that the patient is not receiving Benlysta in combination with Lupkynis (voclosporin) or Saphnelo (anifrolumab-fnia), and not receiving other biologic agents concurrently.

Key Coverage Criteria

This policy refers only to Benlysta (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN).
Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus when all of the following criteria are met: For initial therapy: Diagnosis of active systemic lupus erythematosus, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combi [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis when all of the following criteria are met: For initial therapy: Diagnosis of active lupus nephritis, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combination with Lupkyni [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiv [...]
FDA indication (informational): Benlysta is indicated for the treatment of patients aged 5 years of age and older with active systemic lupus erythematosus who are receiving standard therapy and patients aged 5 years and older with active lupus nephritis who are receiving standard therapy.

20 Active Policies

ARKBLUE-BELIMUMAB-E-G-BENLYSTA-D1439BE66B, Belimumab (e.g., Benlysta)

FLORIDA_BLUE-FLBLUE-BENLYSTA-BELIMUMAB-9231F78906, Benlysta (belimumab)

BCBSLA-00295-A452A295CF, 00295 belimumab (Benlysta)

BCBSM-2027111-223A186B07, BENLYSTA (BELIMUMAB)

HEALTHPARTNERS-CC-AENTRY-045989, Anifrolumab (Saphnelo) and belimumab (Benlysta)

MULTI

POINT32HEALTH-MDMNG-12451, Benlysta (belimumab)

MULTI

POINT32HEALTH-MDMNG-12461, Benlysta (belimumab) Intravenous

MULTI

POINT32HEALTH-MDMNG-12471, Benlysta (belimumab) Intravenous

MULTI

POINT32HEALTH-PMNG-14856, Benlysta (belimumab) Subcutaneous

MULTI

POINT32HEALTH-PMNG-14866, Benlysta (belimumab) Subcutaneous

MULTI

BCBSND-BELIMUMAB-BENLYSTA-1ABD2957F1, Belimumab Benlysta

BCBSNJ-DRUGS-088-EC543C5397, Belimumab (Benlysta)

MODA-BENLYSTA-AEB04CE67C, Benlysta (belimumab)

HEALTHNET_OR-HNOR-BELIMUMAB-BENLYSTA-CP-PHAR-88-107A1C3136, Belimumab (Benlysta); CP.PHAR.88

IBX-COMMERCIAL-08-00-99E-7062D1BCE9, Belimumab (Benlysta) for Intravenous Use

IBX-MEDICARE-ADVANTAGE-MA08-057D-33A1AC883E, Belimumab (Benlysta) for Intravenous Use

EVICORE-MEDICAL_DRUG-DE0DCB31B4CC, Benlysta (belimumab) Intravenous Injection

OSCAR-BENLYSTA-BELIMUMAB-PG014-VER-8-68B035DDB3, Benlysta (belimumab) (PG014, Ver. 8)

UHC-COMM-MD-BENLYSTA-BELIMUMAB-COMMUNITY-PLAN-MEDICA-BF5BBB78A3, Benlysta (Belimumab) – Community Plan Medical Benefit Drug Policy

UHC-POL-benlysta-belimumab, Benlysta (Belimumab)

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Ask Backwork about documentation requirements, denial risks, or coverage in your state.

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J0490, Injection, belimumab, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For initial therapy: documentation of diagnosis of active systemic lupus erythematosus OR documentation of diagnosis of active lupus nephritis (as applicable).
Documentation that severe active central nervous system lupus is absent (policy: 'without severe active central nervous system lupus').
Documentation that the patient is currently receiving at least one standard of care treatment for active systemic lupus erythematosus (examples provided in policy: antimalarials, corticosteroids, or immunosuppressants) that is not a biologic.
For continuation of therapy: documentation that the patient has previously received Benlysta injection for intravenous infusion.
For continuation of therapy: documentation of positive clinical response to prior Benlysta treatment.
Documentation that the patient is not receiving Benlysta in combination with Lupkynis (voclosporin) or Saphnelo (anifrolumab-fnia), and not receiving other biologic agents concurrently.

Key Coverage Criteria

This policy refers only to Benlysta (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN).
Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus when all of the following criteria are met: For initial therapy: Diagnosis of active systemic lupus erythematosus, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combi [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis when all of the following criteria are met: For initial therapy: Diagnosis of active lupus nephritis, without severe active central nervous system lupus; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiving Benlysta in combination with Lupkyni [...]
Benlysta (belimumab) is proven and medically necessary for the treatment of active lupus nephritis for continuation of therapy when all of the following criteria are met: Patient has previously received Benlysta injection for intravenous infusion; documentation of positive clinical response; currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants) that is not a biologic; patient is not receiv [...]
FDA indication (informational): Benlysta is indicated for the treatment of patients aged 5 years of age and older with active systemic lupus erythematosus who are receiving standard therapy and patients aged 5 years and older with active lupus nephritis who are receiving standard therapy.

20 Active Policies

ARKBLUE-BELIMUMAB-E-G-BENLYSTA-D1439BE66B, Belimumab (e.g., Benlysta)

FLORIDA_BLUE-FLBLUE-BENLYSTA-BELIMUMAB-9231F78906, Benlysta (belimumab)

BCBSLA-00295-A452A295CF, 00295 belimumab (Benlysta)

BCBSM-2027111-223A186B07, BENLYSTA (BELIMUMAB)

HEALTHPARTNERS-CC-AENTRY-045989, Anifrolumab (Saphnelo) and belimumab (Benlysta)

MULTI

POINT32HEALTH-MDMNG-12451, Benlysta (belimumab)

MULTI

POINT32HEALTH-MDMNG-12461, Benlysta (belimumab) Intravenous

MULTI

POINT32HEALTH-MDMNG-12471, Benlysta (belimumab) Intravenous

MULTI

POINT32HEALTH-PMNG-14856, Benlysta (belimumab) Subcutaneous

MULTI

POINT32HEALTH-PMNG-14866, Benlysta (belimumab) Subcutaneous

MULTI

BCBSND-BELIMUMAB-BENLYSTA-1ABD2957F1, Belimumab Benlysta

BCBSNJ-DRUGS-088-EC543C5397, Belimumab (Benlysta)

MODA-BENLYSTA-AEB04CE67C, Benlysta (belimumab)

HEALTHNET_OR-HNOR-BELIMUMAB-BENLYSTA-CP-PHAR-88-107A1C3136, Belimumab (Benlysta); CP.PHAR.88

IBX-COMMERCIAL-08-00-99E-7062D1BCE9, Belimumab (Benlysta) for Intravenous Use

IBX-MEDICARE-ADVANTAGE-MA08-057D-33A1AC883E, Belimumab (Benlysta) for Intravenous Use

EVICORE-MEDICAL_DRUG-DE0DCB31B4CC, Benlysta (belimumab) Intravenous Injection

OSCAR-BENLYSTA-BELIMUMAB-PG014-VER-8-68B035DDB3, Benlysta (belimumab) (PG014, Ver. 8)

UHC-COMM-MD-BENLYSTA-BELIMUMAB-COMMUNITY-PLAN-MEDICA-BF5BBB78A3, Benlysta (Belimumab) – Community Plan Medical Benefit Drug Policy

UHC-POL-benlysta-belimumab, Benlysta (Belimumab)

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Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0490 Sign up free

`J0490`, Injection, belimumab, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0490`, Injection, belimumab, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0490, Injection, belimumab, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0490, Injection, belimumab, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0490`, Injection, belimumab, 10 mg

`J0490`, Injection, belimumab, 10 mg