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Benlysta Prior Authorization Resources

Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.

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Prior Authorization Forms

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Ambetter

Last verified: Apr 10, 2026Ambetter - Belimumab Drug Coverage Criteria

Anthem, Inc.

Last verified: Apr 10, 2026Anthem, Inc. - Benlysta Clinical Criteria

Arkansas Blue Cross Blue Shield

Last verified: Apr 15, 2026Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Alabama

Last verified: Apr 10, 2026Blue Cross Blue Shield of Alabama - Benlysta Prior Authorization with Quantity Limit Program Summary

Blue Cross Blue Shield of Massachusetts

Last verified: Apr 10, 2026Blue Cross Blue Shield of Massachusetts - Immune Modulating Drugs Prior Authorization Policy

Blue Cross Blue Shield of Michigan

Last verified: Apr 10, 2026Blue Cross Blue Shield of Michigan - Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage

Last verified: Apr 10, 2026Blue Cross Blue Shield of Michigan - Benlysta Prior Authorization Form (Medical Benefit)

Blue Cross of Idaho Health Services, Inc.

Last verified: Apr 15, 2026Blue Cross of Idaho - General Prior Authorization Form

Blue Shield of California

Last verified: Apr 10, 2026Blue Shield of California - Belimumab Commercial Intravenous Medical Benefit Drug Policy

Last verified: Apr 10, 2026Blue Shield of California - Belimumab Commercial Medical Benefit Drug Policy

Last verified: Apr 10, 2026Blue Shield of California - Belimumab Medi-Cal Medical Benefit Drug Policy

Boeing

Last verified: Apr 10, 2026Boeing - Benlysta Prior Authorization Request Prescriber Fax Form

California

Last verified: Apr 16, 2026California - Uniform Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Apr 15, 2026CDPHP - General Prior Authorization Form

CarelonRx

Last verified: Apr 10, 2026CarelonRx - Benlysta Medical Drug Clinical Criteria

Cigna Corporation

Last verified: Apr 15, 2026Cigna - General Medication Prior Authorization Form

Last verified: Apr 10, 2026Cigna - Belimumab IV Coverage Position Criteria

Last verified: Apr 10, 2026Cigna - Inflammatory Conditions Benlysta Subcutaneous Prior Authorization

Last verified: Apr 16, 2026Cigna - Benlysta Prior Authorization Form

Colorado

Last verified: Apr 16, 2026Colorado - Uniform Prior Authorization Form

Curative Health Insurance

Last verified: Apr 15, 2026Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Apr 15, 2026Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Apr 15, 2026Aetna - Illinois Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medicare Prescription Drug Coverage Determination

Last verified: Apr 15, 2026Aetna - Arizona Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form

Last verified: Apr 15, 2026Aetna - Louisiania Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Last verified: Apr 15, 2026Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form

Last verified: Apr 15, 2026Aetna - California Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Texas Prior Authorization Form

Last verified: Apr 15, 2026Aetna - New Hampshire Prior Authorization Form

Last verified: Apr 10, 2026Aetna - Medicare Part B Benlysta Prior Authorization Form

Last verified: Apr 10, 2026Aetna - Systemic Lupus Erythematosus Medicare Advantage Prescription Drug Step Criteria

Last verified: Apr 10, 2026Aetna - Systemic Lupus Erythematosus Medicare Advantage Step Criteria

Last verified: Apr 10, 2026Aetna - Benlysta Medicare Part B Drug Criteria

Last verified: Apr 16, 2026Aetna - Benlysta Prior Authorization Form

EmblemHealth, Inc.

Last verified: Apr 10, 2026EmblemHealth - Benlysta Prior Authorization Policy

Hawaii Medical Service Association

Last verified: Apr 10, 2026Hawaii Medical Service Association - Benlysta HMSA Prior Authorization Request

Health Partners Plans

Last verified: Apr 15, 2026Health Partners - General Prior Authorization Form

Humana, Inc.

Last verified: Apr 15, 2026Humana - General Prior Authorization Form

Illinois

Last verified: Apr 16, 2026Illinois - Uniform Prior Authorization Form

Independent Health Association, Inc.

Last verified: Apr 15, 2026Independence Health - Premium Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Select Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Value Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Medicare Part D Pharmacy Prior Authorization Form

Indiana

Last verified: Apr 16, 2026Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Apr 15, 2026Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)

Last verified: Apr 15, 2026Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Last verified: Apr 10, 2026Kaiser Permanente - Benlysta Prior Authorization

Louisiana

Last verified: Apr 16, 2026Louisiana - Uniform Prior Authorization Form

Medical Mutual of Ohio Corporation

Last verified: Apr 15, 2026Medical Mutual of Ohio - General Prior Authorization Form

Last verified: Apr 10, 2026Medical Mutual of Ohio - Benlysta Prior Authorization Policy

Minnesota

Last verified: Apr 16, 2026Minnesota - Uniform Prior Authorization Form

Moda Health

Last verified: Apr 10, 2026Moda Health - Benlysta Medical Necessity Criteria

Molina Health Care, Inc.

Last verified: Apr 15, 2026Molina - Ohio Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Mississippi Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina- Utah Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Utah Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - California Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Wisconsin Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Kentucky Pharmacy Prior Authorization Form

Last verified: Apr 10, 2026Molina Healthcare - Benlysta Drug and Biologic Coverage Criteria

MVP Health Care, Inc.

Last verified: Apr 15, 2026MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026MVP Health Care - Pharmacy Prior Authorization Form

Oregon

Last verified: Apr 16, 2026Oregon - Uniform Prior Authorization Form

PA Health and Wellness

Last verified: Apr 10, 2026PA Health and Wellness - Belimumab Drug Coverage Criteria v1.2025

Last verified: Apr 10, 2026PA Health and Wellness - Belimumab Drug Coverage Criteria v2.2025

PacificSource Health Plan

Last verified: Apr 15, 2026Pacific Source - Medicaid Community Solutions Prior Authorization Form

Last verified: Apr 15, 2026Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Apr 15, 2026Premera - Pharmacy Prior Authorization Form

Providence Health System

Last verified: Apr 15, 2026Providence Health Plan - Drug Prior Authorization Form

State of Alaska

Last verified: Apr 10, 2026State of Alaska - Benlysta Prior Authorization Criteria

Superior Health Plan

Last verified: Apr 10, 2026Superior Health Plan - Belimumab Drug Coverage Criteria

Texas

Last verified: Apr 16, 2026Texas - Uniform Prior Authorization Form

UnitedHealthcare

Last verified: Apr 10, 2026UnitedHealthcare - Benlysta Commercial Medical Benefit Drug Policy

Last verified: Apr 10, 2026UnitedHealthcare - Benlysta Pharmacy Prior Authorization Program

Washington

Last verified: Apr 16, 2026Washington - Uniform Prior Authorization Form

Wisconsin

Last verified: Apr 16, 2026Wisconsin - Uniform Prior Authorization Form

See approval requirements for your carrier

Find out what types of documentation and step therapies this carrier may require for coverage.

Check coverage