Pharmacy Prior Authorization Criteria

Lupkynis (voclosporin) - PA, NF

Indications for Prior Authorization

Lupkynis (voclosporin)

• For diagnosis of Lupus Nephritis
  Indicated in combination with a background immunosuppressive therapy regimen for the treatment of adult patients with active lupus nephritis (LN).

  Limitations of Use: Safety and efficacy of Lupkynis have not been established in combination with cyclophosphamide. Use of Lupkynis is not recommended in this situation.

Criteria

Lupkynis

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of active lupus nephritis
AND
• Used in combination with immunosuppressive therapy (e.g., mycophenolate mofetil, methylprednisolone)
AND
• Prescribed by or in consultation with one of the following:
• Nephrologist
• Rheumatologist

Lupkynis

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

Lupkynis

Non Formulary

Length of Approval: 12 Month(s)

• Diagnosis of active lupus nephritis
AND
• Used in combination with immunosuppressive therapy (e.g., mycophenolate mofetil, methylprednisolone)
AND
• Prescribed by or in consultation with one of the following:
• Nephrologist
• Rheumatologist

P & T Revisions

2024-04-03, 2023-10-10, 2023-03-02, 2022-03-03, 2021-12-01, 2021-03-03

References

1. Lupkynis Prescribing Information. Aurinia Pharma U.S., Inc. Rockville, MD. January 2021.

---

Revision History

• 2024-04-03: Annual review: Background and formatting updates.
• 2023-10-10: Patient demonstrates positive clinical response to therapy.
• 2023-03-02: Annual review: No updates required.
• 2022-03-03: Annual review: Background and formatting updates.
• 2021-12-01: Program update to add NF criteria
• 2021-03-03: New program

---