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

Length of Approval: 0 When approved; no reauthorization required

• 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

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming 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

1970-01-01, 2026-06-03, 2025-06-02, 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. October 2025.

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Revision History

• 2026-06-03: 2026 Annual Review: Updated NF criteria verbiage to align with standard language.
• 2025-06-02: Annual review: No criteria changes.
• 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

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