Anifrolumab-fnia (Saphnelo®)

By September 15, 2026: Billing team must prepare systems and workflows for Saphnelo® (anifrolumab-fnia) prior authorization requirement. (1) Update billing software to flag all Saphnelo® claims for mandatory prior authorization initiation. (2) Create or update prior auth request templates to require: positive SLE autoantibody documentation (ANA by IFA ≥1:80, anti-dsDNA, anti-Sm, antiphospholipid antibodies, or low complement); confirmation patient is on concurrent standard SLE therapy (glucocorticoids, antimalarials, or immunosuppressants); rheumatologist or SLE specialist prescriber name and credentials; and exclusion screening (no severe active lupus nephritis or CNS lupus). (3) Train billing staff to identify claims that meet automatic denial criteria: members under 18 years old, non-rheumatologist prescribers without consultation documentation, biologic combination therapy, or active severe nephritis/CNS lupus. (4) Update claim submission procedures to require prior authorization approval documentation before processing. (5) Establish 12-month reauthorization workflow requiring clinical notes demonstrating disease stability or improvement. Failure to obtain prior authorization or submit required documentation will result in claim denials. Coordinate with providers to ensure rheumatologist involvement is documented for all requests.