Summary
UnitedHealthcare Community Plan of New Jersey revised its Saphnelo (anifrolumab-fnia) IV medical policy, effective 2027-01-01. A new continuation and initial criterion requires the prescriber to attest that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, with an explanation submitted, and initial and continuation authorizations are limited to no more than 12 months. Saphnelo for severe active lupus nephritis, severe active CNS lupus, or use with other biologics is listed as not medically necessary.
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What to do
Action · 4 steps
01By 2027-01-01: Billing team and rheumatology providers should update prior authorization requests for Saphnelo IV for Community Plan of New Jersey Medicaid members so each request includes the prescriber attestation and written explanation that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, plus documentation of Benlysta IV or SQ failure, contraindication, or intolerance.
02Front desk and prior auth staff should track the 12-month authorization limit in the prior auth tracker and schedule renewals before expiration, and billing should confirm that claims for Saphnelo in combination with a biologic or Benlysta, or for severe active CNS lupus or lupus nephritis, are not submitted without supporting documentation.
03Note that Saphnelo Pen for self-administration falls under the pharmacy benefit and should be routed separately.
04Claims without the required prior authorization and attestation are expected to be denied.
Original notice
Saphnelo® (Anifrolumab-Fnia)
uhcprovider.com · Always check the source before changing claims.
Related changes
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