Summary
UnitedHealthcare Community Plan of New Mexico revised its Saphnelo (anifrolumab-fnia) IV medical policy, effective 2027-01-01. Coverage for moderate to severe SLE now requires a prescriber attestation, with an explanation, that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, plus a history of failure, contraindication, or intolerance to Benlysta IV or SQ. Continuation and initial authorizations are limited to 12 months, and use with biologics or in severe active CNS lupus or severe active lupus nephritis remains not covered.
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What to do
Action · 3 steps
01By 2027-01-01: Billing team and rheumatology providers should add the new prescriber attestation and Benlysta history requirement to the prior authorization checklist for Saphnelo IV requests for New Mexico Community Plan members, and the practice should collect the required explanation in the chart before submitting.
02Front desk staff should be told that Saphnelo Pen self-administered subcutaneous doses fall under the pharmacy benefit and are not billed as medical IV claims.
03Billing team should update the prior auth tracker so initial and continuation authorizations are requested for no more than 12 months, and watch for the payer's next notice on this policy.
Original notice
Saphnelo® (Anifrolumab-Fnia)
uhcprovider.com · Always check the source before changing claims.
Related changes
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