Summary
UnitedHealthcare Community Plan of Pennsylvania revised its Saphnelo (anifrolumab-fnia) IV medical benefit drug policy, effective 2027-01-01. Starting then, coverage for moderate to severe SLE requires a prescriber attestation, with explanation, that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, along with a history of failure, contraindication, or intolerance to Benlysta IV or SQ, and the policy continues to exclude severe active CNS lupus, severe active lupus nephritis, and combination use with other biologics.
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What to do
Action · 4 steps
01By 2027-01-01: Billing team and providers should, before scheduling Saphnelo IV infusions for Pennsylvania Community Plan Medicaid members, confirm the prescriber can document the new attestation that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, with a written explanation, and that the Benlysta IV or SQ failure, contraindication, or intolerance history is in the chart.
02Update prior authorization request checklists and the front desk prior auth tracker so these elements are collected before scheduling.
03Tell providers and front desk staff that Saphnelo Pen self-administered products are obtained under the pharmacy benefit, not this medical policy.
04Claims submitted without the required prior authorization documentation are expected to be denied, so verify documentation is attached before submission.
Original notice
Saphnelo® (Anifrolumab-Fnia)
uhcprovider.com · Always check the source before changing claims.
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