Summary
Starting 2027-01-01, UnitedHealthcare Community Plan of Tennessee revised its Saphnelo (anifrolumab-fnia) IV medical policy for moderate to severe systemic lupus erythematosus. Initial and continuation requests now require 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 for initial therapy. Saphnelo pen for self-administered subcutaneous injection falls under the pharmacy benefit rather than this policy.
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What to do
Action · 4 steps
01By 2027-01-01: Billing team and providers should confirm that Saphnelo IV requests and claims for Tennessee Medicaid members with UnitedHealthcare Community Plan include the prescriber attestation on self-administration ability and a written explanation, plus documented Benlysta IV or SQ history for initial therapy.
02Update the prior auth tracker and intake checklist accordingly.
03Confirm that Saphnelo pen prescriptions for self-administration are routed to pharmacy benefit processing, and tell providers and front desk staff about the rheumatologist-prescriber, concurrent-biologic, dosing, and 12-month authorization limit requirements.
04Claims without the required prior authorization documentation will be denied.
Original notice
Saphnelo® (Anifrolumab-Fnia)
uhcprovider.com · Always check the source before changing claims.
Related changes
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