Prior Authorization Criteria for Saphnelo (C9086)

Date: January 14, 2022 Attention: Oncology Providers Effective Date: March 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Beginning March 1, 2022, Saphnelo (procedure code C9086) will be available for Medicaid members as a medical benefit. Saphnelo (anifrolumab-fnia) is indicated to treat moderate to severe systemic lupus erythematous (SLE) in adult clients receiving standard therapy. How this impacts providers: There are no prior authorization criteria, but there are age/diagnosis restrictions for Saphnelo (anifrolumab-fnia) C9086 infusion therapy:

• Member needs to be 18 years of age and older.
• Member needs to have a confirmed diagnosis of systemic lupus erythematosus (diagnosis codes: M3210, M3211, M3212, M3213, M3214, M3215, M3219, M328, M329).

Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff. If you have any questions, please email TCHP Department at: TCHPPharmacy@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.