Updated Prior Authorization Information for Benlysta (procedure code J0490) and Saphnelo (procedure code J0491)

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of prior authorization updates for Belimumab (Benlysta), procedure code J0490, and Anifrolumab-fnia (Saphnelo), procedure code J0491. Effective March 1, 2022, there is no prior authorization requirement for both, and age and diagnosis restrictions are indicated below.

Benlysta (J0490) is indicated to treat the following: 

• Active, autoantibody-positive, systemic lupus erythematosus (SLE) in clients who are 5 years of age or older, and receiving standard therapy
• Adult clients with active Lupus Nephritis who are receiving standard therapy
• Diagnoses restricted to: M320, M3210, M3211, M3212, M3213, M3214, M3215, M3219, M328, M329

Saphnelo (J0491) is indicated to treat the following:

• Moderate to severe systemic lupus erythematosus (SLE) in adult clients, 18 years of age and older, who are receiving standard therapy
• Diagnoses restricted to: M3210, M3211, M3212, M3213, M3214, M3215, M3219, M328, M329

Providers can now find information about procedure codes J0490 and J0491, in the current Texas Medicaid Provider Manual (TMPPM), Outpatient Drug Services Handbook, section 6.72, “Lupus Treatment Agents.”

Why is this important?

TCHP recognizes we may serve potentially impacted patients in our membership. We want to ensure that the member meets clinical evidence for treatment.

Next step for providers: Providers should refer to the Outpatient Drug Services Handbook chapter of the TMPPM for more details on the clinical policy and prior authorization requirements.

If you have any questions, please email Provider Relations at:providerrelations@texaschildrens.org.

For access to all Provider Alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.