Does J0491 require prior authorization?

Yes, J0491 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0491?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0491`, Injection, anifrolumab-fnia, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

o Prescribed by or in consultation with a rheumatologist; and o Initial authorization is for no more than 12 months

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Indication: Saphnelo is indicated for the treatment of adult patients with moderate to severe systemic lupus erythematosus (SLE) who are receiving standard therapy.
Saphnelo (anifrolumab-fnia) is proven for the treatment of moderate to severe systemic lupus erythematosus (SLE) when all of the following criteria are met: For initial therapy, all of the following: o Diagnosis of moderate to severe systemic lupus erythematosus, without severe active central nervous system lupus or severe active lupus nephritis; and o Currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroid [...]
Saphnelo is unproven and not medically necessary for: Severe active lupus nephritis Severe active central nervous system (CNS) lupus Use in combination with other biologics
Indication for Saphnelo in adults with moderate to severe systemic lupus erythematosus (SLE) requires: initial therapy with a diagnosis of moderate to severe SLE without severe active CNS lupus or severe active lupus nephritis, currently on at least one non-biologic standard of care for active SLE, not receiving Saphnelo with another biologic or Benlysta, dosing per FDA-labeled SLE dosing, and initial authorization up to 12 months; continuation requires prior Saphnelo IV treatment, documented po [...]
Anifrolumab (Saphnelo) and belimumab (Benlysta) coverage requires comprehensive criteria: rheumatologist supervision, active autoantibody-positive SLE, no severe active nephritis/CNS disease, prior optimization with hydroxychloroquine and immunosuppressants, continued corticosteroid use if tolerated, no concurrent biologic/IV cyclophosphamide, prior Benlysta failure or contraindication for Saphnelo requests, FDA-dosing adherence with patient weight, and acceptable site-of-care for commercial pro [...]

20 Active Policies

ARKBLUE-ANIFROLUMAB-FNIA-E-G-SAPHNELO-B430503AE3, Anifrolumab-fnia (e.g., Saphnelo)

BCBSLA-00767-D93C41432F, 00767 anifrolumab (Saphnelo)

BCBSM-2167520-168242A3C6, SAPHNELO (ANIFROLUMAB-FNIA)

POINT32HEALTH-MDMNG-13716, Saphnelo (anifrolumab-fnia)

MULTI

HEALTHPARTNERS-CC-AENTRY-045989, Anifrolumab (Saphnelo) and belimumab (Benlysta)

MULTI

POINT32HEALTH-MDMNG-13726, Saphnelo (anifrolumab-fnia)

MULTI

MODA-SAPHNELO-677D3574CC, Saphnelo (anifrolumab-fnia)

HEALTHNET_OR-HNOR-ANIFROLIMAB-FNIA-SAPHNELO-CP-PHAR-551-A6968602A5, Anifrolimab-fnia (Saphnelo); CP.PHAR.551

IBX-COMMERCIAL-08-01-82C-D7EAA05258, Anifrolumab-fnia (Saphnelo)

IBX-MEDICARE-ADVANTAGE-MA08-140C-FE22419ED0, Anifrolumab-fnia (Saphnelo)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-saphnelo, Saphnelo (Anifrolumab-Fnia)

AMERIHEALTH-COMMERCIAL-08-01-82C-F0EF0FA6D3, Anifrolumab-fnia (Saphnelo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-140C-C10F11191E, Anifrolumab-fnia (Saphnelo)

BCBSTN-e515eb85f1, Anifrolumab-fnia (Saphnelo)

EVICORE-MEDICAL_DRUG-1C7D91DA3A05, Saphnelo (anifrolumab-fnia)

UHC-COMM-MD-SAPHNELO-ANIFROLUMAB-FNIA-COMMUNITY-PLAN-3270F8E581, Saphnelo (Anifrolumab-Fnia) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-SAPHNELO-ANIFROLUMAB-FNIA-COMMERCIAL-AND-14939EB7D1, Saphnelo (Anifrolumab-Fnia) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-saphnelo, Saphnelo (Anifrolumab-Fnia)

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J0491, Injection, anifrolumab-fnia, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

o Prescribed by or in consultation with a rheumatologist; and o Initial authorization is for no more than 12 months

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Indication: Saphnelo is indicated for the treatment of adult patients with moderate to severe systemic lupus erythematosus (SLE) who are receiving standard therapy.
Saphnelo (anifrolumab-fnia) is proven for the treatment of moderate to severe systemic lupus erythematosus (SLE) when all of the following criteria are met: For initial therapy, all of the following: o Diagnosis of moderate to severe systemic lupus erythematosus, without severe active central nervous system lupus or severe active lupus nephritis; and o Currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroid [...]
Saphnelo is unproven and not medically necessary for: Severe active lupus nephritis Severe active central nervous system (CNS) lupus Use in combination with other biologics
Indication for Saphnelo in adults with moderate to severe systemic lupus erythematosus (SLE) requires: initial therapy with a diagnosis of moderate to severe SLE without severe active CNS lupus or severe active lupus nephritis, currently on at least one non-biologic standard of care for active SLE, not receiving Saphnelo with another biologic or Benlysta, dosing per FDA-labeled SLE dosing, and initial authorization up to 12 months; continuation requires prior Saphnelo IV treatment, documented po [...]
Anifrolumab (Saphnelo) and belimumab (Benlysta) coverage requires comprehensive criteria: rheumatologist supervision, active autoantibody-positive SLE, no severe active nephritis/CNS disease, prior optimization with hydroxychloroquine and immunosuppressants, continued corticosteroid use if tolerated, no concurrent biologic/IV cyclophosphamide, prior Benlysta failure or contraindication for Saphnelo requests, FDA-dosing adherence with patient weight, and acceptable site-of-care for commercial pro [...]

20 Active Policies

ARKBLUE-ANIFROLUMAB-FNIA-E-G-SAPHNELO-B430503AE3, Anifrolumab-fnia (e.g., Saphnelo)

BCBSLA-00767-D93C41432F, 00767 anifrolumab (Saphnelo)

BCBSM-2167520-168242A3C6, SAPHNELO (ANIFROLUMAB-FNIA)

POINT32HEALTH-MDMNG-13716, Saphnelo (anifrolumab-fnia)

MULTI

HEALTHPARTNERS-CC-AENTRY-045989, Anifrolumab (Saphnelo) and belimumab (Benlysta)

MULTI

POINT32HEALTH-MDMNG-13726, Saphnelo (anifrolumab-fnia)

MULTI

MODA-SAPHNELO-677D3574CC, Saphnelo (anifrolumab-fnia)

HEALTHNET_OR-HNOR-ANIFROLIMAB-FNIA-SAPHNELO-CP-PHAR-551-A6968602A5, Anifrolimab-fnia (Saphnelo); CP.PHAR.551

IBX-COMMERCIAL-08-01-82C-D7EAA05258, Anifrolumab-fnia (Saphnelo)

IBX-MEDICARE-ADVANTAGE-MA08-140C-FE22419ED0, Anifrolumab-fnia (Saphnelo)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-saphnelo, Saphnelo (Anifrolumab-Fnia)

AMERIHEALTH-COMMERCIAL-08-01-82C-F0EF0FA6D3, Anifrolumab-fnia (Saphnelo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-140C-C10F11191E, Anifrolumab-fnia (Saphnelo)

BCBSTN-e515eb85f1, Anifrolumab-fnia (Saphnelo)

EVICORE-MEDICAL_DRUG-1C7D91DA3A05, Saphnelo (anifrolumab-fnia)

UHC-COMM-MD-SAPHNELO-ANIFROLUMAB-FNIA-COMMUNITY-PLAN-3270F8E581, Saphnelo (Anifrolumab-Fnia) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-SAPHNELO-ANIFROLUMAB-FNIA-COMMERCIAL-AND-14939EB7D1, Saphnelo (Anifrolumab-Fnia) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-saphnelo, Saphnelo (Anifrolumab-Fnia)

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0491 Sign up free

`J0491`, Injection, anifrolumab-fnia, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0491`, Injection, anifrolumab-fnia, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0491, Injection, anifrolumab-fnia, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0491, Injection, anifrolumab-fnia, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0491`, Injection, anifrolumab-fnia, 1 mg

`J0491`, Injection, anifrolumab-fnia, 1 mg