By Counterforce Health Team in Soliris (eculizumab) —

Getting Soliris (Eculizumab) Covered by Humana in Washington: Complete Prior Authorization and Appeals Guide

Quick Start: Getting Soliris Covered by Humana in Washington

Soliris (eculizumab) requires prior authorization from Humana in Washington and is covered under the medical benefit (Part B/Medicare Advantage), not pharmacy benefit. The fastest path to approval: (1) Ensure meningococcal vaccination is current and documented, (2) Have your provider submit the "Request for Medicare Prescription Drug Coverage Determination" form with complete diagnostic confirmation (antibody tests for NMOSD, flow cytometry for PNH), and (3) Include all prior treatment failures and contraindications. Start today by calling Humana at 800-555-CLIN (2546) to confirm your specific plan's requirements and download the current PA form.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You Need More Information
  7. If Your Request Is Denied
  8. Appeals Process in Washington
  9. Renewal and Reauthorization
  10. Common Denial Reasons and Solutions
  11. Frequently Asked Questions
  12. Quick Reference Checklist

What This Guide Covers

This comprehensive guide helps Washington residents with Humana Medicare Advantage or Medicare Part D plans navigate the prior authorization process for Soliris (eculizumab), a high-cost specialty medication used to treat paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD).

Who this helps:

  • Patients newly prescribed Soliris who need insurance approval
  • Clinicians submitting prior authorization requests
  • Patients facing denials who need to appeal
  • Caregivers navigating the coverage process

Soliris is among the most expensive biologics available, often exceeding $500,000 annually before rebates. However, with proper documentation and persistence, most medically necessary requests can be approved.

Before You Start: Verify Your Coverage

Confirm Your Plan Type

Medical vs. Pharmacy Benefit: Soliris infusions are covered under Humana's medical benefit (Medicare Part B or Medicare Advantage), not the pharmacy benefit (Part D). This is crucial because the authorization process, forms, and appeals procedures differ significantly.

Check Formulary Status

Soliris is typically classified as a Tier 5 specialty drug on Humana formularies, requiring the highest cost-sharing and strict utilization management. Visit Humana's drug list portal to confirm your specific plan's coverage.

Verify Network Status

Ensure your infusion center or specialty pharmacy is in Humana's network. Out-of-network administration can result in significantly higher costs or complete denial of coverage.

Gather Required Documentation

Essential Clinical Information

Diagnosis Confirmation:

  • For NMOSD: Positive AQP4 antibody test results
  • For PNH: Flow cytometry showing PNH clones
  • For aHUS: Complement testing and genetic analysis if applicable
  • For gMG: Anti-AChR antibody confirmation and clinical assessment

ICD-10 Codes:

  • PNH: D59.5
  • aHUS: D59.3
  • gMG: G70.00
  • NMOSD: G36.0

Vaccination Requirements

Critical: Humana strictly enforces meningococcal vaccination requirements due to Soliris's 1000-2000x increased infection risk. Required vaccines include:

  • Meningococcal conjugate vaccine (serogroups A, C, W, Y)
  • Meningococcal serogroup B vaccine
  • Must be administered at least 2 weeks before starting Soliris

If urgent treatment is needed: Document antibiotic prophylaxis started immediately and vaccination scheduled as soon as possible.

Prior Treatment Documentation

Include detailed records of:

  • Previous therapies tried and failed
  • Reasons for discontinuation (lack of efficacy, adverse reactions)
  • Contraindications to alternative treatments
  • Duration of each prior therapy

Supporting Documentation Checklist

  • Complete medical records
  • Laboratory results confirming diagnosis
  • Vaccination records
  • Prior authorization form (complete)
  • Prescriber's medical necessity letter
  • Insurance card and member ID

Submit Your Prior Authorization Request

Submission Methods

Preferred Method: Online through Humana's provider portal Alternative Methods:

  • Fax: 877-486-2621
  • Phone: 800-555-CLIN (2546), Monday-Friday, 8 a.m.-8 p.m. local time

Required Form

Download the "Request for Medicare Prescription Drug Coverage Determination" from Humana's pharmacy prior authorization page.

Clean Request Packet Components

  1. Completed PA form with all sections filled
  2. Medical necessity letter from prescriber
  3. Diagnostic test results confirming eligible condition
  4. Vaccination documentation
  5. Prior treatment history with outcomes
  6. Current clinical notes supporting need for Soliris
Tip: Incomplete submissions are the #1 cause of delays. Double-check every required field before submitting.

Follow-Up and Timeline Management

Standard Timelines

  • Standard review: Up to 30 days for Part B/Medicare Advantage decisions
  • Expedited review: 72 hours if health could be seriously jeopardized by delay
  • Part D appeals: 7 days standard, 72 hours expedited

When to Follow Up

  • Day 3: Confirm receipt of your submission
  • Day 10: Check status if no initial response
  • Day 20: Escalate if approaching deadline without decision

Sample Follow-Up Script

"Hello, I'm calling to check the status of a prior authorization request for Soliris submitted on [date]. The member ID is [number] and the reference number is [if available]. Can you provide an update on the review timeline?"

Document everything: Reference numbers, representative names, and dates of all conversations.

If You Need More Information

Medical Necessity Questions

Be prepared to provide additional clinical justification addressing:

  • Why Soliris is medically necessary for this specific patient
  • Why alternative treatments are inappropriate or have failed
  • Expected clinical outcomes and monitoring plan
  • Long-term treatment goals

Literature Support

Include citations from:

  • FDA prescribing information
  • Peer-reviewed clinical studies
  • Professional society guidelines
  • Recognized drug compendia for off-label uses

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, pulling the right citations and clinical evidence to support approval.

If Your Request Is Denied

Understanding Denial Letters

Common denial codes and meanings:

  • Non-formulary: Drug not on preferred list
  • Step therapy: Must try preferred alternatives first
  • Medical necessity: Insufficient clinical justification
  • Vaccination: Missing required immunizations

Immediate Next Steps

  1. Review the denial letter carefully for specific reasons
  2. Request peer-to-peer review with medical director
  3. Gather additional supporting documentation
  4. File internal appeal within required timeframe

Appeals Process in Washington

Internal Appeals with Humana

Deadline: 65 calendar days from denial notice date Submission: Via Humana's member portal or mail to address on denial letter Timeline: Decision within 30 days (72 hours for expedited)

External Review Process

If internal appeals are exhausted, Washington residents can request independent external review through a certified Independent Review Organization (IRO).

Key Details:

  • Deadline: 180 days from final internal denial
  • Process: Submit request to Washington Office of the Insurance Commissioner
  • Timeline: IRO decision within 20-45 days (72 hours for expedited)
  • Outcome: IRO decision is binding on Humana

Washington State Resources

SHIBA Program: Free Medicare counseling and appeals assistance

Office of the Insurance Commissioner:

  • Consumer Advocacy: 1-800-562-6900
  • Website resources for appeal templates and guidance

Renewal and Reauthorization

When to Start

Begin reauthorization process 30-45 days before current approval expires to avoid treatment interruptions.

Required Updates

  • Current clinical status and treatment response
  • Updated laboratory values
  • Continued medical necessity justification
  • Any changes in diagnosis or treatment goals
  • Vaccination status updates

Calendar Reminders

Set reminders for:

  • 60 days before expiration: Begin gathering documentation
  • 45 days before: Submit reauthorization request
  • 30 days before: Follow up on status

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing vaccination Provide immunization records Vaccination dates and lot numbers
Insufficient diagnosis Submit confirmatory testing Antibody tests, genetic analysis
Step therapy not met Document prior failures Treatment history with outcomes
Medical necessity Enhanced clinical justification Detailed necessity letter
REMS non-compliance Provider enrollment confirmation REMS program documentation

Frequently Asked Questions

Q: How long does Humana prior authorization take for Soliris in Washington? A: Standard reviews take up to 30 days, while expedited reviews (for urgent medical situations) must be completed within 72 hours.

Q: What if Soliris is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or have failed.

Q: Can I request an expedited appeal if denied? A: Yes, if the delay could seriously jeopardize your health. Your doctor must provide clinical justification for expedited processing.

Q: Does step therapy apply if I've already failed treatments in another state? A: Yes, but document all prior treatments regardless of where they occurred. Humana should accept out-of-state treatment history.

Q: What happens if I start Soliris before approval? A: You may be responsible for the full cost unless you receive retroactive approval. Emergency situations may qualify for retroactive coverage.

Q: How do I find a Humana in-network infusion center? A: Use Humana's provider directory online or call customer service. Confirm network status before scheduling treatments.

Quick Reference Checklist

Before Starting

  • Verify medical benefit coverage (not pharmacy)
  • Confirm in-network infusion center
  • Check current formulary tier
  • Download current PA form

Documentation Needed

  • Diagnostic test results (antibody/genetic confirmation)
  • Vaccination records (meningococcal A,C,W,Y,B)
  • Prior treatment failures documented
  • Medical necessity letter from prescriber
  • Complete PA form

Submission

  • Submit via preferred method (online portal)
  • Keep copies of everything
  • Document reference numbers
  • Set follow-up reminders

If Denied

  • Review denial letter for specific reasons
  • Request peer-to-peer review
  • File internal appeal within 65 days
  • Consider external review if needed

From our advocates: We've seen patients successfully overturn Soliris denials by ensuring vaccination documentation was complete and providing detailed antibody confirmation for their specific condition. The key is addressing every requirement in the initial submission rather than waiting for the denial. This composite experience reflects common patterns we observe, though individual outcomes vary.

For complex cases requiring detailed appeal strategies, Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals by identifying specific denial reasons and crafting responses aligned to each payer's requirements.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance company. Coverage policies and procedures may change. Always verify current requirements directly with Humana and consult official plan documents for the most up-to-date information specific to your situation.

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