By Counterforce Health Team in Soliris (eculizumab) —

How Long Does It Take to Get Soliris (Eculizumab) Approved by Aetna (CVS Health) in Ohio? Complete Timeline Guide

Answer Box: Fastest Path to Soliris Approval in Ohio

Standard timeline: 5-15 business days for Aetna (CVS Health) prior authorization decisions; up to 72 hours for expedited reviews when urgent medical need is documented.

First step today: Your prescriber should download Aetna's Soliris Precertification Form (GR-68742), gather vaccination records, lab results, and prior therapy documentation, then submit via fax (1-844-268-7263) or provider portal.

Ohio advantage: After internal appeals, you have 180 days to request external review through the Ohio Department of Insurance (1-800-686-1526) with binding decisions typically within 30 days.

Table of Contents

What Affects Approval Timeline

Several factors influence how quickly Aetna (CVS Health) processes your Soliris (eculizumab) prior authorization in Ohio:

Documentation completeness is the biggest factor. Complete submissions with all required elements—vaccination records, diagnostic labs, prior therapy failures, and clinical justification—process faster than incomplete ones requiring additional information requests.

Medical urgency can accelerate review. If your prescriber documents that standard processing would "seriously jeopardize your life, health, or ability to regain maximum function," Aetna must decide within 72 hours instead of the standard 5-15 business days.

Indication complexity matters. Straightforward cases like paroxysmal nocturnal hemoglobinuria (PNH) with clear flow cytometry results typically process faster than complex atypical hemolytic uremic syndrome (aHUS) cases requiring genetic testing or biopsy results.

Note: CVS Specialty Pharmacy exclusively dispenses Soliris, so your prescription automatically routes through their system for benefit verification and clinical review.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submission, gather these required documents:

Diagnostic Evidence:

  • Flow cytometry results showing PNH clone ≥10% (for PNH)
  • Anti-AChR antibody test results (for myasthenia gravis)
  • AQP4-IgG antibody results (for NMOSD)
  • Kidney biopsy or genetic testing (for aHUS)

Vaccination Requirements:

  • MenACWY and MenB vaccination records from ≥2 weeks before first dose
  • Documentation of any contraindications to vaccination

Prior Therapy Documentation:

  • Dates, dosages, and outcomes of previous treatments
  • Specific reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • For myasthenia gravis: ≥12 months of immunosuppressive therapy plus IVIG trials

Clinical Information:

  • Current lab values (LDH, hemoglobin, platelet count within 30 days)
  • ICD-10 diagnosis codes
  • Weight-based dosing calculations
  • Site of care justification

Verification Steps

  1. Confirm eligibility through myAetna portal or call 1-800-TRY-AETNA
  2. Check formulary status on the current Aetna Precertification List
  3. Verify prescriber credentials and REMS program enrollment

Submission to Initial Review (1-5 Days)

How to Submit

Primary method: Complete the Aetna Soliris Injectable Medication Precertification Request Form (GR-68742) and submit via:

  • Fax: 1-844-268-7263
  • Provider portal (Availity or Aetna's system)
  • Mail to address listed on form

Alternative portals: Some prescribers use CoverMyMeds or EviCore systems for streamlined submission.

What Reviewers Check First

Aetna's utilization management team initially verifies:

  1. Member eligibility and benefits (active coverage, specialty pharmacy benefit)
  2. Prescriber authorization (appropriate specialty, REMS enrollment)
  3. Basic medical necessity (FDA-approved indication, appropriate diagnosis)
  4. Safety requirements (vaccination status, contraindication screening)
Tip: Incomplete submissions get placed in a "pending additional information" queue, adding 5-10 business days to the timeline.

Decision Window and Outcomes

Standard Processing Timeline

Review Type Timeline Triggers
Standard 5-15 business days Routine submissions
Expedited ≤72 hours Urgent medical need with physician attestation
Additional info +5-10 days Incomplete initial submission

Reading Your Decision Letter

Approval letters include:

  • Authorization number and effective dates
  • Approved dosing and frequency
  • CVS Specialty Pharmacy contact information
  • Any conditions or limitations

Denial letters specify:

  • Exact reason(s) for denial
  • Missing documentation requirements
  • Appeal rights and deadlines
  • Reference to specific policy criteria

If Denied: Appeal Timeline

Ohio provides robust appeal rights with specific timelines:

Internal Appeals with Aetna

Level 1 (Standard):

  • File within: 180 days of denial
  • Decision timeline: 30 days standard, 72 hours if expedited
  • How to file: Online portal, phone (1-800-TRY-AETNA), or written request

Level 2 (Expedited):

  • When available: Life-threatening situations or serious jeopardy to health
  • Timeline: 72 hours maximum
  • Requirements: Physician certification of urgency

External Review Through Ohio

After exhausting internal appeals, Ohio law provides external review:

Timeline: 180 days from final internal denial to request external review Process: File with your health plan, which forwards to Ohio Department of Insurance Decision: 30 days standard, 72 hours expedited Binding: Yes, if decision favors patient

Contact: Ohio Department of Insurance Consumer Services at 1-800-686-1526

From our advocates: We've seen Soliris appeals succeed when prescribers include detailed timelines of prior therapy failures and current lab trends showing disease progression. One case involved a myasthenia gravis patient whose appeal was initially denied but approved after external review when the family provided comprehensive documentation of IVIG failures and worsening symptoms.

Renewal Cycles and Reauthorization

Initial Authorization Period

Most Soliris approvals start with 6-month authorizations to assess treatment response.

Reauthorization Requirements

Annual renewals typically require:

  • Evidence of clinical response (reduced hemolysis for PNH, fewer exacerbations for myasthenia gravis)
  • Updated lab values within 30 days
  • Continued medical necessity documentation
  • Prescriber attestation of ongoing benefit

Submit renewal requests 30-45 days before current authorization expires to avoid treatment interruption.

2026 Policy Changes

Starting January 1, 2026, Aetna requires new prior authorization for autoimmune conditions, with preference for biosimilars (Epysqli/eculizumab-aagh, Bkemv/eculizumab-aeeb). Existing patients typically receive 90-day transition periods.

Timeline Visual Summary

Milestone Standard Timeline Expedited Timeline Key Actions
Pre-submission 1-2 days Same day Gather documents, verify eligibility
Submission Same day Same day Submit complete PA packet
Initial review 3-5 days 24 hours Aetna reviews for completeness
Medical review 5-10 days 48 hours Clinical evaluation against criteria
Decision 5-15 total days ≤72 hours Approval/denial notification
If denied - Internal appeal 30 days 72 hours Submit appeal with additional evidence
External review (Ohio) 30 days 72 hours Independent medical review

Time-Saving Tips for Faster Approval

Submit Complete Packets Upfront

Include all required documentation in your initial submission. Counterforce Health helps patients and clinicians prepare comprehensive appeals by identifying denial reasons and drafting targeted, evidence-backed responses that align with payer policies.

Use Electronic Portals

Provider portals process faster than fax submissions and provide real-time status updates.

Request Peer-to-Peer Reviews

If initial review seems unfavorable, request a physician-to-physician discussion before formal denial.

Coordinate with CVS Specialty

Since CVS Specialty exclusively dispenses Soliris, early coordination can expedite the fulfillment process once approved.

Track Status Weekly

Follow up if you haven't received a decision within expected timeframes—delays sometimes indicate lost paperwork.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Diagnosis criteria not met Submit comprehensive lab results Flow cytometry, antibody tests, genetic testing
Missing vaccination records Provide proof of MenACWY + MenB Vaccination cards, physician records
Insufficient prior therapy Document specific failures/intolerance Treatment dates, outcomes, discontinuation reasons
Non-formulary status Request formulary exception Medical necessity letter, alternative contraindications
Step therapy not met Document biosimilar failures Trial outcomes for Bkemv or Epysqli
Experimental use Cite FDA approval and guidelines FDA labeling, specialty society recommendations

Frequently Asked Questions

How long does Aetna (CVS Health) PA take in Ohio? Standard prior authorization takes 5-15 business days. Expedited reviews for urgent medical situations are decided within 72 hours.

What if Soliris (eculizumab) is non-formulary? Request a formulary exception by demonstrating medical necessity and contraindications to preferred alternatives. Include detailed clinical rationale.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Your physician must certify the urgency, and Aetna must decide within 72 hours.

Does step therapy apply if I've failed treatments outside Ohio? Yes, document prior therapy failures regardless of where they occurred. Include dates, dosages, and specific reasons for discontinuation.

What happens if my appeal is denied? You can request external review through the Ohio Department of Insurance within 180 days. Their decision is binding on Aetna.

How often do I need reauthorization? Initial approvals typically last 6 months, then annual reauthorizations based on continued medical necessity and treatment response.

What if I can't afford Soliris? Contact Alexion OneSource for patient assistance programs, copay support, and foundation grant information.

Can I appeal while continuing treatment? During internal appeals, coverage typically continues. For external reviews, continuation depends on your specific plan terms and Ohio regulations.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals and prior authorizations, contact the Ohio Department of Insurance at 1-800-686-1526.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.