By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Aetna CVS Health in Illinois: Prior Authorization Guide

Answer Box: Getting Soliris (Eculizumab) Covered by Aetna CVS Health in Illinois

Eligibility: Soliris requires prior authorization from Aetna CVS Health for all plan types in Illinois. Fastest path to approval: Submit the complete Aetna Soliris prior authorization form with diagnosis documentation (PNH, aHUS, gMG, or NMOSD), lab results, prior therapy records, and proof of meningococcal vaccination. First step today: Download the current Aetna Soliris request form and verify your plan type via the Aetna member portal.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Appeals Process in Illinois
  9. Renewal and Re-authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps patients and clinicians navigate Aetna CVS Health's prior authorization process for Soliris (eculizumab) in Illinois. Whether you have commercial insurance, Medicare, or Medicaid through Aetna, you'll find step-by-step instructions, required forms, and appeal strategies.

Soliris is FDA-approved for paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). Given its high cost—up to $500,000 annually—virtually all insurance plans require prior authorization.

Who this helps: Patients prescribed Soliris, their caregivers, and healthcare providers managing prior authorization requests in Illinois.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Log into your Aetna member portal or call the number on your insurance card to determine:

  • Commercial plan: Employer-sponsored or individual market
  • Medicare Advantage: Aetna Medicare plans
  • Medicaid: Aetna Better Health of Illinois

Each plan type has slightly different prior authorization requirements and timelines.

Step 2: Check Medical vs. Pharmacy Benefit

Soliris may be covered under your medical benefit (when given at infusion centers) or pharmacy benefit (when dispensed through specialty pharmacy). This affects:

  • Which forms to use
  • Where to submit requests
  • Billing codes (J1299 for medical, NDC for pharmacy)

Contact Aetna at 1-888-632-3862 (commercial) or 1-800-624-0756 (Medicare) to verify.

Step 3: Confirm Network Status

Ensure your prescribing physician and planned infusion site are in-network. Out-of-network providers face additional hurdles and may require separate authorization.

Gather What You Need

Required Documentation

For all indications:

  • Completed Aetna Soliris prior authorization form
  • Patient demographics and insurance information
  • Prescriber NPI and contact information
  • Proof of meningococcal vaccination (MenACWY and MenB) completed ≥2 weeks before treatment

Diagnosis-specific requirements:

Indication Required Lab Values Additional Documentation
PNH Elevated LDH ≥1.5× upper normal, low haptoglobin, flow cytometry showing PNH clones Transfusion history, hemolysis evidence
aHUS Thrombocytopenia (<150×10⁹/L), elevated LDH, schistocytes on blood smear Exclusion of STEC-HUS and TTP
gMG Positive acetylcholine receptor (AChR) antibodies Documentation of generalized weakness, prior therapy failures
NMOSD Positive anti-AQP4-IgG antibodies Clinical presentation consistent with NMOSD

Prior Therapy Documentation

Aetna typically requires evidence of:

  • Previous treatments tried and failed
  • Dates of therapy trials
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Supporting clinical notes
Clinician Corner: Medical Necessity Letter Checklist

Include these elements in your supporting letter:Patient's specific diagnosis with ICD-10 codeClinical presentation and disease severityPrior therapies attempted with outcomesWhy Soliris is medically necessary vs. alternativesDosing plan and monitoring strategyReferences to FDA labeling and clinical guidelines

Submit the Request

Electronic Submission (Preferred)

  1. Availity Portal: Most providers use Availity for electronic prior authorization
  2. Novologix Platform: For specialty drugs through Availity
  3. Direct EMR Integration: Some systems connect directly to Aetna

Alternative Submission Methods

  • Fax: Use the fax number provided on the prior authorization form (verify current number)
  • Mail: Send to the address specified for your plan type
  • Phone: Call Aetna's prior authorization line for urgent requests

Clean Request Packet Checklist

✓ Completed prior authorization form with all fields filled ✓ Supporting clinical documentation ✓ Lab results and diagnostic tests ✓ Prior therapy documentation ✓ Vaccination records ✓ Prescriber attestation of medical necessity

Follow-Up and Timelines

Illinois-Specific Timelines

Per Illinois insurance regulations, Aetna must respond within:

  • Pre-service requests: 15 business days
  • Post-service requests: 30 calendar days
  • Urgent/expedited requests: 72 hours

When to Follow Up

  • Day 3: Confirm receipt of your submission
  • Day 10: Check status if no response received
  • Day 14: Request expedited review if approaching deadline

Sample Follow-Up Script

"This is [Name] calling about prior authorization request #[Reference Number] for Soliris for patient [Patient Name], DOB [Date]. Can you provide the current status and expected decision date?"

Document all interactions with reference numbers and representative names.

If You're Asked for More Information

Aetna may request additional documentation for medical necessity. Common requests include:

  • Recent clinical notes showing disease progression
  • Additional lab values or imaging studies
  • Specialist consultation reports
  • Literature support for off-label uses

Respond promptly—delays can reset review timelines. Submit additional information via the same method as your original request.

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Diagnosis criteria not met Submit additional lab results, specialist confirmation
Missing vaccination documentation Provide vaccination records or prophylaxis plan
Step therapy required Document failures/contraindications to preferred alternatives
Non-formulary status Request formulary exception with medical necessity letter
Experimental/investigational Cite FDA approval and published guidelines

Peer-to-Peer Review

Request a peer-to-peer (P2P) discussion between your prescriber and Aetna's medical director:

P2P Request Script: "I'd like to request a peer-to-peer review for the Soliris denial. When can Dr. [Prescriber Name] speak with your medical director about this case?"

Appeals Process in Illinois

Internal Appeal (First Level)

Timeline: File within 60-180 days of denial (check your specific plan)

How to file:

  • Online through Aetna member portal
  • Phone: Call number on denial letter
  • Written appeal: Mail to address on denial notice

Decision timeline:

  • Standard: 15 days (pre-service) or 30 days (post-service)
  • Urgent: 72 hours

External Review (Illinois IRO)

If your internal appeal is denied, Illinois law guarantees independent external review.

Timeline: Request within 4 months of final adverse determination

Process:

  1. Contact Illinois Department of Insurance at 877-527-9431
  2. Complete external review application
  3. Independent physician reviewer evaluates your case
  4. Decision within 45 days (72 hours for urgent cases)

The external review is binding—if approved, Aetna must cover Soliris.

From Our Advocates

We've seen successful appeals when families submitted comprehensive documentation upfront, including detailed prior therapy records and specialist letters explaining why biosimilar alternatives weren't suitable. The key is thorough preparation rather than rushing the initial submission.

Renewal and Re-authorization

Soliris authorizations typically last 6-12 months. Calendar your renewal 30-45 days before expiration.

Renewal Requirements

  • Updated clinical notes showing ongoing need
  • Current lab values demonstrating treatment response
  • Documentation of continued disease activity or risk
  • Confirmation of ongoing vaccination compliance

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned with each payer's specific requirements, helping patients and clinicians navigate complex prior authorization processes more effectively.

Quick Reference Checklist

Before submitting:

  • Downloaded current Aetna Soliris PA form
  • Verified plan type and benefit coverage
  • Gathered diagnosis documentation with ICD-10
  • Collected prior therapy records
  • Obtained vaccination records
  • Prepared medical necessity letter

After submission:

  • Documented submission date and method
  • Recorded reference number
  • Set follow-up reminders
  • Prepared for potential additional requests

If denied:

  • Reviewed denial reason carefully
  • Gathered additional supporting evidence
  • Filed internal appeal within deadline
  • Considered peer-to-peer review
  • Prepared for external review if needed

FAQ

How long does Aetna prior authorization take for Soliris in Illinois? Standard requests: 15 business days. Urgent requests: 72 hours. Submit early to avoid treatment delays.

What if Soliris is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or contraindicated.

Can I request expedited review? Yes, if delays would seriously jeopardize your health. Provide supporting documentation from your physician explaining the urgency.

Does step therapy apply if I've failed treatments outside Illinois? Yes, document all prior therapies regardless of where they were tried. Include medical records and dates of treatment.

What's the difference between internal and external appeal? Internal appeals are reviewed by Aetna. External appeals are reviewed by independent physicians through Illinois's IRO process and are binding.

How much does Soliris cost without insurance? List price approaches $500,000 annually. Patient assistance programs may be available through Alexion Access Navigator.

Can my doctor handle the prior authorization? Yes, most providers submit PA requests. However, patients can also initiate appeals and external reviews independently.

What if I'm switching from another insurance plan? Document your treatment history and current clinical status. Aetna may honor continuity of care for established therapies.

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Coverage decisions depend on individual plan terms and medical circumstances. Consult your healthcare provider and insurance plan documents for specific guidance.

Need Help? Contact the Illinois Department of Insurance Office of Consumer Health Insurance at 877-527-9431 or the Illinois Attorney General's Health Care Helpline at 1-877-305-5145 for assistance with insurance appeals.

For complex cases requiring targeted appeal strategies, Counterforce Health offers specialized support in converting insurance denials into successful approvals through evidence-based appeal preparation.

Sources & Further Reading

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