By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (eculizumab) Covered by Aetna in Virginia: Forms, Appeals & Contact Guide

Answer Box: Get Soliris Covered by Aetna in Virginia

Soliris (eculizumab) requires prior authorization from Aetna CVS Health for all FDA-approved indications including PNH, aHUS, generalized myasthenia gravis, and NMOSD. The fastest path: submit electronically through CoverMyMeds or Surescripts (decisions in 6 seconds), include specific antibody/lab results for your diagnosis, and ensure meningococcal vaccination documentation. If denied, Virginia law gives you 180 days for internal appeals and 120 days for external review through the State Corporation Commission. Start today: verify your plan's formulary status and gather diagnostic labs.

Table of Contents

Start Here: Verify Your Plan

Before submitting a prior authorization request, confirm your Aetna plan details and Soliris coverage status. All Aetna plans require precertification for Soliris, regardless of indication.

Check your coverage:

  • Log into your Aetna member portal or call member services
  • Verify if your plan uses CVS Caremark for specialty drugs
  • Confirm your plan covers complement inhibitors (Soliris is typically on specialty tier)
Note: Self-funded employer plans may have different requirements. Ask HR if your plan follows standard Aetna policies or has custom coverage rules.

Prior Authorization Forms & Requirements

FDA-Approved Indications Covered by Aetna

Soliris is covered for these specific conditions with required documentation:

Indication Required Documentation Key Labs/Tests
PNH (reduce hemolysis) Flow cytometry showing GPI-AP deficiency LDH levels, transfusion history
aHUS (complement-mediated TMA) Lab evidence of TMA, exclusion of STEC Platelet count, LDH, creatinine
Generalized myasthenia gravis Adult patients only Positive anti-AChR antibodies required
NMOSD Adult patients only Positive anti-AQP4 antibodies required

Not covered: Shiga toxin E. coli-related HUS (STEC-HUS).

Required Forms

Soliris-specific PA form: Aetna Soliris Request Form 68742 (verify current version)

Key submission requirements:

  • Complete medical history and diagnosis with ICD-10 codes
  • Laboratory results confirming diagnosis
  • Documentation of meningococcal vaccination (≥2 weeks before treatment)
  • REMS program enrollment confirmation
  • Prior therapy trials and outcomes (if applicable)

Electronic Submission Portals

Electronic prior authorization (ePA) is 2-3 times faster than fax submissions, with some decisions returned in less than 6 seconds.

  • CoverMyMeds: Free provider registration, EHR integration available
  • Surescripts: Direct submission from most major EHR systems
  • Arrive Health: Web-based portal with document upload capability

Benefits of ePA:

  • Upload chart notes and supporting documents
  • Include urgency indicators for life-threatening situations
  • Real-time validation of member eligibility and medication details
  • Automated clinical questionnaires specific to Soliris
Tip: The ePA system provides diagnosis-specific questions that ensure all required documentation is captured upfront, reducing delays and additional requests.

Fax & Phone Contacts

Soliris-Specific Contacts

Prior Authorization:

  • Phone: 1-866-752-7021 (TTY: 711)
  • Fax: 1-888-267-3277 (TTY: 711)

Medicare Advantage Plans:

  • Phone: 1-866-503-0857 (TTY: 711)
  • Fax: 1-844-268-7263 (TTY: 711)

General CVS Caremark Prior Authorization

  • Phone: 1-800-294-5979 (Monday-Friday, 8:00 AM - 6:00 PM CST)
  • Fax: 1-888-601-8461

Cover sheet requirements:

  • Member ID and date of birth
  • Prescriber NPI and contact information
  • Urgency level (routine vs. expedited)
  • Complete form number (68742 for Soliris)

Specialty Pharmacy Requirements

Soliris is typically dispensed through specialty pharmacies due to its complex handling and administration requirements.

CVS Specialty Pharmacy onboarding:

  1. Prescription sent from prescriber to CVS Specialty
  2. Prior authorization approval obtained
  3. Patient enrollment and benefits verification
  4. Coordination with infusion center for delivery
  5. Patient education and monitoring setup

Transfer from another specialty pharmacy:

  • Contact CVS Specialty at the number provided in your approval
  • Provide current prescription details and remaining refills
  • Coordinate timing to avoid treatment gaps
Important: Soliris requires refrigeration and has specific stability requirements. Only use specialty pharmacies experienced with complement inhibitors.

Support & Case Management

Provider Support Lines

Commercial plans: 1-888-632-3862 (TTY: 711) Medicare plans: 1-800-624-0756 (TTY: 711)

What to ask provider support:

  • Current PA form version and submission requirements
  • Expected review timeline for your specific case
  • Required clinical documentation checklist
  • Site of care requirements (home vs. infusion center)

Member Services

Aetna member services: Available through your member ID card CVS Caremark: 1-800-CAREMARK for pharmacy-specific questions

Case management services:

  • Medication therapy management
  • Prior authorization status tracking
  • Coordination between medical and pharmacy benefits
  • Patient assistance program referrals

Virginia Appeals Process

If your Soliris prior authorization is denied, Virginia law provides multiple appeal options with specific timelines.

Internal Appeals with Aetna

Timeline: 180 days from denial to file internal appeal Standard review: 30-45 days for decision Expedited review: 72 hours (Medicare), varies for commercial

Required documents:

  • Copy of denial letter
  • Additional medical records not previously submitted
  • Updated clinical notes supporting medical necessity
  • Peer-reviewed literature (if applicable)

Virginia External Review

After exhausting internal appeals, Virginia residents can request independent external review through the State Corporation Commission Bureau of Insurance.

Timeline: 120 days from final internal denial Forms: Form 216-A (External Review Request) Contact:

Review timeline:

  • Standard: 45 days
  • Expedited: 72 hours (life-threatening), 6 business days (experimental/investigational)

Virginia's external review is binding on the insurer and provides an independent clinical assessment by board-certified physicians.

Virginia advantage: The state offers expedited external review for cancer treatment denials without requiring completion of internal appeals first.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Diagnosis criteria not met Submit complete lab workup Flow cytometry (PNH), antibody tests (MG/NMOSD)
Missing vaccination proof Provide immunization records Meningococcal vaccine ≥2 weeks prior
Insufficient prior therapy Document treatment history Medication trials, dates, outcomes, intolerances
Not medically necessary Clinical justification letter Symptom severity, functional impact, treatment goals
Non-formulary status Formulary exception request Contraindications to preferred alternatives
Site of care issues Verify infusion requirements Home infusion vs. outpatient facility approval

Clinician Corner: Medical Necessity Letter Checklist

When writing a medical necessity letter for Soliris, include:

✓ Specific diagnosis with ICD-10 codes and confirming lab results
✓ Disease severity and functional impact on patient
✓ Prior therapies tried, duration, and reasons for discontinuation
✓ Clinical rationale for Soliris based on FDA labeling
✓ Treatment goals and expected outcomes
✓ Monitoring plan and safety considerations
✓ Guideline support from relevant medical societies

Key references to cite:

  • FDA prescribing information for approved indications
  • Relevant clinical practice guidelines for PNH, aHUS, MG, or NMOSD
  • Peer-reviewed studies supporting efficacy in patient's specific condition

FAQ

How long does Aetna prior authorization take for Soliris in Virginia? Electronic submissions through ePA platforms can receive decisions in seconds to hours. Fax submissions typically take 5-10 business days. Aetna must respond within timeframes specified in your plan documents.

What if Soliris is not on my formulary? Request a formulary exception by documenting medical necessity and contraindications to preferred alternatives. Include clinical evidence supporting Soliris over other complement inhibitors.

Can I get expedited approval for urgent cases? Yes. Mark requests as urgent when the patient's condition is life-threatening or rapidly deteriorating. Provide physician certification of urgency and expected timeline without treatment.

Does Virginia require step therapy for complement inhibitors? Step therapy requirements vary by plan. Some may require trial of biosimilar eculizumab products (Bkemv, Epysqli) before brand Soliris. Check your specific plan's coverage policy.

What if I'm denied due to "experimental" use? Ensure you're requesting for an FDA-approved indication. For off-label uses, provide evidence from recognized compendia and peer-reviewed literature. Consider external review if clinical evidence is strong.

How do I find patient assistance for Soliris? Contact Alexion Access Navigator for manufacturer support programs, copay assistance, and foundation grant referrals. Virginia residents may also qualify for state pharmaceutical assistance programs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer. For complex cases like Soliris appeals, having the right documentation and strategy can make the difference between approval and denial.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies and requirements change frequently. Always verify current requirements with Aetna and consult with your healthcare provider for medical decisions. For assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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