By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Blue Cross Blue Shield of Michigan: Complete Guide with Forms, Timelines, and Appeal Scripts

Answer Box: Getting Soliris Covered by BCBS Michigan

To get Soliris (eculizumab) covered by Blue Cross Blue Shield of Michigan, you'll need prior authorization through their NovoLogix system. Since July 2024, BCBS Michigan requires patients to try Empaveli (pegcetacoplan) first for most indications unless contraindicated. The fastest path: work with your specialist to submit a complete PA request addressing step therapy requirements, include comprehensive lab results and treatment history, and be prepared for potential peer-to-peer review. If denied, you have 60 days to file an internal appeal and can request external review through Michigan DIFS within 127 days.

First step today: Contact your prescribing specialist to begin gathering required documentation and discuss step therapy alternatives.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all lines of business BCBS Michigan Provider Portal
Step Therapy Must try Empaveli first (effective July 2024) BCBS Step Therapy Alert
Formulary Status Medical benefit drug requiring PA NovoLogix system
Specialist Required Hematologist, neurologist, or nephrologist Plan policy requirements
Vaccination Meningococcal vaccine ≥2 weeks before start FDA Soliris label
Appeal Deadline 60 days from denial for internal appeal BCBS member materials

Step 1: Set Your Goal and Partner with Your Provider

Your success depends on a strong partnership with your prescribing specialist. Soliris is FDA-approved for paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), AChR-positive generalized myasthenia gravis, and AQP4-positive neuromyelitis optica spectrum disorder. Each indication has specific diagnostic criteria that BCBS Michigan evaluates carefully.

Key 2024 change: BCBS Michigan now requires step therapy with Empaveli (pegcetacoplan) for most patients before approving Soliris or Ultomiris. This applies to commercial plans effective July 22, 2024, and Medicare Advantage plans for PNH starting September 16, 2024.

Clinician Corner: The NovoLogix system will prompt specific questions about Empaveli use, failure, or contraindications. Be prepared with dates, doses, and objective outcomes from any Empaveli trial, or clear documentation of why Empaveli is clinically inappropriate.

Step 2: Prepare for Your Visit

Come to your appointment with a detailed timeline of your condition and treatments. This preparation will help your doctor write a stronger medical necessity letter.

Symptom Timeline Checklist:

  • Date of diagnosis with supporting labs/imaging
  • Hospitalizations, ICU stays, or emergency visits
  • Transfusion history (dates, units, reasons)
  • Thrombotic events or complications
  • Current functional limitations and quality of life impact

Treatment History Documentation:

  • All medications tried with exact dates, doses, and duration
  • Reasons for discontinuation (lack of efficacy, side effects, contraindications)
  • Response to each therapy with objective measures
  • Any emergency treatments (plasmapheresis, IVIG, dialysis)

For PNH patients: Document LDH levels, transfusion frequency, and hemolysis symptoms. BCBS typically requires LDH ≥1.5 times upper normal limit plus clinical symptoms.

For aHUS patients: Gather evidence of thrombotic microangiopathy (low platelets, elevated LDH, kidney dysfunction) and exclusion of other causes like STEC-HUS or TTP.

For myasthenia gravis: Confirm AChR antibody positivity and document inadequate response to at least two standard therapies.

Step 3: Build Your Evidence Kit

Work with your healthcare team to gather comprehensive supporting documentation before the PA submission.

Essential Lab Results:

  • Flow cytometry results for PNH (GPI-anchored protein deficiency)
  • Complete blood count with differential
  • LDH, haptoglobin, and indirect bilirubin levels
  • Kidney function tests (creatinine, eGFR)
  • Disease-specific antibody tests (AChR, AQP4)

Clinical Documentation:

  • Specialist consultation notes
  • Hospital discharge summaries
  • Imaging reports (MRI for NMOSD patients)
  • Pathology reports if relevant
  • Vaccination records (especially meningococcal)

Treatment Records:

  • Pharmacy records showing prior medication trials
  • Infusion center records for previous biologics
  • Documentation of adverse events or contraindications

Counterforce Health specializes in helping patients and clinicians compile this type of comprehensive evidence package for complex prior authorization requests, turning insurance denials into targeted, evidence-backed appeals.

Step 4: Medical Necessity Letter Structure

Your specialist's letter of medical necessity is crucial for approval. Here's the structure that aligns with BCBS Michigan's evaluation criteria:

Opening Paragraph:

  • State the specific indication and FDA approval status
  • Include patient identifiers and dates of service
  • Request expedited review if clinically urgent

Diagnosis and Clinical Criteria:

  • ICD-10 codes
  • Date of diagnosis with supporting evidence
  • Disease severity and progression
  • Baseline laboratory values

Treatment History:

  • Chronological list of all prior therapies
  • Specific documentation of Empaveli trial/failure or contraindication
  • Reasons why alternatives are inappropriate
  • Response to previous treatments with objective measures

Rationale for Soliris:

  • Clinical necessity based on FDA labeling
  • Dosing plan (induction and maintenance)
  • Monitoring plan
  • Risk-benefit assessment

Safety Considerations:

  • Meningococcal vaccination status
  • Ongoing infection monitoring plan
  • REMS program enrollment
Template Language: "Based on the above clinical facts, Soliris is indicated and medically necessary for the treatment of [specific indication] in this patient. Alternative therapies including [list alternatives] are clinically inappropriate due to [specific reasons]."

Step 5: Support Peer-to-Peer Review

If BCBS Michigan requests a peer-to-peer review, help your provider prepare by offering specific availability windows and a concise case summary.

Phone Script for Scheduling: "This is [Provider Name] requesting to schedule a peer-to-peer review for [Patient Name] regarding Soliris prior authorization. I'm available [specific days/times] and can discuss the medical necessity and step therapy considerations. The case involves [brief clinical summary] where Empaveli is contraindicated due to [specific reason]."

Case Summary for Provider:

  • One-page summary of key clinical points
  • Step therapy documentation ready for discussion
  • Specific questions or objections to address
  • Guidelines or literature references to cite

Peer-to-Peer Focus Areas:

  • Address BCBS's specific denial reasons point by point
  • Emphasize consequences of treatment delay
  • Discuss why formulary alternatives are inadequate
  • Reference FDA labeling and specialty guidelines

Step 6: Document Everything After Your Visit

Keep detailed records of all communications and submissions to support potential appeals.

What to Save:

  • Copy of all PA submissions and supporting documents
  • Confirmation numbers from NovoLogix submissions
  • Email confirmations and portal messages
  • Notes from phone calls with dates and representative names
  • Any interim decisions or requests for additional information

Portal Messaging Tips:

  • Use clear subject lines: "Soliris PA Follow-up - [Patient Name]"
  • Reference specific case numbers or confirmation codes
  • Attach additional documentation as requested
  • Follow up on promised callback dates

Step 7: Practice Respectful Persistence

Maintain regular but respectful contact throughout the review process.

Follow-up Cadence:

  • Week 1: Confirm PA submission received
  • Week 2: Check on review status if no decision
  • Week 3: Offer additional documentation if needed
  • Beyond 15 days: Escalate to supervisory review

Escalation Script: "We submitted a prior authorization for Soliris on [date] and haven't received a decision within your standard timeframe. Given the serious nature of [condition], we're requesting expedited review and would like to speak with a supervisor about next steps."

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Step therapy not met Document Empaveli trial/failure or contraindication Pharmacy records, clinical notes, adverse event documentation
Insufficient diagnosis documentation Submit complete diagnostic workup Flow cytometry, antibody tests, imaging reports
Missing vaccination Provide vaccination records or prophylaxis plan Immunization records, antibiotic prophylaxis orders
Not medically necessary Strengthen clinical rationale Specialist letter, treatment history, guideline references
Experimental/investigational Cite FDA approval and guidelines FDA labeling, specialty society recommendations

Appeals Process for BCBS Michigan

If your initial PA is denied, follow this structured appeals process:

Level 1: Internal Appeal

  • Deadline: 60 days from denial notice
  • Submission: BCBS Michigan Member Appeal Form
  • Timeline: 30 days for preservice appeals
  • Contact: Use prescription drug appeal address on BCBS resolving problems page

Level 2: External Review

  • Deadline: 127 days from final internal denial
  • Authority: Michigan Department of Insurance and Financial Services (DIFS)
  • Process: Online form or paper submission
  • Timeline: Up to 60 days standard, 72 hours expedited
  • Contact: 877-999-6442

Expedited Appeals: Available when delay could seriously jeopardize life, health, or ability to regain maximum function. Requires physician certification of urgency.

From Our Advocates: We've seen several successful Soliris appeals where the key was documenting specific clinical deterioration that would occur with formulary alternatives. One case involved a PNH patient where the appeal emphasized that switching from stable Soliris therapy could trigger life-threatening hemolytic crisis, supported by detailed lab trends and hospitalization history.

When to Escalate to Michigan DIFS

Consider external review through Michigan DIFS when:

  • BCBS Michigan upholds denial after internal appeals
  • The denial involves medical necessity determination
  • You have strong clinical evidence supporting Soliris use
  • Delay poses significant health risks

DIFS External Review Process:

  1. Complete internal appeals first (unless plan fails to follow procedures)
  2. Submit DIFS external review form within 127 days
  3. Include final denial letter and supporting medical records
  4. DIFS assigns independent medical review
  5. Decision is binding on BCBS Michigan

The external review is free and conducted by independent medical experts. DIFS has stated that more Michiganders are successfully appealing denied claims through this process.

For patients who need help navigating complex appeals, Counterforce Health provides specialized support in turning insurance denials into successful, evidence-backed appeals for medications like Soliris.

FAQ

How long does BCBS Michigan take to decide on Soliris PA? Standard prior authorization decisions are typically made within 15 calendar days. Urgent requests are decided within 72 hours when delay could jeopardize health.

What if Soliris isn't on the formulary? Soliris requires prior authorization as a medical benefit drug. It's not excluded but requires meeting specific clinical criteria and step therapy requirements.

Can I request an expedited appeal? Yes, if delay could seriously jeopardize your life, health, or ability to regain maximum function. Your physician must certify the urgency in writing.

Does the step therapy requirement apply if I'm already on Soliris? Existing patients may be grandfathered, but new authorizations and renewals are subject to the Empaveli step therapy requirement unless contraindicated.

What's the difference between commercial and Medicare Advantage requirements? Both require PA and step therapy, but Medicare Advantage step therapy for PNH started September 16, 2024, while commercial started July 22, 2024.

How do I know if my employer group is exempt from step therapy? Check the "Specialty Pharmacy Prior Authorization Master Opt-in/Opt-out Group list" available through BCBS Michigan or ask your HR department.

What if I can't afford Soliris even with coverage? Contact Alexion's patient assistance programs and explore foundation grants. Many rare disease foundations offer copay assistance for eligible patients.

Can my doctor handle the appeals process for me? Yes, your physician or authorized representative can file appeals on your behalf with proper authorization forms.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific condition and treatment options. Insurance coverage policies change frequently; verify current requirements with your plan. For personalized assistance with insurance appeals and prior authorizations, consider consulting with healthcare advocacy services.

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