By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (eculizumab) Covered by Cigna in Ohio: Complete Coding, Prior Authorization, and Appeals Guide

Answer Box: Get Soliris (eculizumab) Covered by Cigna in Ohio

Fastest Path to Approval: Submit complete prior authorization with proper coding (HCPCS J1300, correct NDC 25682-0001-01, diagnosis-specific ICD-10), meningococcal vaccination records, and REMS enrollment documentation. If denied, file internal appeal within 180 days, then request Ohio external review through Independent Review Organization (IRO). Start today: Download Cigna's Soliris PA form and gather vaccination records.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Soliris Indications
  3. Product Coding: HCPCS, NDC, and Units
  4. Clean Prior Authorization Anatomy
  5. Frequent Coding Pitfalls
  6. Verification with Cigna Resources
  7. Appeals Playbook for Ohio
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Soliris (eculizumab) is almost always billed as a medical benefit because it requires IV infusion by healthcare providers. Understanding this distinction is crucial for proper coding and reimbursement.

Medical Benefit Path (Standard):

  • Uses HCPCS J-codes for billing
  • Requires site-of-care documentation
  • Includes administration costs
  • Subject to medical necessity reviews

Pharmacy Benefit Path (Rare):

  • Limited to specialty pharmacies
  • Uses NDC-only billing
  • Requires different prior authorization forms
Note: Cigna typically processes Soliris through their medical benefit with Express Scripts managing specialty drug reviews.

ICD-10 Mapping for Soliris Indications

Proper diagnosis coding is essential for Soliris approval. Each indication requires specific diagnostic confirmation and documentation.

Indication Primary ICD-10 Code Required Documentation
Paroxysmal Nocturnal Hemoglobinuria (PNH) D59.5 (PNH) or related hemolysis codes Flow cytometry (CD55/CD59 deficiency), FLAER test
Atypical Hemolytic Uremic Syndrome (aHUS) D59.3 (Non-autoimmune hemolytic anemia) Genetic/complement testing, exclusion of other TMA
Generalized Myasthenia Gravis G70.00 (without exacerbation) or G70.01 (with exacerbation) AChR+ antibodies, MG-ADL score, specialist confirmation
NMOSD Use optic neuritis/myelitis codes as appropriate AQP4+ antibodies, MRI findings, neurologist evaluation

Documentation Words That Support Coding:

  • "Confirmed by flow cytometry"
  • "Genetic testing positive for complement pathway mutation"
  • "Failed conventional therapy"
  • "Specialist-confirmed diagnosis"

Product Coding: HCPCS, NDC, and Units

HCPCS J-Code: J1300 (Injection, eculizumab, 10 mg)

  • Each unit = 10 mg of eculizumab
  • Calculate units: Total dose ÷ 10 mg

NDC Code: 25682-0001-01 (300 mg/30 mL vial)

  • Use 11-digit HIPAA-compliant format
  • NDC units = total mg administered (not vials)

Units Calculation Example:

  • Patient receives 1200 mg dose
  • HCPCS units: 1200 ÷ 10 = 120 units of J1300
  • NDC units: 1200 mg (4 vials × 300 mg each)

Required Modifiers:

  • -RE: REMS compliance (some payers require)
  • Site-specific modifiers as needed

Clean Prior Authorization Anatomy

A complete Cigna prior authorization for Soliris must include:

Essential Elements Checklist:

  • Patient demographics and Cigna ID
  • Prescriber NPI and REMS enrollment proof
  • Diagnosis with ICD-10 code
  • Meningococcal vaccination records (≥2 weeks prior)
  • Medical necessity statement
  • Prior therapy documentation
  • Dosing rationale and monitoring plan
  • Site-of-care justification

Medical Necessity Statement Template:

Patient has [diagnosis] confirmed by [specific test]. Prior treatments 
including [list medications] were discontinued due to [lack of efficacy/
adverse events]. Soliris is medically necessary as [clinical rationale]. 
Patient has completed required meningococcal vaccination on [date].

Frequent Coding Pitfalls

Common Error Impact Fix
Using vial count instead of mg for NDC units Claim rejection Always use total mg administered
Missing vaccination documentation Automatic denial Attach dated vaccination records
Incorrect J1300 unit calculation Underpayment or rejection Double-check: total mg ÷ 10
Wrong ICD-10 for indication Medical necessity denial Use indication-specific codes
Missing REMS enrollment PA denial Verify prescriber in REMS database

Unit Conversion Errors: The most common mistake is calculating J1300 units incorrectly. Remember: 1 unit of J1300 = 10 mg eculizumab, not 1 mg.

Verification with Cigna Resources

Before submitting your prior authorization:

  1. Check Current Forms: Download the latest Cigna Soliris PA form
  2. Verify Formulary Status: Review Cigna's formulary for tier placement
  3. Confirm Submission Method:
    • Fax: 855-840-1678
    • Online: CoverMyMeds portal
    • EHR: SureScripts integration
Tip: Call Cigna provider services at 1-800-88CIGNA to verify current submission requirements before sending your PA.

Appeals Playbook for Ohio

If your Soliris prior authorization is denied, Ohio provides multiple appeal levels:

Internal Appeals (Cigna)

Timeline: 180 days from denial date Process:

  1. Submit written appeal with additional documentation
  2. Standard review: 15 days
  3. Expedited review: 72 hours (if urgent)

External Review (Ohio Department of Insurance)

Timeline: 180 days after final internal denial Process:

  1. Request external review through Ohio Department of Insurance
  2. Independent Review Organization (IRO) assigned
  3. Decision timeline:
    • Standard: 30 days
    • Expedited: 72 hours
  4. IRO decision is binding on Cigna

Ohio External Review Statistics: Approximately 35-38% of external reviews result in reversal of insurer denials.

Appeal Template for Soliris

[Date]
Cigna Appeals Department
Re: Prior Authorization Appeal - Soliris (eculizumab)
Patient: [Name, DOB, Cigna ID]

I am appealing the denial of Soliris (eculizumab) for my patient with 
[diagnosis]. The denial was based on [reason from denial letter].

Medical Necessity Justification:
- Patient meets FDA-approved criteria for [indication]
- Required meningococcal vaccination completed [date]
- Prior therapies failed: [list with dates and reasons]
- Soliris is the only appropriate treatment due to [clinical rationale]

Attached documentation includes:
- Updated clinical notes
- Vaccination records
- Lab results confirming diagnosis
- Treatment history

Expedited review requested due to [urgent medical need].

[Provider signature and credentials]

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Soliris. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer's specific workflow.

Quick Audit Checklist

Before submitting any Soliris claim or prior authorization:

Coding Verification:

  • J1300 units calculated correctly (total mg ÷ 10)
  • NDC format is 11-digit HIPAA compliant
  • ICD-10 matches confirmed diagnosis
  • Required modifiers included

Documentation Complete:

  • Meningococcal vaccination proof (dated ≥2 weeks prior)
  • REMS enrollment verified
  • Medical necessity clearly stated
  • Prior therapy failures documented
  • Specialist confirmation attached

Submission Requirements:

  • Current Cigna form used
  • All required fields completed
  • Supporting documents attached
  • Submission method verified

FAQ

How long does Cigna prior authorization take for Soliris in Ohio? Standard requests: 15 days. Expedited requests: 72 hours. Mark urgent cases for faster review.

What if Soliris is non-formulary on my Cigna plan? Request a formulary exception through Cigna's exception process. Include clinical rationale for why covered alternatives aren't appropriate.

Can I request an expedited appeal in Ohio? Yes. Both Cigna internal appeals and Ohio external reviews offer expedited timelines (72 hours) if delay would jeopardize your health.

What happens if I miss the 180-day appeal deadline? You lose the right to internal and external appeals for that denial. File appeals promptly after receiving denial letters.

Does step therapy apply to Soliris? Cigna may require trials of other medications first. Request step therapy override with documentation of prior failures or contraindications.

How do I contact Ohio Department of Insurance for help? Call 1-800-686-1526 for consumer assistance with health coverage appeals and external review questions.

This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by plan. For personalized assistance with complex prior authorizations and appeals, Counterforce Health helps patients and clinicians navigate insurance denials with evidence-based appeals tailored to each payer's requirements.

Sources & Further Reading

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