By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Cigna in Washington: Complete Prior Authorization Guide and Appeal Process

Answer Box: Getting Soliris Covered by Cigna in Washington

To get Soliris (eculizumab) covered by Cigna in Washington, you need: (1) Complete prior authorization with diagnosis confirmation, vaccination records, and specialist documentation; (2) Submit via Cigna's provider portal or fax to 855.840.1678; (3) If denied, use Washington's strong external review process through the Insurance Commissioner within 180 days. Start today: Contact your specialist to gather required clinical documentation and confirm meningococcal vaccination status. Washington residents have binding external review rights that often overturn initial denials.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Checklist
  4. Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Setup
  7. After Submission: Tracking Your Request
  8. Appeals Process in Washington
  9. Common Denial Reasons & Solutions
  10. Cost Assistance Programs
  11. Frequently Asked Questions

Who Should Use This Guide

This guide is for Washington residents with Cigna coverage who need Soliris (eculizumab) for FDA-approved conditions: paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis with positive acetylcholine receptor antibodies, or neuromyelitis optica spectrum disorder with positive aquaporin-4 antibodies.

Expected outcome: With proper documentation, most clinically appropriate requests get approved. If initially denied, Washington's external review process has helped many patients access rare disease medications through independent medical review.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage with prescription benefits
  • Prior authorization required for all Soliris indications
  • Specialty pharmacy mandate: Must use Cigna's preferred specialty pharmacy (typically Accredo)
  • Site of care restrictions: Cigna may require justification for infusion location

Plan Type Considerations

  • Commercial plans: Follow standard PA process outlined below
  • Medicare Advantage: Similar requirements with potential additional documentation
  • Self-funded employer plans: May have different appeal rights (contact U.S. Department of Labor if needed)

Clinical Criteria Checklist

Diagnosis-Specific Requirements

Condition Required Documentation Specialist Requirement
PNH Flow cytometry showing GPI-anchored protein deficiency Hematologist
aHUS Clinical diagnosis; rule out Shiga toxin E. coli HUS Hematologist/Nephrologist
gMG AChR+ antibodies, MG-ADL score ≥6, MGFA class II-IV Neurologist
NMOSD AQP4+ antibodies, clinical evidence Neurologist

Universal Requirements

Step Therapy Requirements

  • PNH/aHUS: No step therapy typically required (first-line treatment)
  • gMG/NMOSD: Must document failure/intolerance of ≥2 immunosuppressive therapies

Documentation Requirements

Medical Necessity Letter Components

Your specialist should include:

  1. Confirmed diagnosis with supporting test results
  2. Disease severity and functional impact
  3. Prior treatments attempted and outcomes
  4. Clinical rationale for Soliris specifically
  5. Treatment goals and monitoring plan
  6. Vaccination status and safety considerations

Required Attachments

  • Recent laboratory results
  • Imaging studies (if applicable)
  • Prior therapy documentation
  • Vaccination records
  • Specialist consultation notes
Tip: Incomplete documentation is the #1 cause of delays. Ensure all required elements are included before submission.

Submission Process

Step-by-Step Submission

  1. Download current PA form from Cigna provider resources
  2. Complete all required fields (patient info, diagnosis codes, clinical rationale)
  3. Attach supporting documentation listed above
  4. Submit via:
    • Fax: 855.840.1678
    • Online: CoverMyMeds portal
    • EHR integration: If available
  5. For urgent cases: Call 800.882.4462 after submission

Timeline Expectations

  • Standard review: 72 hours to 5 business days
  • Expedited review: 24-72 hours (for urgent medical situations)
  • Additional information requests: May extend timeline by 5-10 days

Specialty Pharmacy Setup

Accredo Enrollment Process

  1. Prescriber completes Accredo enrollment form
  2. Fax to Accredo: 888.302.1028
  3. Patient receives welcome call for insurance verification
  4. Coordinate shipment and nursing support if needed

Transfer from Another Pharmacy

  • New prescription required (cannot transfer specialty medications)
  • Coordinate timing to avoid treatment gaps
  • Verify insurance approval before shipment

After Submission: Tracking Your Request

What to Track

  • Confirmation number from submission
  • Review timeline (standard vs. expedited)
  • Additional information requests
  • Decision notification method

Status Check Schedule

  • Day 3: If no confirmation received, call Cigna
  • Day 7: Follow up if no decision
  • Day 14: Escalate if still pending

Appeals Process in Washington

Washington residents have strong appeal rights that often result in coverage approval for medically necessary treatments.

Internal Appeals with Cigna

Appeal Level Timeline to File Cigna Decision Time Requirements
First Level 180 days from denial 30 days (72h expedited) Appeal letter + clinical documentation
Second Level Within 180-day window 30 days Additional evidence recommended
Peer-to-Peer Within 30 days of denial Immediate discussion Doctor-to-doctor review

External Review (Washington State)

After exhausting internal appeals, you can request binding external review:

  • File within: 180 days of final Cigna denial
  • Contact: Washington Insurance Commissioner at 1-800-562-6900
  • Decision timeline: 30 days (72 hours expedited)
  • Cost: Free to patient
  • Outcome: Binding on Cigna if overturned
From our advocates: We've seen many Washington patients successfully overturn Cigna denials for rare disease medications through external review. The key is providing comprehensive clinical evidence that demonstrates medical necessity according to current treatment guidelines, not just the insurer's internal policies.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Missing vaccination proof Submit vaccination records Meningococcal vaccine documentation
Incomplete diagnosis confirmation Provide definitive test results Flow cytometry (PNH), antibody tests (gMG/NMOSD)
Insufficient prior therapy documentation Detail previous treatments Medication lists, response/intolerance notes
Site of care not approved Justify infusion location Medical necessity for specific setting
Not medically necessary Strengthen clinical rationale Updated specialist letter, guidelines citations

Cost Assistance Programs

Manufacturer Support

  • Alexion Access Navigator: Patient support services
  • Copay assistance: May be available for commercially insured patients
  • Free drug programs: For uninsured/underinsured patients

State and Foundation Resources

  • Washington Apple Health: Medicaid coverage for eligible residents
  • Patient Access Network Foundation: Grants for specialty medications
  • HealthWell Foundation: Copay assistance programs

Counterforce Health helps patients navigate insurance denials by creating targeted, evidence-based appeals that turn rejections into approvals. Our platform analyzes your specific denial and generates customized appeal letters that address payer requirements while incorporating the latest clinical evidence.

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Soliris in Washington? A: Standard reviews take 72 hours to 5 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

Q: What if Soliris is non-formulary on my plan? A: You can request a formulary exception through the same PA process, providing medical necessity justification for why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal in Washington? A: Yes, both Cigna internal appeals and Washington external reviews offer expedited timelines (72 hours) for cases where health could be in serious jeopardy.

Q: Does step therapy apply if I've tried treatments outside Washington? A: Yes, prior therapy documentation from any location counts toward step therapy requirements. Ensure your specialist includes detailed records of previous treatments.

Q: What happens if the external review upholds Cigna's denial? A: The external review decision is final for insurance purposes, but you can still contact the Washington Insurance Commissioner for guidance or consider legal consultation.

Q: Do I need a specialist to prescribe Soliris? A: Yes, Cigna requires prescription by or consultation with relevant specialists: hematologists for PNH/aHUS, neurologists for gMG/NMOSD.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. Always consult with your healthcare provider and insurance plan directly. For personalized assistance with appeals and prior authorizations, consider working with Counterforce Health to maximize your chances of approval.

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