By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Humana in Georgia: Complete Coding, Authorization & Appeals Guide

Quick Answer: Getting Soliris (Eculizumab) Covered by Humana in Georgia

Soliris (eculizumab) requires prior authorization from Humana for all FDA-approved conditions. The fastest path: ensure meningococcal vaccination ≥2 weeks prior, gather diagnostic labs (flow cytometry for PNH, AQP4-IgG for NMOSD), and submit through CenterWell Specialty Pharmacy with proper ICD-10 coding. Use D59.5 for PNH, G36.0 for NMOSD, G70.00/01 for myasthenia gravis. If denied, you have 65 days to appeal internally, then escalate to federal Medicare review. Start today: Call Humana member services to verify coverage and get the Soliris-specific fax form.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Soliris Conditions
  3. HCPCS, J-Codes, and NDC Requirements
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls to Avoid
  6. Verifying Codes with Humana
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Georgia
  9. Cost Assistance Options
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Soliris (eculizumab) falls under Medicare Part B medical benefit when administered by healthcare providers, not Part D pharmacy coverage. This distinction matters for Humana Medicare Advantage plans in Georgia.

Key Billing Pathway:

  • Medical claims: Use CMS-1500 or UB-04 forms with HCPCS J-codes
  • Administration: Pair with IV infusion codes (96365 for initial ≤1 hour)
  • Revenue codes: 0636 (drugs) or 0510 (clinic) for facility billing
Note: Humana follows CMS Coverage Database guidelines for physician-administered biologics like Soliris.

ICD-10 Mapping for Soliris Conditions

Accurate diagnosis coding is crucial for Humana prior authorization approval. Here are the primary ICD-10 codes:

Condition ICD-10 Code Documentation Requirements
Paroxysmal Nocturnal Hemoglobinuria (PNH) D59.5 Flow cytometry showing CD55/CD59 deficiency; LDH >1.5x ULN; transfusion dependence
Atypical HUS D59.3 Microangiopathic hemolytic anemia; thrombocytopenia <150,000/μL; no Shiga toxin
Myasthenia Gravis G70.00 (without exacerbation)
G70.01 (with exacerbation)		 Anti-AChR or anti-MuSK antibodies; inadequate response to ≥2 immunosuppressants
NMOSD G36.0 AQP4-IgG positive; core clinical characteristics per 2015 IPND criteria

Supporting Documentation Words: Include "complement-mediated," "refractory to," "inadequate response," and specific lab values in provider notes to strengthen medical necessity.

HCPCS, J-Codes, and NDC Requirements

Current J-Code Transition

Critical Update: Soliris J-codes changed April 1, 2025:

Effective Period HCPCS Code Dosage per Unit Example: 1200mg Dose
Before 4/1/2025 J1300 10 mg 120 units
On/After 4/1/2025 J1299 2 mg 600 units

Required Modifiers

  • RE: Full compliance with FDA REMS (required by Medicare)
  • JZ: Zero drug discarded (when applicable)
  • TB: 340B drug pricing program (informational)

NDC Format

Use 11-digit HIPAA format: N42568200010 for 300 mg/30 mL vial. Medicare and Medicaid require NDC on medical claims with HCPCS codes.

Clean Prior Authorization Request

Humana's Soliris PA Process:

  1. Verify coverage: Call member services with patient ID
  2. Use specific form: Download Humana's Soliris fax form
  3. Submit to: CenterWell Specialty Pharmacy (fax: 1-877-405-7940)
  4. Timeline: 30 days for pre-service decisions

Essential Documentation Package

Clinical Requirements:

  • Signed provider letter with ICD-10 diagnosis
  • Lab results confirming diagnosis (flow cytometry for PNH, AQP4-IgG for NMOSD)
  • Treatment history showing inadequate response to alternatives
  • Dosing/monitoring plan

Safety Requirements:

  • Proof of meningococcal vaccination (MenACWY and MenB) ≥2 weeks prior
  • REMS program enrollment confirmation
  • Patient safety counseling documentation
From our advocates: We've seen approvals accelerate when providers include specific lab values and vaccination dates in their initial submission, rather than generic statements about "appropriate vaccination." Insurance reviewers appreciate concrete documentation.

Common Coding Pitfalls to Avoid

Unit Conversion Errors

Wrong: Billing 1200 mg as 1200 units under J1299 (2 mg per unit) Correct: 1200 mg ÷ 2 mg = 600 units

Mismatched Date Ranges

Using J1300 for dates of service after March 31, 2025 will result in automatic denials.

Missing NDC

Medicare requires both HCPCS and NDC on the same claim line. Omitting NDC is a frequent rejection cause.

Incomplete Vaccination Documentation

Stating "appropriately vaccinated" without specific dates and vaccine types leads to delays.

Verifying Codes with Humana

Before submitting:

  1. Check formulary status: Soliris appears on Humana's 2025 Medicare Prior Authorization List
  2. Confirm current J-codes: Reference CMS updates for post-March 2025 billing
  3. Verify patient eligibility: Use Humana provider portal or call verification line

Cross-Reference Resources:

Pre-Submission Audit Checklist

Documentation Review:

  • ICD-10 code matches primary diagnosis
  • J-code appropriate for date of service
  • NDC matches vial size being billed
  • Units calculated correctly (mg ÷ mg per unit)
  • Vaccination proof includes dates and vaccine types
  • REMS enrollment documented
  • Provider signature and NPI included

Technical Check:

  • Form submitted to correct fax number
  • Patient ID and member number accurate
  • All required fields completed
  • Supporting documents attached

Appeals Process in Georgia

If Humana denies your Soliris request, Georgia residents follow federal Medicare appeals timelines:

Level 1: Humana Internal Appeal

  • Deadline: 65 days from denial notice
  • Decision timeframe: 30 days (pre-service) or 60 days (post-service)
  • Submit via: Availity Essentials portal (preferred) or mail
  • Required: Original denial notice, clinical records, medical necessity letter

Level 2: QIC Reconsideration

  • Deadline: 180 days from redetermination notice
  • Decision timeframe: 60 days
  • Process: Automatic escalation to Qualified Independent Contractor

Georgia-Specific Resources

While Medicare appeals don't go through Georgia DOI, you can contact the Georgia Office of Insurance at 404-656-2070 for guidance on non-Medicare coverage issues.

Expedited Appeals: Available for medically urgent situations; decided within 72 hours.

Cost Assistance Options

Soliris costs exceed $500,000 annually, making financial assistance crucial:

Manufacturer Support:

  • Alexion OneSource patient assistance program
  • Copay assistance for eligible patients
  • REMS support and vaccination coordination

Foundation Grants:

  • HealthWell Foundation
  • Patient Access Network Foundation
  • Check eligibility based on diagnosis and income

Medicare Coverage:

  • Part B covers 80% after deductible
  • Medigap or Medicare Advantage may cover remaining 20%

FAQ

How long does Humana prior authorization take for Soliris in Georgia? Standard decisions take 30 days for pre-service requests. Expedited reviews are completed within 72 hours for urgent medical situations.

What if Soliris is non-formulary on my Humana plan? Humana supports formulary exceptions based on medical necessity. Submit documentation showing why formulary alternatives are inappropriate.

Can I appeal if I haven't tried step therapy medications? Yes, if you have contraindications or prior failures with required step therapy drugs. Document specific reasons why alternatives won't work.

Does Georgia have special external review rights for Medicare denials? Medicare appeals follow federal processes, not Georgia state external review. After Humana's internal appeal, cases escalate to federal QIC reconsideration.

What vaccination proof does Humana require? Documentation of MenACWY and MenB vaccines given ≥2 weeks before Soliris initiation, including specific dates and vaccine lot numbers.

How do I request an expedited appeal in Georgia? Contact Humana member services immediately and provide documentation that delay poses serious risk to your health. Expedited appeals are decided within 72 hours.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies specific denial reasons, and drafts point-by-point rebuttals using the right medical evidence and payer-specific requirements—making the appeals process more efficient for complex medications like Soliris.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies and requirements may change; verify current information with official sources before submitting requests.

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