By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Humana in Michigan: Prior Authorization Guide and Appeal Templates

Answer Box: Getting Soliris (Eculizumab) Covered by Humana in Michigan

Soliris requires prior authorization from Humana. Submit comprehensive clinical documentation including confirmed diagnosis (flow cytometry for PNH, antibody testing for gMG/NMOSD), vaccination records, and medical necessity justification. If denied, you have 65 days to appeal internally, then 127 days for external review through Michigan DIFS. Start today: Contact your prescriber to initiate the PA request via Humana's provider portal or fax to 877-486-2621.

Table of Contents

  1. Understanding Your Denial Letter
  2. Common Fixable Causes
  3. First-Level Appeal Strategy
  4. Peer-to-Peer Review
  5. Michigan External Review Process
  6. Appeal Templates and Scripts
  7. Tracking Your Appeal
  8. Medical Necessity Boosters
  9. If Your Appeal Fails

Coverage at a Glance: Soliris (Eculizumab) and Humana in Michigan

Requirement Details Where to Find Source
Prior Authorization Always required Humana Provider Portal Humana PA List
Coverage Type Part B (infusion) or Part D Depends on administration site Humana Drug Coverage
Vaccination Required MenACWY and MenB ≥2 weeks before ACIP guidelines FDA Label
Appeal Deadline 65 days from denial Member materials Humana Policy
External Review 127 days after internal denial Michigan DIFS Michigan PRIRA
Expedited Appeals 72 hours with physician letter Same as above DIFS Guidelines

Understanding Your Denial Letter

When Humana denies Soliris coverage, the letter will specify the exact reason. Common denial codes include:

  • Missing vaccination documentation - Most frequent cause
  • Insufficient diagnostic confirmation - Need flow cytometry for PNH or specific antibody tests
  • Site of care restrictions - Must use in-network infusion center
  • Step therapy requirements - May need to try alternatives first

Look for the appeal deadline (typically 65 days) and the member ID you'll need for all correspondence.

Note: Soliris denials often involve multiple issues. Address each reason systematically in your appeal.

Common Fixable Causes

Missing Vaccination Records

Humana requires proof of meningococcal vaccination (both MenACWY and MenB) completed at least 2 weeks before starting Soliris. If urgent, submit documentation of antibiotic prophylaxis.

Fix: Request vaccination records from your provider and submit via the Humana provider portal.

Incomplete Diagnostic Documentation

Each Soliris indication has specific requirements:

  • PNH: Flow cytometry showing ≥5% clone size, elevated LDH ≥1.5× ULN
  • Atypical HUS: Exclusion of Shiga toxin, TMA confirmation
  • Generalized MG: Anti-AChR antibody positive results
  • NMOSD: Anti-AQP4 antibody positive confirmation

Fix: Work with your specialist to compile comprehensive lab reports and diagnostic imaging.

Site of Care Issues

Soliris must be administered at an approved in-network infusion center, not at home or retail pharmacy locations.

Fix: Verify your infusion center's network status by calling Humana member services.

First-Level Appeal Strategy

What to Include in Your Appeal

  1. Complete member information (name, DOB, member ID)
  2. Detailed medical necessity letter from prescriber
  3. All diagnostic test results specific to your condition
  4. Vaccination documentation or prophylaxis records
  5. Prior treatment history and failures/intolerances
  6. Current clinical status and functional impairment

Structuring Your Medical Necessity Letter

Your prescriber should address:

  • Confirmed diagnosis with specific lab values
  • Disease severity and impact on daily functioning
  • Prior therapies attempted and reasons for failure
  • Clinical rationale for Soliris specifically
  • Treatment goals and expected outcomes
  • Monitoring plan for safety and efficacy

Submission Methods

  • Fastest: Humana provider portal (decisions within 1 business day)
  • Fax: 877-486-2621 (up to 7 days for decision)
  • Mail: Check your denial letter for specific address

Peer-to-Peer Review

If your initial appeal is denied, request a peer-to-peer review where your prescriber speaks directly with Humana's medical director.

Scheduling the Call

Contact Humana at the number on your denial letter and request a peer-to-peer review. Have your prescriber's schedule ready.

Prep Checklist for Your Doctor

  • Patient's complete medical history
  • Specific diagnostic criteria met
  • Failed prior therapies with dates and reasons
  • Current functional status and quality of life impact
  • Literature supporting Soliris use for your condition

Michigan External Review Process

If Humana upholds their denial after internal appeals, Michigan residents can request an independent external review through the Department of Insurance and Financial Services (DIFS).

Timeline and Process

  1. File within 127 days of Humana's final internal denial
  2. Submit online at Michigan DIFS External Review or call 877-999-6442
  3. Standard review: Decision within 60 days
  4. Expedited review: Decision within 72 hours (requires physician letter stating delay would seriously jeopardize health)

Required Documentation

  • Copy of original denial letter
  • All medical records supporting your case
  • Physician statement of medical necessity
  • DIFS external review form (available online)

The Independent Review Organization's decision is binding on Humana - if they overturn the denial, Humana must provide coverage.

Appeal Templates and Scripts

Patient Phone Script for Humana

"Hello, I'm calling about a prior authorization denial for Soliris. My member ID is [ID number]. I'd like to file an appeal and request information about the peer-to-peer review process. Can you please connect me with someone who can help start this process?"

Email Template for Medical Records

"Dear [Provider Name], I need comprehensive medical records for my Humana appeal for Soliris coverage, including: diagnostic test results, vaccination records, prior treatment history, and current clinical notes. The appeal deadline is [date]. Please send these directly to Humana at [fax number] with a copy to me. Thank you."

Tracking Your Appeal

Create a simple log to track your appeal progress:

Date Action Taken Contact Method Response Received Next Step
PA submitted Provider portal Await decision
Appeal filed Fax 7-day response expected
Peer-to-peer requested Phone Scheduling callback

Set calendar reminders for all deadlines - missing them can forfeit your appeal rights.

Medical Necessity Boosters

Guideline Citations

Reference established treatment guidelines in your appeal:

  • PNH: International PNH Interest Group recommendations
  • Atypical HUS: Kidney Disease: Improving Global Outcomes (KDIGO) guidelines
  • Myasthenia Gravis: American Academy of Neurology practice parameters
  • NMOSD: American Academy of Neurology guidelines

Document Functional Impairment

Include specific examples of how your condition affects daily activities:

  • Inability to work or attend school
  • Difficulty with basic self-care
  • Frequent hospitalizations or transfusions
  • Quality of life measures and validated scales

Safety Considerations

Highlight any contraindications to alternative treatments or previous adverse events that make Soliris the safest option.

If Your Appeal Fails

Alternative Coverage Options

  • Formulary exceptions for similar medications
  • Quantity limit overrides if dosing differs from standard
  • Patient assistance programs through Alexion Access Navigator
  • State pharmaceutical assistance programs in Michigan

Filing a Regulatory Complaint

Contact Michigan DIFS at 877-999-6442 if you believe Humana violated state insurance regulations during the appeals process.

Clinician Corner: Medical Necessity Letter Essentials

Healthcare providers should ensure their letters include:

✓ Specific diagnosis with ICD-10 codes
✓ Diagnostic test results with dates and values
✓ Complete prior treatment history
✓ Current functional status assessment
✓ Treatment goals and monitoring plan
✓ Literature supporting Soliris use
✓ Statement of medical necessity

From Our Advocates: "We've seen appeals succeed when providers include specific functional assessments and quality of life measures. A letter stating 'patient needs Soliris' isn't enough - document exactly how the condition impacts their daily life and why alternatives won't work."

FAQ: Soliris Coverage by Humana in Michigan

How long does Humana prior authorization take in Michigan?
Electronic submissions through the provider portal typically receive decisions within 1 business day. Fax submissions may take up to 7 days for standard requests.

What if Soliris isn't on Humana's formulary?
You can request a formulary exception by demonstrating medical necessity and showing that preferred alternatives are ineffective or contraindicated.

Can I request an expedited appeal in Michigan?
Yes, both Humana and Michigan DIFS offer expedited reviews when delays would seriously jeopardize your health. You'll need a physician letter confirming urgency.

Does step therapy apply if I've tried alternatives outside Michigan?
Yes, document all prior therapies regardless of where they were tried. Humana will consider your complete treatment history.

What happens if I miss the appeal deadline?
Missing deadlines can forfeit your appeal rights. Contact Humana immediately if you're approaching a deadline - they may grant extensions in exceptional circumstances.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and creates targeted, evidence-backed appeals that align with each payer's requirements and procedural standards.

Getting Soliris covered requires persistence and thorough documentation, but Michigan residents have strong appeal rights through both Humana's internal process and the state's external review system. The key is acting quickly, gathering comprehensive evidence, and working closely with your healthcare team throughout the process.

Sources and Further Reading

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals, contact Michigan DIFS at 877-999-6442.

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