By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Humana in Ohio: Complete Guide to Prior Authorization and Appeals

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

Soliris (eculizumab) requires prior authorization from Humana in Ohio. The fastest path: submit via Availity Essentials portal with complete medical documentation including diagnosis confirmation, vaccination records, and medical necessity letter. Humana has 7 days to respond for standard requests. If denied, you have 65 days to appeal internally, then 180 days for Ohio external review through the Department of Insurance.

First step today: Verify your Humana plan covers Soliris, gather vaccination records (especially meningococcal), and have your doctor prepare clinical documentation supporting medical necessity.

Table of Contents

  1. Verify Your Humana Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Process
  4. Medical Necessity Requirements
  5. Appeals Process in Ohio
  6. Specialty Pharmacy Coordination
  7. Support Contacts and Resources
  8. Common Denial Reasons and Solutions
  9. FAQ

Verify Your Humana Plan and Coverage

Before starting the prior authorization process, confirm your specific Humana plan details:

Coverage Verification Steps:

  1. Check your member ID card for plan type (Medicare Advantage, Part D, commercial, or Ohio Medicaid)
  2. Call Member Services at the number on your card to verify Soliris coverage
  3. Review your formulary - Soliris may be non-formulary, requiring additional documentation
Note: Humana's Medicare Advantage plans in Ohio have a relatively low prior authorization denial rate of approximately 3.5% (2023), but specialty drugs like Soliris face stricter review due to their high cost (often exceeding $500,000 annually).

Required Forms and Documentation

Prior Authorization Request

Primary Form: Download Humana's prior authorization form through the Availity Essentials portal or contact your provider's office.

Essential Documentation:

  • Member Humana ID, name, and date of birth
  • Diagnosis codes (ICD-10) for approved indications:
    • PNH (Paroxysmal Nocturnal Hemoglobinuria)
    • Atypical HUS (Hemolytic Uremic Syndrome)
    • Generalized Myasthenia Gravis (AChR-positive)
    • NMOSD (Neuromyelitis Optica Spectrum Disorder, AQP4-positive)
  • Prescribing provider NPI and facility information
  • Meningococcal vaccination records (required ≥2 weeks before treatment)

Medical Necessity Letter Checklist

Your prescriber should include:

  • Confirmed diagnosis with supporting lab results (flow cytometry, complement testing)
  • Prior treatment history and failures/intolerances
  • Clinical rationale citing FDA labeling or peer-reviewed guidelines
  • Dosing plan and monitoring schedule
  • Alternative therapy assessment and why they're inappropriate

Submission Portals and Process

Electronic Submission (Preferred)

Availity Essentials Portal:

  • Register at Availity.com
  • Navigate to prior authorization section
  • Upload all supporting documentation
  • Response time: 7 days for standard requests, 24-72 hours for expedited

Phone Alternative:

  • Humana Pharmacy Prior Authorization: 800-523-0023
  • For urgent requests, specify expedited review needed

Submission Tips

Tip: Include all clinical documentation with your initial submission. Incomplete requests delay approval and may result in automatic denials.

Required Attachments:

  • Complete medical records
  • Laboratory results confirming diagnosis
  • Vaccination documentation
  • Prior therapy documentation
  • Provider attestation letter

Medical Necessity Requirements

Humana evaluates Soliris requests based on FDA-approved indications and clinical guidelines:

Condition Required Documentation Key Criteria
PNH Flow cytometry results, LDH levels Clone size >10%, transfusion dependence or thrombosis
Atypical HUS Complement studies, ADAMTS13 Complement-mediated, not infection-related
Myasthenia Gravis AChR antibodies, clinical severity Generalized disease, inadequate response to standard therapy
NMOSD AQP4 antibodies, MRI findings Confirmed diagnosis, relapsing disease

Vaccination Requirements

Critical: Soliris increases meningococcal infection risk. Humana requires:

  • Meningococcal vaccination ≥2 weeks before starting treatment
  • Current vaccination records in submission
  • If urgent treatment needed, antibiotic prophylaxis plan

Appeals Process in Ohio

Internal Appeal (First Level)

Timeline: 65 days from denial notice Process: Submit redetermination request with additional clinical evidence Decision time: 7 days for standard, 72 hours for expedited

Appeal Form: Available through your Humana member portal or by calling Member Services.

Ohio External Review (Second Level)

If Humana upholds the denial, Ohio residents can request external review:

Timeline: 180 days from final internal denial Process: Request through Humana, who forwards to Ohio Department of Insurance Review body: Independent Review Organization (IRO) Decision time: 30 days standard, 72 hours expedited Cost: Free to patient

Ohio Department of Insurance Contact:

Specialty Pharmacy Coordination

Soliris requires specialty pharmacy dispensing and infusion center administration:

Enrollment Process

  1. Prior authorization approval must be obtained first
  2. CenterWell Specialty Pharmacy (Humana's preferred) will contact you
  3. Infusion site coordination - ensure facility is in-network
  4. Patient education on administration and monitoring

Transfer from Another Pharmacy

If switching to Humana coverage:

  • Provide current prescription and medical records
  • Coordinate timing to avoid treatment gaps
  • Verify new infusion site network status

Support Contacts and Resources

Humana Contact Numbers

  • Member Services: Number on your ID card
  • Provider Services: 800-457-4708
  • Pharmacy Prior Authorization: 800-523-0023

Ohio-Specific Resources

  • Ohio Department of Insurance: 800-686-1526
  • OSHIIP (Medicare help): 800-686-1578
  • UHCAN Ohio (advocacy): Consumer assistance for appeals

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Missing vaccination Submit proof of meningococcal vaccine Vaccination records ≥2 weeks old
Insufficient diagnosis confirmation Provide definitive test results Flow cytometry, genetic testing, antibody results
Site of care restrictions Verify in-network infusion center Provider network verification
Step therapy not met Document prior therapy failures Treatment history, adverse events
Quantity limits Justify dosing based on weight/severity Clinical notes, dosing calculations

FAQ

How long does Humana prior authorization take in Ohio? Standard requests: 7 days. Expedited requests: 24-72 hours if urgency is documented.

What if Soliris is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Include why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if treatment delay would seriously jeopardize your health. Your doctor must provide clinical justification for urgency.

Does step therapy apply if I've tried treatments outside Ohio? Yes, document all prior therapies regardless of location. Include dates, outcomes, and reasons for discontinuation.

What happens if Humana denies my appeal? You can request Ohio external review within 180 days. The Independent Review Organization provides binding decisions.

Are there financial assistance programs for Soliris? Yes, Alexion offers patient assistance programs. Contact their support line or visit their website for eligibility requirements.

When Coverage Gets Complicated

Navigating insurance approvals for rare disease treatments like Soliris can feel overwhelming, especially when dealing with prior authorization requirements and potential denials. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, targeted rebuttals that address each plan's specific requirements. Their platform analyzes denial letters and plan policies to identify the exact basis for denial, then drafts point-by-point appeals using the right clinical evidence and procedural requirements for each payer.

From Our Advocates: "We've seen many Soliris approvals succeed when the initial submission includes comprehensive vaccination documentation and clear diagnostic confirmation. One common mistake is submitting incomplete flow cytometry results for PNH cases - make sure the clone size and clinical correlation are clearly documented. While every case is different, thorough preparation of the medical necessity letter often makes the difference between approval and denial."

For additional support with complex approvals, Counterforce Health's platform can help ensure your appeal addresses Humana's specific criteria while meeting Ohio's procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For official Ohio insurance regulations and consumer assistance, contact the Ohio Department of Insurance at 800-686-1526.

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