By Counterforce Health Team in Soliris (eculizumab) —

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

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

Yes, Humana covers Soliris (eculizumab) in Pennsylvania, but requires strict prior authorization. The medication typically falls under Tier 5 (specialty tier) with 25-33% coinsurance. Your fastest path to approval: 1) Ensure meningococcal vaccination is completed at least 2 weeks before treatment, 2) Have your prescriber submit complete diagnostic documentation and REMS enrollment proof to Humana Clinical Pharmacy Review, 3) If denied, you have 65 days to appeal internally, then 4 months for Pennsylvania's external review process that overturns ~50% of denials.

Start today: Contact your prescriber to confirm they're enrolled in the Soliris REMS program and gather all required lab results and prior therapy documentation.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Documentation Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy Network
  9. Pennsylvania External Review
  10. Troubleshooting Common Issues

Coverage Basics

Is Soliris Covered by Humana?

Soliris (eculizumab) is covered by Humana Medicare Advantage and Part D plans in Pennsylvania, but it's classified as a high-cost specialty medication requiring prior authorization. The drug is typically placed on Tier 5 (specialty tier) of Humana's formulary, which means you'll pay coinsurance rather than a flat copay—usually 25-33% of the drug's cost.

Which Conditions Qualify?

Humana covers Soliris for FDA-approved indications:

  • Paroxysmal nocturnal hemoglobinuria (PNH) to reduce hemolysis
  • Atypical hemolytic uremic syndrome (aHUS) to inhibit complement-mediated thrombotic microangiopathy
  • Generalized myasthenia gravis (gMG) in adults who are anti-AChR antibody positive
  • Neuromyelitis optica spectrum disorder (NMOSD) in adults who are AQP4-antibody positive

Important: Soliris is not indicated for STEC-HUS (Shiga toxin E. coli-related hemolytic uremic syndrome).

Prior Authorization Process

Who Submits the Request?

Your prescriber must submit the prior authorization request to Humana Clinical Pharmacy Review. While patients can submit requests directly, provider submission is standard for specialty medications like Soliris.

How to Submit

Prescribers can submit via:

  • Humana provider portal (fastest option)
  • Fax: Check current fax number on Humana's provider portal
  • Phone: Contact Humana Clinical Pharmacy Review directly
Tip: Humana has committed to processing 95% of electronic prior authorization requests within one business day, making the online portal your best bet for speed.

Required REMS Program Compliance

Before prescribing Soliris, your doctor must be enrolled in the ULTOMIRIS and SOLIRIS REMS program due to the risk of life-threatening meningococcal infections. Key requirements include:

  • Prescriber enrollment at UltSolREMS.com or by calling 1-888-765-4747
  • Patient counseling about infection risks and providing a Patient Safety Card
  • Meningococcal vaccination (both MenACWY and MenB) at least 2 weeks before first dose
  • Antibiotic prophylaxis if urgent treatment can't wait for vaccination

Timing and Urgency

Standard Timeline

  • Electronic submissions: Decision within 1 business day (95% of cases)
  • Other submissions: Up to 30 days for pre-service decisions
  • Payment decisions: Up to 60 days

Expedited Reviews

For urgent situations where delay could jeopardize your health:

  • Standard expedited: 72 hours or less
  • Life-threatening situations: 24 hours

Your prescriber must provide clinical justification for expedited processing and may need to complete a Physician Certification for Expedited Review.

Documentation Criteria

Essential Documentation by Condition

For PNH:

  • Flow cytometry results demonstrating PNH clones
  • Elevated LDH levels
  • Transfusion history (if applicable)
  • Evidence of hemolysis

For aHUS:

  • Complement testing results
  • Genetic analysis (if available)
  • Exclusion of STEC-HUS and TTP
  • Evidence of thrombotic microangiopathy

For Generalized Myasthenia Gravis:

  • Positive anti-AChR antibody test results
  • Clinical assessment confirming generalized symptoms
  • Prior therapy trials and outcomes

For NMOSD:

  • Positive AQP4 antibody test
  • MRI findings consistent with NMOSD
  • Clinical history supporting diagnosis

Universal Requirements

All requests must include:

  • Definitive diagnosis with supporting lab results
  • Meningococcal vaccination records or documentation of prophylactic antibiotics
  • Complete treatment history including prior therapies tried, duration, and reasons for discontinuation
  • Provider's medical necessity statement
  • REMS program enrollment confirmation

Costs and Financial Assistance

Humana Coverage Details

As a Tier 5 specialty medication, Soliris typically requires:

  • 25-33% coinsurance (not a flat copay)
  • Prior authorization (always required)
  • Specialty pharmacy dispensing for most plans

Given Soliris' high cost (potentially $500,000+ annually), even with coinsurance, your out-of-pocket expenses could be substantial until you reach Medicare's catastrophic coverage threshold.

Financial Assistance Options

  • Alexion Access Navigator: Patient support program offering financial assistance and care coordination
  • Medicare Extra Help: Low-income subsidy program that can significantly reduce costs
  • State pharmaceutical assistance programs in Pennsylvania
  • Patient advocacy organizations for rare disease support

Denials and Appeals

Common Denial Reasons

Denial Reason How to Address
Insufficient diagnostic documentation Submit complete lab results, imaging, and clinical notes
Missing vaccination records Provide proof of meningococcal vaccination or antibiotic prophylaxis plan
REMS non-compliance Confirm prescriber enrollment and patient counseling documentation
Alternative therapy not tried Document contraindications or failures of required step therapy
Non-formulary status Request formulary exception with clinical justification

Humana Internal Appeals Process

If your initial request is denied:

  1. Internal Appeal (Level 1)
    • Timeline: 65 days from denial notice
    • Method: Submit via Humana member portal, phone, or mail
    • Required: Copy of denial letter, additional supporting documentation
  2. Internal Appeal (Level 2)
    • Timeline: 60 days from Level 1 decision
    • Process: Automatic review by different personnel
    • Expedited option: Available for urgent situations

Scripts for Common Situations

Calling Humana about PA Status: "Hello, I'm calling to check the status of a prior authorization request for Soliris, eculizumab, for [patient name], member ID [number]. Can you tell me if additional documentation is needed and the expected decision timeline?"

Requesting Peer-to-Peer Review: "I'm requesting a peer-to-peer review for the denied Soliris prior authorization. The patient has [specific condition] with [key clinical findings], and this medication is medically necessary because [brief rationale]. When can we schedule the clinical discussion?"

Pennsylvania External Review

Pennsylvania offers one of the strongest consumer protection systems in the country for appealing insurance denials. If Humana denies your Soliris coverage after internal appeals, you can request an independent external review through the Pennsylvania Insurance Department.

Key Benefits of PA's System

  • High success rate: ~50% of external appeals are overturned in favor of patients
  • Binding decisions: If the independent reviewer approves coverage, Humana must comply
  • State oversight: Pennsylvania directly manages the process (not federal contractors)

External Review Process

  1. Complete internal appeals first and receive Final Adverse Benefit Determination
  2. Submit external review request within 4 months via PA.gov external review portal
  3. Standard timeline: 45 days for decision
  4. Expedited timeline: 72 hours for urgent cases

Required Documentation

  • Humana's final denial letter
  • All prior appeal correspondence
  • Medical records supporting the need for Soliris
  • Physician statement of medical necessity
  • For expedited review: Physician Certification for Expedited Review
From our advocates: We've seen several Pennsylvania patients successfully overturn Soliris denials through external review by focusing on the specific diagnostic criteria in their cases. The key is presenting clear lab results that definitively establish the diagnosis alongside documentation showing why alternative treatments aren't appropriate. While outcomes vary, thorough preparation significantly improves your chances.

Renewal Requirements

Soliris prior authorization must be renewed annually. Humana requires updated documentation showing:

  • Continued medical necessity for the specific indication
  • Clinical response to treatment or lack of suitable alternatives
  • Updated lab results relevant to your condition
  • Ongoing REMS compliance including current vaccination status
  • Review of any new contraindications or safety concerns

Pro tip: Start your renewal process 30-60 days before your current authorization expires to avoid treatment interruptions.

Specialty Pharmacy Network

Soliris is typically covered under Humana's medical benefit (Part B or Medicare Advantage) rather than the pharmacy benefit due to its intravenous administration. This means:

  • Infusion center administration is usually required
  • In-network facility must be used for coverage
  • Site of care requirements may apply
  • Different cost-sharing rules than retail pharmacy medications

Verify that your planned infusion site is in Humana's network before starting treatment.

Troubleshooting Common Issues

Portal Problems

If Humana's provider portal is down or not accepting your submission, try:

  • Fax submission as backup
  • Phone submission with case number documentation
  • Email confirmation of any verbal submissions

Missing Forms

All current Humana prior authorization forms are available on their provider portal. If you can't locate the specific Soliris form, contact Humana Clinical Pharmacy Review directly.

Urgent Situations

If you need Soliris urgently and prior authorization is pending:

  • Request expedited review with clinical justification
  • Consider emergency/temporary coverage options
  • Document all communications for potential appeals

When to Contact Pennsylvania Regulators

If you encounter problems with Humana's appeals process or believe they're not following proper procedures, contact:

  • Pennsylvania Insurance Department Consumer Services Bureau
  • File a complaint if appeals timelines aren't met
  • Request assistance with the external review process

The Pennsylvania Insurance Department has been proactive in protecting consumers' rights and can provide guidance on your specific situation.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling appeals that align with each payer's specific requirements, potentially saving months of back-and-forth communication.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Soliris in Pennsylvania? A: Electronic submissions typically receive decisions within 1 business day. Other methods may take up to 30 days for pre-service decisions.

Q: What if Soliris is non-formulary on my Humana plan? A: You can request a formulary exception by providing clinical justification for why covered alternatives aren't appropriate for your specific condition.

Q: Can I request an expedited appeal in Pennsylvania? A: Yes, both Humana internal appeals and Pennsylvania external reviews offer expedited options for urgent medical situations.

Q: Does step therapy apply if I've tried treatments outside Pennsylvania? A: Yes, prior therapy documentation from any location is typically accepted, but you'll need complete medical records showing what was tried and why it failed.

Q: What happens if I start Soliris before vaccination is complete? A: Your prescriber must provide antibiotic prophylaxis for at least 2 weeks and document the urgent medical necessity that couldn't wait for vaccination.

Q: How much will I pay for Soliris with Humana coverage? A: As a Tier 5 medication, you'll typically pay 25-33% coinsurance. Given the high cost, consider financial assistance programs and Medicare Extra Help if eligible.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and requirements can change. Always verify current policies with Humana and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals in Pennsylvania, consider contacting the Pennsylvania Health Law Project or other qualified patient advocacy organizations.

If you need help turning a Soliris denial into a successful appeal, Counterforce Health specializes in creating evidence-based appeals that address payers' specific coverage criteria and procedural requirements.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.