By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by UnitedHealthcare in Virginia: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Soliris (Eculizumab) Covered by UnitedHealthcare in Virginia

UnitedHealthcare requires prior authorization for Soliris (eculizumab) under the medical benefit (HCPCS J1299) with diagnosis-specific criteria including lab confirmation, failed prior therapies, and REMS compliance. Submit PA via UnitedHealthcare provider portal or fax to 1-844-403-1028. If denied, you have 180 days for internal appeals and 120 days for Virginia State Corporation Commission external review using Form 216-A. Start today: Verify your diagnosis meets UnitedHealthcare's criteria and gather vaccination records.

Table of Contents

  1. Verify Your Plan and Find the Right Policy
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Digital Tools
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Network and Transfers
  6. Support Lines and Contact Information
  7. Virginia External Review and Consumer Resources
  8. Appeals Playbook for UnitedHealthcare Denials
  9. Common Denial Reasons and Solutions
  10. FAQ: Soliris Coverage Questions

Verify Your Plan and Find the Right Policy

Before starting your Soliris prior authorization, confirm your specific UnitedHealthcare plan type and coverage details. Soliris (eculizumab) is covered under UnitedHealthcare's medical benefit, not pharmacy benefit, which affects where you submit requests.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all indications UHC Provider Portal UHC Medical Policy
Formulary Status Medical benefit (HCPCS J1299) Provider portal drug lookup UHC Specialty Drug List
Step Therapy Biosimilars preferred over brand Medical policy documents UHC Complement Inhibitors Policy
REMS Compliance Meningococcal vaccination required FDA prescribing information FDA Access Data
Appeals Deadline 180 days from denial notice Member handbook Virginia Insurance Code

Log into the UnitedHealthcare Provider Portal to access current medical policies and confirm your patient's specific plan requirements. The complement inhibitors policy (updated September 2025) outlines coverage criteria for Soliris across PNH, aHUS, generalized myasthenia gravis, and NMOSD.

Prior Authorization Forms and Requirements

UnitedHealthcare uses OptumRx for specialty drug prior authorizations, even for medical benefit drugs like Soliris. No drug-specific form exists—use the general OptumRx PA Request Form.

Required Clinical Documentation

For PNH (Paroxysmal Nocturnal Hemoglobinuria):

  • Flow cytometry confirming PNH clones
  • Elevated LDH (>1.5x upper limit of normal)
  • Low haptoglobin levels
  • ICD-10: D59.5

For aHUS (Atypical Hemolytic Uremic Syndrome):

  • Exclusion of STEC-HUS and TTP
  • Evidence of thrombotic microangiopathy
  • Renal function labs
  • ICD-10: D59.32, D59.39

For Generalized Myasthenia Gravis:

  • Positive anti-AChR antibody test
  • MGFA Class II-IV severity
  • Failure of ≥2 immunosuppressants over 12 months
  • ICD-10: G70.00

For NMOSD (Neuromyelitis Optica Spectrum Disorder):

  • Positive AQP4 antibody
  • ≥1 documented attack
  • Multiple sclerosis ruled out
  • Neurologist diagnosis

REMS Documentation Requirements

All Soliris requests must include proof of meningococcal vaccination completed ≥2 weeks before treatment initiation. If vaccination is contraindicated, provide documentation of prophylactic antibiotic therapy and physician attestation of REMS program enrollment.

Clinician Corner: When writing your medical necessity letter, address each denial criterion specifically. Include exact lab values, dates of prior therapy trials, and specific reasons for treatment failures or contraindications. Reference FDA labeling and relevant clinical guidelines to strengthen your request.

Submission Portals and Digital Tools

Primary Submission Methods

UnitedHealthcare Provider Portal (Recommended):

  • Access at uhcprovider.com
  • Upload PA forms, clinical notes, and lab results
  • Real-time status tracking via TrackIt system
  • Instant confirmation of submission

CoverMyMeds Integration:

  • Search for "OptumRx" or "UnitedHealthcare"
  • Select Soliris from drug list
  • Electronic submission with status updates

Fax Submission:

  • Non-urgent requests: 1-844-403-1028 (CMS-Comm)
  • UnitedHealthcare specific: 1-844-403-1027
  • Include complete PA form and all supporting documents

Expedited Review Process

For urgent requests where standard timelines could jeopardize patient health, call 1-800-711-4555 to request expedited review. Provide clinical justification for urgency, such as:

  • Active hemolytic crisis in PNH
  • Rapid disease progression
  • Authorization expiring within 7 days

Specialty Pharmacy Network and Transfers

Soliris requires dispensing through UnitedHealthcare's specialty pharmacy network due to REMS requirements and cold-chain storage needs.

In-Network Specialty Pharmacies

  • Optum Specialty Pharmacy (preferred)
  • Accredo Health Group
  • AllianceRx Walgreens Pharmacy
  • CVS Caremark Specialty
  • Option Care Health (for infusion coordination)

Transfer Process Between Pharmacies

If you need to transfer from Accredo to Optum Specialty or another network pharmacy:

  1. Confirm PA Status: Verify current authorization via UHC provider portal
  2. Contact Current Pharmacy: Request prescription transfer to new pharmacy
  3. Enroll with New Pharmacy: Provide patient demographics, insurance details, and shipping address
  4. Coordinate with Infusion Site: Ensure drop-ship acceptance and cold storage capability
  5. Track Shipment: Monitor temperature-controlled delivery (typically 2-3 business days)

Patient Registration with Alexion

All Soliris patients must register with Alexion Customer Operations at 1-888-765-4747. This registration is required for drug dispensing and REMS compliance tracking.

Support Lines and Contact Information

UnitedHealthcare Contact Numbers

Provider Services: 1-800-711-4555

  • PA status inquiries
  • Expedited review requests
  • Technical portal support

Member Services: Number on back of insurance card

  • Coverage verification
  • Appeal status updates
  • General benefit questions

OptumRx Specialty: 1-800-711-4555

  • Specialty drug PA submissions
  • Clinical review status
  • Pharmacy network questions

What to Ask When Calling

For PA Status:

  • Reference number from submission
  • Expected decision timeline
  • Any missing documentation needed

For Denials:

  • Specific denial reason
  • Required documentation for appeal
  • Peer-to-peer review availability

For Appeals:

  • Internal appeal submission method
  • Required forms and deadlines
  • Expedited review criteria

Virginia External Review and Consumer Resources

Virginia provides robust consumer protections for health insurance appeals through the State Corporation Commission (SCC) Bureau of Insurance.

Virginia External Review Process

After exhausting UnitedHealthcare's internal appeals (both reconsideration and appeal levels), you have 120 days from the final denial notice to request external review.

Submit Form 216-A to:

  • Email: [email protected]
  • Mail: SCC Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Required Documents:

  • Completed Form 216-A (download from SCC website)
  • Final UnitedHealthcare denial letter
  • Medical records supporting medical necessity
  • Signed medical records release form

Timeline and Outcomes

  • Standard Review: 45 days for decision
  • Expedited Review: 72 hours if physician certifies serious health jeopardy
  • Success Rate: National average ~40-50% overturn rate with strong documentation
  • Cost: Free to consumers

Consumer Assistance

Virginia SCC Consumer Services: 1-877-310-6560

  • Pre-filing guidance on Form 216-A
  • Eligibility determination
  • Process explanation and timeline clarification

Virginia Managed Care Ombudsman: 1-877-310-6560

  • HMO and managed care plan assistance
  • Informal resolution attempts
  • Appeal rights education

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify specific denial reasons and draft point-by-point rebuttals aligned with payer requirements, incorporating the right clinical evidence and procedural documentation to maximize approval chances.

Appeals Playbook for UnitedHealthcare Denials

Internal Appeals Process

Level 1: Reconsideration (First Internal Appeal)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days standard, 72 hours expedited
  • Method: UHC provider portal, fax, or mail
  • Requirements: Denial letter, additional clinical documentation, provider support letter

Level 2: Appeal (Second Internal Appeal)

  • Deadline: Within 12-month total process window
  • Timeline: 15-20 business days
  • Method: Same as Level 1
  • Focus: Address specific denial reasons with new evidence

Peer-to-Peer Review

Request within 24 hours of denial via provider portal form. This allows direct physician-to-physician discussion of clinical necessity before formal appeals.

External Review (Final Step)

Submit Virginia SCC Form 216-A within 120 days of final internal denial. Independent medical review by board-certified specialists in relevant field.

Common Denial Reasons and Solutions

Denial Reason Required Documentation to Overturn
Diagnosis criteria not met Lab results, flow cytometry, antibody tests with reference ranges
Prior therapy requirements Detailed treatment history with dates, dosages, outcomes, and reasons for discontinuation
Missing REMS compliance Vaccination records, REMS enrollment confirmation, or contraindication documentation
Step therapy not completed Medical necessity for brand over biosimilar with clinical justification
Insufficient medical necessity Comprehensive clinical notes, treatment goals, monitoring plan, and guideline references

Scripts for Common Scenarios

Patient calling for PA status: "Hello, I'm calling to check the status of a prior authorization for Soliris, eculizumab, for [patient name], member ID [number]. Can you tell me the current status and if any additional information is needed?"

Provider requesting peer-to-peer: "I need to request a peer-to-peer review for a Soliris denial for my patient with [diagnosis]. The case involves [brief clinical summary]. When can we schedule this discussion?"

FAQ: Soliris Coverage Questions

Q: How long does UnitedHealthcare prior authorization take for Soliris in Virginia? A: Standard PA decisions are made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Soliris is non-formulary on my plan? A: Soliris is covered under the medical benefit, not pharmacy formulary. Step therapy may apply, requiring trial of preferred biosimilars first unless contraindicated.

Q: Can I request an expedited appeal if my authorization is denied? A: Yes, if your physician certifies that standard appeal timelines could seriously jeopardize your health or ability to regain function.

Q: Does step therapy apply if I've been stable on Soliris from another state? A: Continuation of therapy exceptions are available. Provide documentation of current stability and potential risks of switching.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by UnitedHealthcare. External appeals are conducted by independent medical reviewers through Virginia's SCC Bureau of Insurance.

Q: How much does Soliris cost without insurance coverage? A: List price can exceed $500,000 annually. Alexion offers patient assistance programs—contact 1-888-765-4747 for eligibility screening.

Q: Can I use Alexion's copay assistance with UnitedHealthcare? A: Copay assistance availability varies by plan type. Commercial plans typically allow manufacturer assistance, while government plans (Medicare, Medicaid) do not.

Q: What happens if my appeal is denied by Virginia external review? A: The external review decision is final and binding. You may still pursue legal action if you believe laws were violated, or explore other coverage options during open enrollment.

From our advocates: We've seen many Soliris appeals succeed when providers include specific lab values showing disease activity, document exact dates and outcomes of prior therapy trials, and clearly explain why biosimilar alternatives aren't appropriate. The key is addressing each denial criterion with concrete clinical evidence rather than general statements about medical necessity.

When working with Counterforce Health, we help identify these specific gaps in initial submissions and craft targeted appeals that speak directly to UnitedHealthcare's coverage criteria, significantly improving approval odds for complex cases like Soliris.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider for medical decisions. For additional assistance with Virginia insurance issues, contact the SCC Bureau of Insurance at 1-877-310-6560.

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