By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by UnitedHealthcare in Washington: Complete Guide to Prior Authorization, Appeals, and State Resources

Quick Start: Your Path to Soliris Coverage in Washington

Getting Soliris (eculizumab) covered by UnitedHealthcare in Washington requires prior authorization with strict documentation. First step: Verify your plan type (commercial, Medicaid/Apple Health, or Medicare) and gather diagnosis labs, vaccination records, and prior therapy history. Submit PA through the UnitedHealthcare Provider Portal with complete clinical documentation. If denied, Washington law provides strong appeal rights including independent external review through certified organizations. Most denials overturn with proper documentation and persistence.

Table of Contents

  1. Verify Your Plan and Policy Requirements
  2. Required Forms and Documentation
  3. Submission Portals and Online Tools
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Phone Numbers and Case Management
  7. Washington State Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. Costs and Financial Assistance

1. Verify Your Plan and Policy Requirements

Before starting your Soliris request, you need to identify which UnitedHealthcare policy governs your coverage.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all indications UHC Complement Inhibitors Policy
Specialist Prescriber Hematologist (PNH/aHUS) or Neurologist (gMG/NMOSD) UHC Medical Policy
Meningococcal Vaccination Required ≥2 weeks before first dose FDA Soliris Label
REMS Enrollment Prescriber must enroll in safety program Alexion REMS Program
Site of Care Restrictions May require cost-effective infusion setting UHC Site of Care Policy

Plan-Specific Considerations

UnitedHealthcare Community Plan (Apple Health/Medicaid): Follow the four-step appeal process outlined in Washington state regulations. Appeals must be filed within 60 days of denial.

Commercial/Exchange Plans: Governed by UnitedHealthcare's Complement Inhibitors policy with potential step therapy requirements for biosimilars.

Medicare Advantage: Subject to Part B medical benefit rules with possible step therapy starting in 2026 for certain plans.

2. Required Forms and Documentation

Core Prior Authorization Requirements

UnitedHealthcare requires comprehensive documentation for Soliris approval:

Diagnosis-Specific Documentation:

  • PNH: Flow cytometry confirming PNH clones, LDH >1.5x upper limit normal, hemolysis markers, ICD-10 D59.5
  • aHUS: Evidence of thrombotic microangiopathy, exclusion of STEC-HUS and TTP, ICD-10 D59.32/D59.39
  • Generalized Myasthenia Gravis: Anti-AChR antibody positive, MGFA class II-IV, failure of ≥2 immunosuppressive therapies
  • NMOSD: AQP4-IgG positive, documented attack history, multiple sclerosis ruled out

Universal Requirements:

  • Specialist consultation notes (hematologist for PNH/aHUS, neurologist for gMG/NMOSD)
  • Meningococcal vaccination records dated ≥14 days before treatment start
  • REMS program enrollment documentation
  • Complete prior therapy history with dates, doses, and reasons for discontinuation
Tip: UnitedHealthcare doesn't have a Soliris-specific PA form. Use the general OptumRx specialty drug prior authorization form available through the provider portal.

Medical Necessity Letter Checklist

Your clinician's letter should include:

  • Clear diagnosis with supporting lab values
  • FDA-approved indication or guideline support
  • Prior treatments tried and failed (with specific dates and outcomes)
  • Clinical rationale for Soliris over alternatives
  • Proposed dosing schedule and monitoring plan
  • Treatment goals and expected outcomes

3. Submission Portals and Online Tools

Primary Submission Method: UnitedHealthcare Provider Portal

Access: UHCProvider.com → Sign in with One Healthcare ID → Prior Authorization and Notification tool

Features:

  • Real-time PA requirement verification
  • Electronic form submission with document upload
  • Status tracking and decision notifications
  • Appeals submission capability

Alternative Electronic Routes:

  • CoverMyMeds: Select "OptumRx" or "UnitedHealthcare" and choose Soliris from the drug list
  • EHR-integrated ePA: Most major EHR systems support direct submission to UnitedHealthcare

Member Portal Access

Members can check authorization status through:

  • UnitedHealthcare member portal (link on ID card)
  • OptumRx portal for pharmacy benefit questions
  • Mobile apps for real-time updates

4. Fax Numbers and Mailing Addresses

UnitedHealthcare Community Plan of Washington (Apple Health/Medicaid)

Appeals Fax: 1-801-994-1082 Appeals Mailing Address: UnitedHealthcare Community Plan
P.O. Box 31364
Salt Lake City, UT 84131-0364

Expedited Appeals Phone: 1-877-542-8997

Commercial and Medicare Plans

Prior Authorization Fax: 1-844-403-1028 (verify with current provider materials) General PA Questions: Use plan-specific number on member ID card

Note: Fax numbers can vary by plan and year. Always verify the current fax number from your denial letter or provider portal before submitting appeals.

Cover Sheet Best Practices

Include on every fax:

  • Member name and ID number
  • Provider name and NPI
  • "URGENT" marking if expedited review needed
  • Clear indication this is for Soliris (eculizumab) PA or appeal
  • Page count and contact information

5. Specialty Pharmacy Network

In-Network Specialty Pharmacies

UnitedHealthcare requires Soliris to be dispensed through contracted specialty pharmacies:

  • Optum Specialty Pharmacy (usually preferred)
  • Accredo Health Group
  • AllianceRx Walgreens Pharmacy
  • CVS Caremark Specialty
  • Option Care Health (for home/ambulatory infusion)

Enrollment Process

  1. Verify Network: Confirm which specialty pharmacy is required for your specific plan
  2. Provider Coordination: Send prescription directly to the designated specialty pharmacy
  3. Member Enrollment: Pharmacy will contact member for insurance verification and delivery coordination
  4. Cold Chain Management: Specialty pharmacy handles temperature-controlled shipping and storage
Important: Never send Soliris prescriptions to retail pharmacies. The drug requires specialized handling and REMS compliance verification.

6. Support Phone Numbers and Case Management

Provider Support

Prior Authorization Questions: Use the number listed on your plan-specific PA page or member ID card Example (Texas Community Plan): 888-887-9003 (verify for Washington plans)

Provider Portal Technical Support: Available through UHCProvider.com help section

Member Support

General Customer Service: Number on back of member ID card Case Management: Request transfer to "case management" or "care management" for complex conditions Pharmacy Benefits: OptumRx number on ID card for drug coverage questions

What to Ask When Calling

For PA Status:

  • "I need the status of prior authorization for Soliris (eculizumab)"
  • "What additional documentation is needed?"
  • "Can you provide the authorization number and approval dates?"

For Appeals:

  • "I want to file an appeal for a denied Soliris prior authorization"
  • "Can you transfer me to the appeals department?"
  • "What is the deadline for filing this appeal?"

Counterforce Health helps patients and providers navigate these complex prior authorization and appeal processes by analyzing denial letters and crafting evidence-based appeals that address specific payer requirements.

7. Washington State Appeals and External Review

Washington provides strong consumer protections for insurance denials through a multi-level appeal system.

UnitedHealthcare Community Plan (Apple Health) - Four-Step Process

Step 1: UnitedHealthcare Internal Appeal

  • Deadline: 60 calendar days from denial date
  • How to file: Phone (1-877-542-8997), fax (1-801-994-1082), or mail
  • Expedited option: 72-hour decision for urgent health needs

Step 2: State Administrative Hearing

  • Deadline: 120 calendar days from appeal decision
  • Process: Washington Office of Administrative Hearings (OAH)
  • Expedited option: Available when delay risks health

Step 3: Independent Review Organization (IRO)

  • Deadline: 21 calendar days from hearing decision
  • Cost: Free to member
  • Process: UnitedHealthcare sends case to certified IRO within 3 working days

Step 4: Health Care Authority Board of Appeals

  • Process: Final review under WAC 182-501-0160
  • Limitations: Certain "Exception to Rule" decisions cannot be appealed

Commercial/Employer Plans

Internal Appeals: Typically 180 days from denial to file External Review: Available after exhausting internal appeals

  • Contact Washington Office of Insurance Commissioner (OIC)
  • Consumer Advocacy Line: 1-800-562-6900
  • Independent Review Organization assigned by OIC
  • Decision within 30 days (72 hours for expedited)

Timeline for Appeals Success

Most successful Soliris appeals in Washington follow this pattern:

  1. Initial denial (often for incomplete documentation)
  2. Peer-to-peer review (clinician discusses case with medical director)
  3. Internal appeal with comprehensive clinical package
  4. Approval or escalation to external review
From our advocates: We've seen that Washington's external review process is particularly effective for rare disease medications. One patient's Soliris denial was overturned at the IRO level when an independent hematologist reviewed the complete clinical picture, even though the insurer's initial reviewer had denied the case twice.

8. Common Denial Reasons and Solutions

Denial Reason How to Overturn
Incomplete diagnosis documentation Submit flow cytometry report (PNH), complement testing (aHUS), antibody results (gMG/NMOSD)
Missing vaccination records Provide meningococcal vaccine documentation ≥14 days before treatment or prophylaxis plan
Insufficient prior therapy trials Document specific dates, doses, and outcomes of previous treatments
Step therapy not met Request medical exception with clinical rationale or document biosimilar intolerance
Site of care not approved Justify hospital outpatient setting with medical necessity for monitoring
REMS non-compliance Submit prescriber REMS enrollment confirmation and patient education documentation

Strengthening Your Appeal

Clinical Evidence to Include:

  • Recent laboratory trends showing disease progression
  • Functional assessments (MG-ADL scores for myasthenia gravis, quality of life measures)
  • Hospitalization records related to the condition
  • Specialist recommendations supporting Soliris over alternatives

Guideline References:

  • FDA prescribing information for indication-specific criteria
  • Professional society guidelines (American Society of Hematology for PNH, American Academy of Neurology for NMOSD)
  • Peer-reviewed literature supporting off-label uses if applicable

9. Costs and Financial Assistance

Manufacturer Support Programs

Alexion Access Navigator:

  • Prior authorization support
  • Appeals assistance
  • Financial counseling
  • Insurance verification services
  • Website: alexionaccessnavigator.com

Patient Assistance Programs:

  • Copay assistance for commercially insured patients
  • Free drug program for uninsured/underinsured patients
  • Bridge therapy during appeals process

State and Federal Resources

Washington Apple Health: Full coverage when medically necessary and properly documented Medicare Part B: Coverage under durable medical equipment benefit when administered in approved settings Foundation Grants: Patient advocacy organizations often provide emergency assistance

Cost-Saving Strategies

  1. Biosimilar Options: Bkemv (interchangeable) and Epysqli may be preferred by some UnitedHealthcare plans
  2. Site of Care Optimization: Home infusion or ambulatory centers cost less than hospital outpatient
  3. Shared Savings Programs: Some UnitedHealthcare plans offer member incentives for cost-effective care

When dealing with complex prior authorizations and appeals, Counterforce Health specializes in turning insurance denials into successful approvals by crafting targeted, evidence-backed appeals that address each payer's specific requirements and clinical criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations change frequently. Always verify current requirements with your insurance plan and healthcare providers. For personalized assistance with appeals and prior authorizations, consult with qualified professionals or patient advocacy services.

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