By Counterforce Health Team in Soliris (eculizumab) —

Work With Your Doctor to Get Soliris (Eculizumab) Covered by Cigna in Michigan: Appeal Forms and Clinical Evidence Guide

Quick Answer: Getting Soliris (Eculizumab) Covered by Cigna in Michigan

Eligibility: Soliris requires prior authorization through Cigna's specialty pharmacy (Accredo/Express Scripts) for FDA-approved conditions: PNH, atypical HUS, generalized myasthenia gravis, and NMOSD. Key requirements: meningococcal vaccination ≥2 weeks before treatment, confirmed diagnosis with specific lab tests, and documentation of medical necessity.

Fastest path: Your doctor submits prior authorization via CoverMyMeds or ExpressPAth with complete clinical documentation. If denied, file internal appeal within 60 days, then Michigan DIFS external review within 127 days.

Start today: Gather insurance cards, diagnosis confirmation, vaccination records, and prior treatment history. Contact your prescriber to begin the PA process using HCPCS code J1299.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Preparation: What to Bring Your Doctor
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After Your Visit: Documentation Strategy
  7. Respectful Persistence and Follow-Up
  8. Michigan Appeals Process
  9. FAQ

Set Your Goal: Understanding Approval Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Mandatory for all new Soliris prescriptions Cigna Specialty Pharmacy
HCPCS Code Use J1299 (effective April 1, 2025) Cigna Provider Updates
Meningococcal Vaccination Required ≥2 weeks before first dose FDA Soliris Label
Diagnosis Confirmation Lab tests specific to condition Alexion PA Criteria
Site of Care IV infusion center or hospital Payer policy varies

Your partnership with your doctor is crucial because Soliris approval requires precise clinical documentation that only your healthcare provider can supply. The medication costs over $500,000 annually, making payers particularly strict about medical necessity criteria.

Note: Cigna processes Soliris through specialty pharmacy partners Accredo and Express Scripts, not regular retail pharmacies.

Visit Preparation: What to Bring Your Doctor

Symptom Timeline Documentation

Create a detailed symptom diary covering:

  • Onset dates: When symptoms first appeared and progression over time
  • Functional impact: How symptoms affect daily activities, work, or school
  • Severity markers: Hospitalizations, transfusions, or emergency visits
  • Current status: Recent lab values, imaging results, or clinical assessments

Treatment History Summary

Document all previous therapies with specific details:

  • Medications tried: Names, doses, duration of treatment
  • Outcomes: Why each treatment failed (ineffective, intolerable side effects, contraindications)
  • Dates: When treatments were started and stopped
  • Provider notes: Any documentation from specialists about treatment failures

For conditions like generalized myasthenia gravis, this might include immunosuppressants, plasmapheresis, or IVIG. For PNH, document transfusion history and complement inhibitor trials.

Insurance and Medical Records

Bring complete documentation:

  • Current Cigna insurance card and policy information
  • Previous denial letters or prior authorization attempts
  • Lab results confirming diagnosis (flow cytometry for PNH, antibody tests for myasthenia gravis)
  • Specialist consultation notes
  • Hospital discharge summaries if applicable

Building Your Evidence Kit

Diagnostic Confirmation Requirements

For Generalized Myasthenia Gravis:

  • Positive anti-acetylcholine receptor (AChR) antibodies
  • Clinical evidence of generalized weakness
  • MGFA classification score

For PNH:

  • Flow cytometry showing ≥5% PNH clone in granulocytes or monocytes
  • Elevated LDH ≥1.5× upper limit of normal
  • Evidence of hemolysis or thrombotic complications

For Atypical HUS:

  • Evidence of complement-mediated thrombotic microangiopathy
  • Exclusion of other TMA causes
  • Renal function documentation

For NMOSD:

  • AQP4-IgG antibody positivity
  • Clinical relapse history
  • MRI evidence of CNS lesions

Published Guidelines and References

Your doctor should reference relevant clinical guidelines:

  • FDA prescribing information for your specific indication
  • Specialty society recommendations (American Association of Neuromuscular & Electrodiagnostic Medicine for myasthenia gravis)
  • Peer-reviewed studies supporting Soliris use for your condition
  • Complement inhibitor therapy guidelines

Medical Necessity Letter Structure

Essential Components

A strong medical necessity letter should include:

Patient Information Section:

  • Full name, date of birth, Cigna policy number
  • Specific diagnosis with ICD-10 codes
  • Date of diagnosis confirmation

Clinical Rationale:

  • Detailed description of disease severity and progression
  • Objective clinical findings (lab values, imaging, functional assessments)
  • Risk of disease complications without treatment
  • Why Soliris is the most appropriate therapy

Treatment History:

  • Complete list of prior therapies with specific names, doses, and durations
  • Documented reasons for treatment failures or intolerances
  • Contraindications to alternative treatments

Safety Compliance:

  • Confirmation of meningococcal vaccination status
  • REMS program enrollment
  • Patient education documentation
From our advocates: We've seen the strongest letters include specific lab values with normal ranges, exact dates of treatment trials, and clear statements about functional decline. Generic statements about "treatment failure" are less compelling than "Patient required 4 units of packed RBCs monthly despite maximum tolerated corticosteroid therapy."

Sample Letter Framework

[Date]
[Cigna Medical Director]
[Address from denial letter]

RE: Prior Authorization Request for Soliris (eculizumab)
Patient: [Name], DOB: [Date], Policy: [Number]

Dear Medical Director:

I am requesting coverage for Soliris (eculizumab) for my patient with [specific diagnosis], who meets all FDA-approved criteria for therapy.

CLINICAL PRESENTATION:
[Patient's] condition was diagnosed on [date] based on [specific tests]. Current severity is evidenced by [objective measures].

TREATMENT HISTORY:
The patient has failed the following therapies:
- [Drug name]: [dose], [duration], discontinued due to [specific reason with dates]
- [Continue for all relevant treatments]

MEDICAL NECESSITY:
Soliris is indicated for [condition] and addresses the underlying complement-mediated pathophysiology. Without treatment, [patient] faces [specific risks: transfusion dependence, renal failure, respiratory crisis].

SAFETY COMPLIANCE:
- Meningococcal vaccination completed [date]
- REMS enrollment confirmed
- Patient counseled on infection risks

I have attached supporting documentation and am available for peer-to-peer review.

Sincerely,
[Physician name, credentials, contact information]

Supporting Peer-to-Peer Reviews

Preparation Strategy

If Cigna requests a peer-to-peer review, help your doctor prepare by:

Providing availability windows: Offer multiple time slots when you can be reached for additional questions

Creating a concise case summary: Prepare a one-page overview with:

  • Key diagnostic findings
  • Treatment timeline with specific outcomes
  • Current functional status
  • Risks of treatment delay

Gathering supporting materials: Ensure your doctor has easy access to:

  • Recent lab results
  • Imaging studies
  • Specialist consultation notes
  • Treatment response documentation

Key Talking Points for Physicians

Diagnosis confirmation: "Patient meets FDA criteria for [condition] based on [specific test results with dates]"

Medical necessity: "Standard therapies have failed as evidenced by [objective measures], and delay in complement inhibition therapy poses risk of [specific complications]"

Safety compliance: "Patient is fully vaccinated per ACIP guidelines and enrolled in the REMS program with appropriate monitoring"

Clinical monitoring: "We will track response through [specific measures] and adjust therapy as clinically indicated"

After Your Visit: Documentation Strategy

What to Save

Keep copies of all documentation:

  • Prior authorization submission confirmation
  • Medical necessity letter
  • Supporting lab results and imaging
  • Insurance correspondence
  • Provider notes from your visit

Patient Portal Communication

Use your Cigna member portal and your doctor's patient portal to:

  • Track prior authorization status
  • Upload additional documentation if requested
  • Communicate updates about your condition
  • Schedule follow-up appointments

Organizing Your Records

Create a dedicated file (physical or digital) with:

  • Chronological timeline of treatments and outcomes
  • Insurance correspondence by date
  • Lab results with reference ranges highlighted
  • Contact information for all providers involved in your care

Respectful Persistence and Follow-Up

Appropriate Follow-Up Cadence

Week 1: Confirm prior authorization submission and tracking number Week 2: Check status via member portal or phone Week 3: Contact prescriber's office if no decision received Week 4+: Escalate to appeals process if denied

How to Escalate Politely

When following up with Cigna:

  • Reference your case number or prior authorization ID
  • Ask for specific timelines for decisions
  • Request written confirmation of any verbal communications
  • Document the name and employee ID of representatives you speak with

When working with your doctor's office:

  • Acknowledge their workload while emphasizing urgency
  • Offer to help gather additional documentation
  • Ask about peer-to-peer review opportunities
  • Request updates via patient portal to minimize phone calls

Michigan Appeals Process

Step-by-Step Appeals Timeline

Internal Appeal (Cigna):

  1. Deadline: 60 days from denial date
  2. Method: Written appeal via member portal, mail, or fax
  3. Timeline: Decision within 30 days (72 hours for expedited)
  4. Required: Denial letter, additional clinical evidence, provider support

External Review (Michigan DIFS):

  1. Deadline: 127 days from final Cigna denial
  2. Method: DIFS External Review Request Form
  3. Timeline: 60 days for standard review, 72 hours for expedited
  4. Cost: Free to patient
  5. Decision: Binding on Cigna

When to Request Expedited Review

Request expedited review if delay could:

  • Cause serious jeopardy to life or health
  • Result in loss of limb or major bodily function
  • Lead to severe pain that cannot be managed without the treatment

Your doctor must provide written certification of medical urgency for expedited reviews.

Michigan Resources

  • DIFS Consumer Hotline: 877-999-6442
  • Online complaint filing: Michigan.gov/DIFS
  • External review forms: Available online or by phone request

FAQ

Q: How long does Cigna prior authorization take for Soliris in Michigan? A: Standard prior authorization decisions are typically made within 15 business days. Expedited requests (for urgent medical needs) must be decided within 72 hours.

Q: What if Soliris is not on Cigna's formulary? A: You can request a formulary exception through the prior authorization process. Your doctor must demonstrate medical necessity and why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal in Michigan? A: Yes, both Cigna internal appeals and Michigan DIFS external reviews offer expedited pathways when delay poses serious health risks. Your doctor must certify the urgency.

Q: Does step therapy apply if I've tried treatments outside Michigan? A: Yes, treatment history from other states counts toward step therapy requirements. Ensure your Michigan provider has complete records of prior therapies and outcomes.

Q: What happens if I'm already receiving Soliris and Cigna denies continued coverage? A: Existing patients have appeal rights for coverage continuation. Document clinical response and ongoing medical necessity. Michigan law provides continuity protections during appeals.

Q: Are there financial assistance programs for Soliris? A: Yes, Alexion offers patient assistance through Alexion OneSource. Additional support may be available through foundations and state programs.

Q: Can I switch from Soliris to Ultomiris if Cigna prefers the newer drug? A: Switching between complement inhibitors requires careful clinical evaluation. Your doctor should assess whether Ultomiris is appropriate for your specific condition and response history.

Q: What if my doctor isn't familiar with Soliris prior authorization requirements? A: Share this guide and encourage them to contact Alexion Access Navigator for clinical and reimbursement support. Specialty pharmacy coordinators can also assist with documentation requirements.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Soliris. The platform analyzes denial letters, identifies specific payer criteria, and helps healthcare providers craft targeted, evidence-based appeals that address each plan's requirements. By combining clinical expertise with payer-specific knowledge, Counterforce Health helps patients and providers navigate the complex prior authorization landscape more effectively.

For Michigan patients facing Soliris denials, working with experienced advocates who understand both Cigna's requirements and Michigan's appeal process can significantly improve approval odds while reducing the administrative burden on busy medical practices.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual policy and clinical circumstances. Always consult with your healthcare provider and insurance representative for guidance specific to your situation. For official Michigan insurance appeals information, visit Michigan.gov/DIFS or call 877-999-6442.

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