CommercialPrior AuthHigh impact
Eculizumab (CPB 0807, reviewed 2026-08-11)
Aetna·Nephrology, Hematology, Neurology +1 more·Medical Policy
Effective date
Aug 11, 2026
We identified it
Aug 13, 2026
Summary
Aetna updated its eculizumab (Soliris, Bkemv, Epysqli) policy for commercial plans, establishing coverage criteria for four indications: atypical hemolytic uremic syndrome (aHUS), paroxysmal nocturnal hemoglobinuria (PNH), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). The policy requires precertification for all eculizumab products, mandates neurologist prescription/consultation for gMG and NMOSD, prohibits concomitant use with other complement inhibitors (with limited exceptions), and establishes specific diagnostic and clinical criteria for initial approval and continuation of therapy.
Action Required
Immediately: (1) Billing team must implement mandatory precertification process for all eculizumab products (Soliris, Bkemv, Epysqli) — establish precertification workflow using Aetna contact number (866) 752-7021 or fax (888) 267-3277 before submitting claims. (2) Update billing system and encounter templates to flag gMG and NMOSD cases requiring neurologist consultation/prescription verification. (3) Implement edits to prevent billing for eculizumab when used concomitantly with prohibited complement inhibitors (Ultomiris, Zilbrysq, Empaveli, Fabhalta, PiaSky, Uplizna, Imaavy, Vyvgart, Vyvgart Hytrulo, Rystiggo) — claims submitted with concomitant use will be denied. (4) Verify all initial approval requests include required diagnostic documentation: ADAMTS 13 levels and Shiga toxin status for aHUS; GPI-AP deficiency via flow cytometry and LDH/clinical manifestations for PNH; anti-AChR antibody status, MGFA classification II-IV, MG-ADL score ≥5, and immunosuppressive therapy failure documentation for gMG; anti-AQP4 antibody positivity and core NMOSD clinical characteristics for NMOSD. (5) For reauthorization requests, document positive therapy response per indication (LDH normalization/platelet counts for aHUS; hemoglobin/LDH improvement for PNH; MG-ADL/MMT/Composite improvement for gMG; relapse reduction for NMOSD). Failure to obtain precertification or submit required documentation will result in claim denials. Also reference Aetna's Site of Care Utilization Management Policy for specialty drug infusion location requirements.