Medicare AdvantagePrior AuthMedium impact
MA08.044l, Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™) for intravenous administration
Independence Blue Cross·Hematology, Nephrology, Neurology·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Medicare Advantage policy MA08.044l has updated medical necessity criteria and medical coding requirements for Eculizumab (Soliris) and related biosimilars, and Ravulizumab-cwvz (Ultomiris) for intravenous administration. This affects specialty infusion billing for these high-cost medications used to treat rare blood disorders.
Action Required
Before January 1, 2026: Billing team must review updated medical necessity criteria for Eculizumab (Soliris) and Ravulizumab-cwvz (Ultomiris) infusions. Update prior authorization workflows and documentation requirements in billing system. Ensure providers document updated medical necessity criteria for these specialty medications to prevent claim denials.