Coverage Information
Navigating the insurance landscape
Insurance coverage for SOLIRIS® (eculizumab) varies by payor type and plan. Briefly,
- In the physician office, Medicare is likely to cover and reimburse for SOLIRIS when its use is considered reasonable. Under the current CMS Hospital Outpatient Prospective Payment System (HOPPS), SOLIRIS will be reimbursed separately under a pass-through process. Learn more about likely Medicare coverage in both the physician office and hospital settings.
- Medicaid coverage varies by state Medicaid Agency for both physician office and hospital coverage. However, many agencies will cover and reimburse SOLIRIS in both settings following a coverage review. Learn more about likely Medicaid coverage in both the physician and hospital settings.
- Commercial payors include employer health plans, individual plans, Medicare Advantage (Part C), and Medicaid managed care plans. SOLIRIS coverage varies by payor/plan, based on individual patient healthcare benefits. Learn more about what you may need to obtain commercial payor coverage for SOLIRIS.
Steps you can take to facilitate SOLIRIS coverage
Because PNH is rare, many payors lack a formal SOLIRIS coverage policy. More likely, they will assess each request according to the individual patient's medical need(s). The Alexion Case Manager can help with the following to ensure that your patients are reimbursed for their SOLIRIS treatment:
- Research and understand benefit design for physician-administered drugs under Medicare, Medicaid, and commercial plans
- Request a copy of published coverage or informal coverage and coding requirements for SOLIRIS from payors
- Support initial coverage and reimbursement processes with
- Prior to initiating SOLIRIS therapy, consider supplying payors with the SOLIRIS package insert
Contact a OneSource™ Case Manager at 1.888.SOLIRIS (1.888.765.4747) for additional information and support on denied claims. The Alexion Case Manager wil let you know if the patient has authorized sharing of health information and can also provide copies of the consent form for your files.
Next: Reimbursement