MedicaidPrior AuthHigh impact
Soliris® (eculizumab) and biosimilars (New)
Humana·OH · Hematology, Nephrology, Neurology +1 more·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 6, 2026
Summary
Humana Medicaid (Ohio) has implemented a new prior authorization policy effective August 1, 2026, for Soliris® (eculizumab) and biosimilars (Bkemv, Epysqli) covering four rare conditions: PNH, aHUS, gMG, and NMOSD. The policy establishes specific clinical criteria for approval, including diagnostic confirmations, antibody testing, specialist supervision, and prior treatment requirements depending on indication. Billing teams must implement prior authorization workflows immediately to avoid claim denials for these high-cost specialty medications.
Action Required
By July 15, 2026: (1) Billing team must configure electronic prior authorization system in billing software to require PA approval before claims submission for Soliris/eculizumab and biosimilars (J7323, J7324, J7325) for all Ohio Medicaid members. (2) Create PA requirement checklist specifying required documentation by diagnosis: For PNH—granulocyte/monocyte clone size >5%, LDH >1.5x ULN, and transfusion dependency or thromboembolism history; For aHUS—documentation ruling out STEC-HUS and TTP; For gMG—AChR antibody confirmation, specialist supervision, and prior pyridostigmine + immunosuppressive therapy failure; For NMOSD—AQP4 antibody positivity and core clinical characteristics. (3) Providers must verify member meets all criteria and obtain authorization before dispensing. (4) Update encounter templates and PA request forms to capture required clinical data. (5) Front desk staff must communicate to patients that this medication requires pre-approval. Failure to obtain prior authorization will result in claim denials by Humana Ohio Medicaid. Reference policy document pages 1-3 for full criteria.