Description: Eculizumab injection
Unit: 10 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 600mg IV every week for the first 4 doses
• 900mg IV for the fifth dose
• 900mg IV every 2 weeks
Generalized Myasthenia Gravis (gMG)
Neuromyelitis Optica Spectrum Disorder (NMOSD)
• 900mg IV every week for the first 4 doses
• 1200mg IV for the fifth dose
• 1200mg IV every 2 weeks
Calculate drug reimbursement
(ASP: $19,126.10, Margin: $1,147.57)
# Units to bill:90
Prior auth criteria for Soliris may include but is not limited to:
1. Diagnosis of a primary immunodeficiency or PNH that is not caused by another condition.
2. Patient is 12 years of age or older.
3. Appropriate laboratory tests, including a serum complement C3 and C4 level, are performed and confirm the diagnosis of a primary immunodeficiency or PNH.
4. Patient has not responded adequately to other therapies for the condition.
5. Patient is not pregnant or planning to become pregnant.
6. Patient is willing to comply with routine laboratory monitoring during treatment.
7. Patient is willing to use an effective form of birth control during treatment.
Insurance prior auth guidelines:
Soliris (ALEXION PHARMACEUTICALS)