Eculizumab - Medical Clinical Policy Bulletins

Eculizumab and its biosimilars are covered for the medically necessary treatment of atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH), with specific diagnostic criteria and clinical indicators required, such as blood test results and symptom presence. Precertification is mandatory for all providers and members, and treatment must not be combined with other complement inhibitors, except as specified. Key limitations include coverage being restricted to designated products, adherence to Site of Care Utilization Management, and the necessity for comprehensive documentation supporting the medical necessity claim.

"Eculizumab products are covered when medically necessary for the treatment of specific conditions, as per the policy guidelines."

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