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Ultomiris (ravulizumab-cwvz)


Billing

Code: J1303

Description: Inj., ravulizumab-cwvz 10 mg

Unit: 10 mg

Payment: $221.875

Pay quarter: Q3 2023


Medicare history

Dosage and Frequency

Paroxysmal Nocturnal Hemoglobinuria (PNH)
Atypical Hemolytic Uremic Syndrome (aHUS)
Generalized Myasthenia Gravis (gMG)

Body weight (kg)Loading dose (mg)Maintenance dose (mg)Frequency
5-<10600300every 4 weeks
10-<20600600every 4 weeks
20-<309002100every 8 weeks
30-<4012002700every 8 weeks
40-<6024003000every 8 weeks
60-<10027003300every 8 weeks
100+30003600every 8 weeks


• Start maintenance dose 2 weeks after loading dose
• If patient is currently being treated with SQ administration of Ultomiris, start maintenance IV dose 1 week after last SQ dose
• If patient is being treated with eculizumab, start loading dose at time of next eculizumab dose

• 490mg SQ every 1 week can be an alternate maintenance dosage if patient weighs greater than or equal to 40kg

Calculate drug reimbursement


Total Reimbursement:

$77,611.88

(ASP: $73,218.75, Margin: $4,393.13)


Code:

J1303

# Units to bill:

330

Prior Authorization

Prior auth criteria for Ultomiris may include but is not limited to:


1. Ultomiris is indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH).

2. The diagnosis of PNH must be confirmed by the presence of a high-level hemolytic anemia and the presence of an appropriate clone size (? 10% of granulocytes) or a flow cytometric assay demonstrating the presence of a PNH clone.

3. The patient must be 18 years of age or older.

4. The patient must have failed or be intolerant to other treatments for PNH, including eculizumab.

5. The patient must have an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73 m2 as calculated by the Modification of Diet in Renal Disease (MDRD) equation.

6. The patient must not have active or uncontrolled infections.

7. The patient must not have a history of malignancy other than cutaneous basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) of the skin.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

25682-0022-01

Ultomiris (ALEXION PHARMACEUTICALS)

300 MG


25682-0025-01

Ultomiris (ALEXION PHARMACEUTICALS)

300 MG


25682-0028-01

Ultomiris (ALEXION PHARMACEUTICALS)

1100 MG



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