Drug IndexUltomiris (Ravulizumab)
Billing
Code: J1303
Description: Inj., ravulizumab-cwvz 10 mg
Unit: 10 MG
Payment: $220.752
Pay quarter: Q4 2024
Covered in Part D: No
Drug Cost
Calculate drug cost and reimbursement
Total WAC:
N/ATotal Reimbursement:
N/A(ASP: N/A, Margin: N/A)
.
.# Units to bill:
N/ABillable NDCs
25682-0022-01
Ultomiris (Alexion Pharmaceuticals, Inc.)
1 VIAL, GLASS in 1 CARTON (25682-022-01) / 30 mL in 1 VIAL, GLASS
25682-0025-01
Ultomiris (Alexion Pharmaceuticals, Inc.)
1 VIAL, GLASS in 1 CARTON (25682-025-01) / 3 mL in 1 VIAL, GLASS
25682-0028-01
Ultomiris (Alexion Pharmaceuticals, Inc.)
1 VIAL, GLASS in 1 CARTON (25682-028-01) / 11 mL in 1 VIAL, GLASS
25682-0031-01
Ultomiris (Alexion Pharmaceuticals, Inc.)
1 KIT in 1 CARTON (25682-031-01) * 1 CARTRIDGE in 1 TRAY / 3.5 mL in 1 CARTRIDGE
Prior Authorization
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