Drug IndexUltomiris (ravulizumab-cwvz)
Billing
Code: J1303
Description: Inj., ravulizumab-cwvz 10 mg
Unit: 10 MG
Payment: $221.745
Pay quarter: Q2 2024
Covered in Part D: No
Drug Cost
Calculate drug cost and reimbursement
Total WAC:
$2,348.17Total Reimbursement:
$73,175.85(ASP: $69,033.82, Margin: $4,142.03)
.
.# Units to bill:
330Dosage & Frequency
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Atypical Hemolytic Uremic Syndrome (aHUS)
Generalized Myasthenia Gravis (gMG)
• 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
Atypical Hemolytic Uremic Syndrome (aHUS)
Generalized Myasthenia Gravis (gMG)
| Body weight (kg) | Loading dose (mg) | Maintenance dose (mg) | Frequency |
|---|---|---|---|
| 5-<10 | 600 | 300 | every 4 weeks |
| 10-<20 | 600 | 600 | every 4 weeks |
| 20-<30 | 900 | 2100 | every 8 weeks |
| 30-<40 | 1200 | 2700 | every 8 weeks |
| 40-<60 | 2400 | 3000 | every 8 weeks |
| 60-<100 | 2700 | 3300 | every 8 weeks |
| 100+ | 3000 | 3600 | every 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
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
Prior Authorization
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