Ultomiris Prescribing & Dosing Schedule

Dosage & Administration Drug label Prior authorization Financial assistance Patient education People also ask

Ultomiris(ravulizumab-cwvz)

ULTOMIRIS 245 MG in 3.5 ML Cartridge

Dosage & Administration

* See Full Prescribing Information for instructions on dosage, preparation, and administration.
* Dilute ULTOMIRIS before use.
* Only administer as an intravenous infusion through a 0.2 or 0.22 micron filter.

drug label

Ultomiris Prescribing Information

Contact Medical Science Liaison

Report Adverse Event

prior authorization

Ultomiris Prior Authorization Resources

Most recent state uniform prior authorization forms

Verified: Jun 26, 2024Arizona - Uniform Prior Authorization Form

Verified: Jun 26, 2024Colorado - Uniform Prior Authorization Form

Verified: Jun 26, 2024Hawaii - Uniform Prior Authorization Form

Verified: Jul 26, 2024Illinois - Uniform Prior Authorization Form

Verified: Jun 26, 2024Indiana - Uniform Prior Authorization Form

Verified: Jun 26, 2024Louisiana - Uniform Prior Authorization Form

Verified: Jun 26, 2024Minnesota - Uniform Prior Authorization Form

Verified: Jun 26, 2024New Hampshire - Uniform Prior Authorization Form

Verified: Jun 26, 2024New Mexico - Uniform Prior Authorization Form

Verified: Jun 26, 2024Oregon - Uniform Prior Authorization Form

Verified: Jun 26, 2024Texas - Uniform Prior Authorization Form

Verified: Jul 07, 2024Washington - Uniform Prior Authorization Form

Verified: Jul 07, 2024Wisconsin - Uniform Prior Authorization Form

Coverage Authorization Appeals: Generalized Myasthenia Gravis (gMG)

Letter of Medical Necessity: Generalized Myasthenia Gravis (gMG)

PA Criteria: Generalized Myasthenia Gravis (gMG)

Letter of Medical Necessity: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)

Letter of Medical Necessity: Atypical Hemolytic Uremic Syndrome (aHUS)

Coverage Authorization Appeals: Paroxysmal Nocturnal Hemoglobinuria (PNH)

Letter of Medical Necessity: Paroxysmal Nocturnal Hemoglobinuria (PNH)

Benefits investigation

Ultomiris Start Form: gMG & NMOSD

Ultomiris Start Form: PNH & aHUS

Ultomiris Start Form (Online): All Indications

Reimbursement help (FRM)

Receive Assistance from an FRM Regarding Reimbursement Information

financial assistance

Ultomiris Financial Assistance Options

Copay savings program

Ultomiris Start Form: gMG & NMOSD

Ultomiris Start Form: PNH & aHUS

Ultomiris Start Form (Online): All Indications

Enroll in Patient Savings Program

Learn More

Overview

Reduce patient OOP costs for drug (and occasionally for drug administration/infusion costs or drug-related test costs)

Patient benefit

A portion (or all) of patient OOP (deductible, copay), typically up to monthly and/or annual max

Patient eligibility

Patient must enroll or activate (may permit HCPs to enroll on patient’s behalf for HCP-administered drugs)
Generally, must have commercial insurance (rarely, may permit uninsured patients to use)
May never be used with government insurance

How to sign up

Cards may be downloadable digital cards or hard copies
Some pharmacos offer debit cards with pre-loaded copay benefit
Typically, available through multiple channels (e.g., rep to HCP to patient; pharmacy to patient; patient via website, Hub live agent, or copay vendor (live agent or IVR); patient and HCP via Hub enrollment form)
Some HCP-administered product programs permit HCPs to enroll on a patient’s behalf through via Hub form

patient education

Ultomiris Patient Education

To share resource; ask patient to:

1.Pull out phone

2.Open camera

3.Scan QR code with camera

4.Tap link