Ultomiris

(ravulizumab)

ULTOMIRIS 245 MG in 3.5 ML CartridgeULTOMIRIS 300 MG in 3 ML Injection

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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 Ultomiris prior authorization forms

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Verified: Oct 02, 2023Blue Cross Blue Shield of Michigan - FEP Ultomiris Prior Authorization Form (Medical Benefit)

Verified: Sep 28, 2023Cigna - Ultomiris Prior Authorization Form

Verified: Sep 26, 2023Blue Cross Blue Shield of Michigan - Ultomiris Prior Authorization Form (Medical Benefit)

Verified: Sep 21, 2023Aetna - Medicare Part B Ultomiris Prior Authorization Form

Verified: Sep 21, 2023Aetna - Ultomiris Prior Authorization Form

PDFCoverage Authorization Appeals: Generalized Myasthenia Gravis (gMG)

PDFLetter of Medical Necessity: Generalized Myasthenia Gravis (gMG)

PDFPA Criteria: Generalized Myasthenia Gravis (gMG)

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

PDFCoverage Authorization Appeals: Paroxysmal Nocturnal Hemoglobinuria (PNH)

PDFLetter of Medical Necessity: Paroxysmal Nocturnal Hemoglobinuria (PNH)

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Benefits investigation

Ultomiris Start Form: gMG

Ultomiris Start Form: PNH/aHUS

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Reimbursement help (FRM)

Receive Assistance from an FRM Regarding Reimbursement Information

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financial assistance

Ultomiris financial assistance options

Co-pay savings program

commercial only

Ultomiris Start Form: gMG

Ultomiris Start Form: PNH/aHUS

OTHEREnroll in Patient Savings Program

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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

Getting started on Ultomiris

To share resource; ask patient to:

1.Pull out phone

2.Open camera

3.Scan QR code with camera

4.Tap link