Ultomiris

(ravulizumab)
ULTOMIRIS 245 MG in 3.5 ML CartridgeULTOMIRIS 300 MG in 3 ML Injection
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Dosage & administration

drug label

Ultomiris prescribing information

prior authorization

Ultomiris prior authorization resources

Most recent Ultomiris prior authorization forms

View By Payer
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

PDF
Coverage Authorization Appeals: Generalized Myasthenia Gravis (gMG)

PDF
Letter of Medical Necessity: Generalized Myasthenia Gravis (gMG)

PDF
PA Criteria: Generalized Myasthenia Gravis (gMG)

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

PDF
Coverage Authorization Appeals: Paroxysmal Nocturnal Hemoglobinuria (PNH)

PDF
Letter 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

OTHER
Enroll in Patient Savings Program
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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

Patient toolkit

Ultomiris Infusion Locator
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
About Ultomiris: Generalized Myasthenia Gravis (gMG)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

OTHER
Receiving Ultomiris: Generalized Myasthenia Gravis (gMG)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
Side Effects: Generalized Myasthenia Gravis (gMG)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

OTHER
Patient Resources: Generalized Myasthenia Gravis (gMG)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Myasthenia Gravis Activities of Daily Living (MG-ADL) Assessment Tool
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Patient Brochure: Generalized Myasthenia Gravis (gMG)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
About Ultomiris: Atypical Hemolytic Uremic Syndrome (aHUS)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

OTHER
Receiving Ultomiris: Atypical Hemolytic Uremic Syndrome (aHUS)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
Side Effects: Atypical Hemolytic Uremic Syndrome (aHUS)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

OTHER
Patient Resources: Atypical Hemolytic Uremic Syndrome (aHUS)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Patient Brochure: Atypical Hemolytic Uremic Syndrome (aHUS)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
About Ultomiris: Paroxysmal Nocturnal Hemoglobinuria (PNH)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

OTHER
Patient Resources: Paroxysmal Nocturnal Hemoglobinuria (PNH)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Patient Brochure: Paroxysmal Nocturnal Hemoglobinuria (PNH)
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link
Learn More

Other resources

Ultomiris Infusion Locator
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link
Learn More

people also ask

Ultomiris FAQs

How is the dosage of Ultomiris?Ultomiris is available in 4 dosages, including 100 mg/ml Injection 11 ml, 100 mg/ml Injection 3 ml, 300 mg/30ml Injection 30 ml and 70 mg/ml Cartridge 3.5 ml
What does Ultomiris treat?Ultomiris treats Paroxysmal Hemoglobinuria and Atypical Hemolytic Uremic Syndrome
What is Ultomiris made of?Ultomiris contains ravulizumab which is a Complement Inhibitor
How Is Ultomiris Administered?Ultomiris is administered as a Injectable
What Are The Ultomiris Mechanism Of Action?Ultomiris mechanism of action is Complement Inhibitors
FAQ Data Source