Ultomiris (ravulizumab-cwvz)
Billing
Code: J1303
Description: Inj., ravulizumab-cwvz 10 mg
Unit: 10 mg
Payment: $221.669
Pay quarter: Q4 2023
Dosage and 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
Calculate drug reimbursement
Total Reimbursement:
$73,150.77(ASP: $69,010.16, Margin: $4,140.61)
Code:
J1303# Units to bill:
330Prior Authorization
Prior auth criteria for Ultomiris may include but is not limited to:
1. Ultomiris is indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH).
2. The diagnosis of PNH must be confirmed by the presence of a high-level hemolytic anemia and the presence of an appropriate clone size (? 10% of granulocytes) or a flow cytometric assay demonstrating the presence of a PNH clone.
3. The patient must be 18 years of age or older.
4. The patient must have failed or be intolerant to other treatments for PNH, including eculizumab.
5. The patient must have an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73 m2 as calculated by the Modification of Diet in Renal Disease (MDRD) equation.
6. The patient must not have active or uncontrolled infections.
7. The patient must not have a history of malignancy other than cutaneous basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) of the skin.
Insurance prior auth guidelines:
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
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