Drug IndexUltomiris (Ravulizumab)



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:

N/A

Total Reimbursement:

N/A

(ASP: N/A, Margin: N/A)

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# Units to bill:

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Billable NDCs

25682-0022-01

Ultomiris (Alexion Pharmaceuticals, Inc.)

1 VIAL, GLASS in 1 CARTON (25682-022-01) / 30 mL in 1 VIAL, GLASS


25682-0025-01

Ultomiris (Alexion Pharmaceuticals, Inc.)

1 VIAL, GLASS in 1 CARTON (25682-025-01) / 3 mL in 1 VIAL, GLASS


25682-0028-01

Ultomiris (Alexion Pharmaceuticals, Inc.)

1 VIAL, GLASS in 1 CARTON (25682-028-01) / 11 mL in 1 VIAL, GLASS


25682-0031-01

Ultomiris (Alexion Pharmaceuticals, Inc.)

1 KIT in 1 CARTON (25682-031-01) * 1 CARTRIDGE in 1 TRAY / 3.5 mL in 1 CARTRIDGE



Prior Authorization


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