Ultomiris® (ravulizumab-cwvz) Intravenous Injection

Covers Ultomiris for FDA‑approved PNH, aHUS, anti‑AChR antibody–positive adult generalized myasthenia gravis (gMG), and AQP4‑antibody–positive adult NMOSD (aHUS coverage excludes Shiga‑toxin E. coli–related HUS). Requires indication‑specific diagnostics and specialty prescribers plus documentation of benefit for reauthorization (PNH: GPI‑anchor deficiency on flow cytometry of ≥2 lineages and hematologist involvement; aHUS: exclusion of Shiga‑toxin HUS and nephrologist involvement; gMG: ≥18 years, anti‑AChR+, MGFA II–IV, MG‑ADL ≥6, prior/ongoing pyridostigmine and trial of two immunosuppressants unless contraindicated, neurologist involvement; NMOSD: ≥18 years, positive AQP4‑Ab and neurologist involvement), adherence to weight‑based loading/maintenance dosing, and specified authorization periods (PNH and gMG initial 6 months/renewal 12 months; aHUS 12 months).

"NMOSD: documentation of age (>=18 years) and that Ultomiris is prescribed by or in consultation with a neurologist."