Ravulizumab-cwvz (Ultomiris)

Covered: Ravulizumab-cwvz (Ultomiris) is covered for adults (≥18) with PNH when peripheral blood flow cytometry confirms absence/deficiency of GPI‑anchored proteins on ≥2 cell lineages, limited to the FDA‑approved indication and given IV per the specified weight‑based dosing. Key requirements: prescribed by or in consultation with a hematologist, initial approval 6 months (renewal 12 months) with documentation of continued clinical benefit (e.g., hemoglobin stabilization, reduced transfusions/reduced hemolysis), and records of IV administration and patient weight to support dosing.

"Ultomiris is indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH)."

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