Complement Inhibitors – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers eculizumab products (Bkemv, Epysqli, Soliris), ravulizumab (Ultomiris) and crovalimab (PiaSky) for aHUS, PNH, anti‑AChR positive gMG, and AQP4+ NMOSD, excludes STEC‑HUS, prohibits combination with other complement C5/C3/factor inhibitors, and limits PiaSky to patients ≥13 years/≥40 kg with prior failure/contraindication to specified comparators. Coverage requires indication‑specific documentation (e.g., rule out STEC/TTP and treatment‑naïve for aHUS; PNH flow cytometry; AChR+ MG with MGFA II–IV and MG‑ADL ≥6 after required immunosuppressive failures; neurologist‑confirmed AQP4+ NMOSD with rituximab failure/relapse history), FDA‑label dosing, REMS and meningococcal vaccination, evidence of clinical benefit for continuation, and authorizations ≤12 months.

"Dosing documentation: evidence that the requested product is being prescribed and dosed according to US FDA labeled dosing for the specific indication."