Ultomiris (ravulizumab-cwvz) subcutaneous — Highmark
Atypical hemolytic uremic syndrome (aHUS)
Initial criteria
- age ≥ 18 years
- Diagnosis of aHUS
- Thrombotic microangiopathy (TMA) evidenced by one of the following: low platelet count (thrombocytopenia) OR microangiopathy hemolysis/thrombotic microangiopathy OR decreased kidney function
- One of the following treatment transition criteria: (a) Currently on Ultomiris IV and will start Ultomiris SC 8 weeks after last Ultomiris IV maintenance dose OR (b) Currently on Soliris IV, will receive weight-based Ultomiris IV loading dose at next Soliris dose, and start Ultomiris SC 2 weeks later OR (c) Not on Ultomiris or Soliris, will receive weight-based Ultomiris IV loading dose and start Ultomiris SC 2 weeks later
- Prescriber attests Ultomiris not used in combination with another complement inhibitor for aHUS (e.g., Soliris)
Reauthorization criteria
- Prescriber attests the member has achieved hematologic normalization OR experienced a decrease in thrombotic microangiopathy (TMA) events
Approval duration
12 months