Medicare AdvantagePrior AuthMedium impact
Ultomiris® (ravulizumab-cwvz) (Revised)
Humana·KY, SC · Hematology, Neurology, Nephrology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has updated prior authorization requirements for Ultomiris (ravulizumab-cwvz), a specialty drug used to treat four rare conditions including PNH, aHUS, generalized myasthenia gravis, and neuromyelitis optica spectrum disorder. The policy establishes specific clinical criteria that must be documented for approval, with different requirements for Medicare vs Medicaid patients for myasthenia gravis treatment.
Action Required
By January 1, 2025: Billing team must update prior authorization workflows for Ultomiris (ravulizumab-cwvz) to ensure all clinical criteria are documented before submission. Providers treating PNH must document granulocyte/monocyte clone size >5% and LDH levels 1.5x upper normal limit. For myasthenia gravis patients, ensure Medicare patients have tried Vyvgart first, while Medicaid patients need documentation of pyridostigmine and immunosuppressive therapy trials. Update EMR templates to capture required documentation elements to prevent claim denials.