CommercialPrior AuthHigh impact
Ravulizumab-cwvz (Ultomiris) (CPB 0946, reviewed 2026-08-11)
Aetna·Hematology, Nephrology, Neurology +1 more·Medical Policy
Effective date
Aug 11, 2026
We identified it
Aug 15, 2026
Summary
Aetna has issued a fresh clinical policy (CPB 0946, reviewed 2026-08-11) establishing coverage criteria for Ravulizumab-cwvz (Ultomiris) across four rare disease indications: paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). The policy requires precertification for all Aetna commercial plans, mandates specific diagnostic confirmations and clinical thresholds, prohibits concomitant use with certain competing therapies, and establishes weight-based IV dosing schedules. Billing teams must implement prior authorization workflows immediately and ensure providers understand specialty-specific prescribing requirements and contraindicated drug combinations.
Action Required
IMMEDIATE ACTION REQUIRED: (1) Billing team: Update prior authorization workflow in billing system to require mandatory precertification for all Ravulizumab-cwvz (Ultomiris) claims under Aetna commercial plans. (2) Establish precertification contact process: Direct all Aetna providers to call (866) 752-7021 or fax (888) 267-3277 for prior auth requests before dispensing. (3) Create verification checklist for each indication requiring documented proof of: PNH (GPI-AP deficiency confirmed by flow cytometry, LDH >1.5 ULN); aHUS (Shiga toxin absence, ADAMTS13 >5%); gMG (anti-AChR antibody positive, MGFA class II-IV, MG-ADL ≥5, prior immunosuppressive therapy failure); NMOSD (anti-AQP4 antibody positive, core clinical criteria met). (4) Providers and clinical staff: Flag all claims for concomitant use with prohibited agents (Soliris, Empaveli, Fabhalta, PiaSky for PNH/aHUS; Soliris, Zilbrysq, Imaavy, Vyvgart, Vyvgart Hytrulo, Rystiggo, Uplizna for gMG; other biologics for NMOSD) as non-approvable. Exception: Voydeya is allowed with Ultomiris for PNH. (5) Neurology practices: Ensure prescribers for gMG and NMOSD are documented neurologists; add to precertification forms. (6) Site of service review: Reference Aetna's Site of Care Utilization Management Policy for infusion venue requirements. Claims processed without proper precertification or failing to meet all specified criteria will be denied by Aetna. Update all claim submission processes, encounter documentation templates, and provider education materials by end of business week.