CurrentAetnaPolicy N/A

Ultomiris (ravulizumab-cwvz) Medication Precertification Request

This document is a payer-specific precertification/authorization request form used by Aetna for Ultomiris (ravulizumab-cwvz) to collect patient, provider, clinical, dosing, diagnosis, and site-of-care information required for precertification review.

Policy Summary

PayerAetna

PolicyUltomiris (ravulizumab-cwvz) Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionProvider must complete and submit this Aetna precertification notification form with all required clinical fields legible and completed for Ultomiris precertification review via specified phone or fax numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this is an administrative precertification form used to collect information for Ultomiris precertification.

FormDocument Type

UltomirisDrug Covered

PNH, aHUSCommon Indications

Policy overview

This is an Aetna precertification/authorization request form for Ultomiris (ravulizumab-cwvz) used to collect patient, provider, clinical, dosing, diagnosis, and site-of-care information required for precertification review. The form requires patient identifiers and contact information, weight/height and allergies; insurance and Aetna member details; prescriber licensure, NPI and specialty; and dispensing provider/administration details including place of administration and administration CPT codes.

The form captures product request details (Ultomiris loading and maintenance dose and frequency) and primary/secondary ICD-10 diagnosis codes. It documents site-of-care considerations (outpatient hospital setting, adverse events, venous access issues, behavioral/functional limitations, medical instability) and requests a description of relevant cardiopulmonary, respiratory, renal or other conditions.

The form includes initiation-specific and continuation-specific fields: initiation questions ask about switching from eculizumab and timing of the loading dose relative to the last eculizumab infusion; diagnosis-specific fields request confirmation and diagnostic test results for PNH (flow cytometry, percentage of PNH cells and GPI-deficient PMNs) and aHUS (Shiga toxin status and ADAMTS13 level); continuation fields request evidence of toxicity, disease progression, or clinical response (e.g., LDH, platelets, hemoglobin).

Requests must be signed and dated with a fraud acknowledgement; providers must submit required clinical documentation to support site-of-care rationale, prior eculizumab use/timing if switching, disease confirmation (e.g., flow cytometry for PNH, ADAMTS13 for aHUS), and evidence of response or toxicity for continuation requests. Contact phone and fax numbers for Aetna precertification submission are provided on the form.