Does J1303 require prior authorization?

Yes, J1303 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1303?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`J1303`, Injection, ravulizumab-cwvz, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

NMOSD: documentation of age (>=18 years) and that Ultomiris is prescribed by or in consultation with a neurologist.
NMOSD initial and re-authorization: documentation of positive blood serum test for anti-aquaporin-4 (AQP4) antibody.
PNH: peripheral blood flow cytometry results showing the absence or deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins on at least 2 cell lineages.
PNH: documentation that Ultomiris is prescribed by or in consultation with a hematologist.
PNH re-authorization: documentation of continuing benefit from Ultomiris therapy (e.g., stabilization of hemoglobin levels, decreased transfusion requirements or transfusion independence, reduction in hemolysis).
aHUS: documentation that the individual 'does not have Shiga toxin Escherichia coli related hemolytic uremic syndrome.'

Key Coverage Criteria

Medically necessary for initial therapy of aHUS when: documentation ruling out STEC-HUS and TTP; diagnosis with signs of aHUS; treatment-naïve; FDA-labeled dosing for aHUS; prescribed by hematologist/nephrologist; initial authorization up to 12 months. Continuation requires positive clinical response and dosing per FDA labeling, with reauthorization up to 12 months.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Paroxysmal Nocturnal Hemoglobinuria (PNH): treatment of adult and pediatric patients one month of age and older with paroxysmal nocturnal hemoglobinuria (PNH).
Atypical Hemolytic Uremic Syndrome (aHUS): treatment of adult and pediatric patients one month of age and older with atypical hemolytic uremic syndrome (aHUS) to inhibit complement mediated thrombotic microangiopathy (TMA).
Generalized Myasthenia Gravis (gMG): treatment of adult patients with generalized myasthenia gravis who are anti-acetylcholine receptor (ACHR) antibody-positive.
Neuromyelitis Optica Spectrum Disorder (NMOSD): treatment of neuromyelitis optica spectrum disorder in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

20 Active Policies

ARKBLUE-RAVULIZUMAB-CWVZ-E-G-ULTOMIRIS-EA2D5E3C4A, Ravulizumab-cwvz (e.g., Ultomiris)

BCBSLA-00671-A09B081FA9, 00671 ravulizumab (Ultomiris), eculizumab Products

BCBSMA-093-BE97FF0851, Soliris, Ultomiris, Complement 3 Glomerulopathy (C3G), Myasthenia Gravis, Paroxysmal nocturnal hemoglobinuria (PNH), and Neuromyelitis Optica Policy

BCBSM-2105264-666DFF0D5E, ULTOMIRIS (RAVULIZUMAB-CWVZ)

BCBSNE-X-131-5053ACE7BD, ULTOMIRIS, PIASKY, UPLIZNA, EMPAVELI, PIASKY,RYSTIGGO, IMAAVY

BCBSNJ-DRUGS-061-2EAD318F66, Eculizumab (Soliris) and Ravulizumab-cwvz (Ultomiris)

HEALTHNET_OR-HNOR-RAVULIZUMAB-CWVZ-ULTOMIRIS-CP-PHAR-415-E20863C6A4, Ravulizumab-cwvz (Ultomiris); CP.PHAR.415

MODA-ULTOMIRIS-CF2F90ABF7, Ultomiris (ravulizumab-cwvz)

IBX-COMMERCIAL-08-00-84M-20FD6F6CEC, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous administration

IBX-MEDICARE-ADVANTAGE-MA08-044L-DB6102C6B3, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous  administration

UMR-POL-UMR-complement-inhibitors, Complement C5 Inhibitors

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-complement-inhibitors, Complement C5 Inhibitors

AMERIHEALTH-COMMERCIAL-08-00-84M-1360D6ACC1, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous administration

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-044L-63881A4CDB, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous  administration

BCBSTN-5230e75895, Ravulizumab-cwvz (Ultomiris)

EVICORE-MEDICAL_DRUG-9FA94F9C939C, Ultomiris (ravulizumab-cwvz) Intravenous Injection

UHC-POL-complement-inhibitors, Complement C5 Inhibitors

OSCAR-ULTOMIRIS-RAVULIZUMAB-CWVZ-PG189-VER-4-48023887C7, Ultomiris (ravulizumab-cwvz) (PG189, Ver. 4)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J1303 Sign up free

J1303, Injection, ravulizumab-cwvz, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

NMOSD: documentation of age (>=18 years) and that Ultomiris is prescribed by or in consultation with a neurologist.
NMOSD initial and re-authorization: documentation of positive blood serum test for anti-aquaporin-4 (AQP4) antibody.
PNH: peripheral blood flow cytometry results showing the absence or deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins on at least 2 cell lineages.
PNH: documentation that Ultomiris is prescribed by or in consultation with a hematologist.
PNH re-authorization: documentation of continuing benefit from Ultomiris therapy (e.g., stabilization of hemoglobin levels, decreased transfusion requirements or transfusion independence, reduction in hemolysis).
aHUS: documentation that the individual 'does not have Shiga toxin Escherichia coli related hemolytic uremic syndrome.'

Key Coverage Criteria

Medically necessary for initial therapy of aHUS when: documentation ruling out STEC-HUS and TTP; diagnosis with signs of aHUS; treatment-naïve; FDA-labeled dosing for aHUS; prescribed by hematologist/nephrologist; initial authorization up to 12 months. Continuation requires positive clinical response and dosing per FDA labeling, with reauthorization up to 12 months.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Paroxysmal Nocturnal Hemoglobinuria (PNH): treatment of adult and pediatric patients one month of age and older with paroxysmal nocturnal hemoglobinuria (PNH).
Atypical Hemolytic Uremic Syndrome (aHUS): treatment of adult and pediatric patients one month of age and older with atypical hemolytic uremic syndrome (aHUS) to inhibit complement mediated thrombotic microangiopathy (TMA).
Generalized Myasthenia Gravis (gMG): treatment of adult patients with generalized myasthenia gravis who are anti-acetylcholine receptor (ACHR) antibody-positive.
Neuromyelitis Optica Spectrum Disorder (NMOSD): treatment of neuromyelitis optica spectrum disorder in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

20 Active Policies

ARKBLUE-RAVULIZUMAB-CWVZ-E-G-ULTOMIRIS-EA2D5E3C4A, Ravulizumab-cwvz (e.g., Ultomiris)

BCBSLA-00671-A09B081FA9, 00671 ravulizumab (Ultomiris), eculizumab Products

BCBSMA-093-BE97FF0851, Soliris, Ultomiris, Complement 3 Glomerulopathy (C3G), Myasthenia Gravis, Paroxysmal nocturnal hemoglobinuria (PNH), and Neuromyelitis Optica Policy

BCBSM-2105264-666DFF0D5E, ULTOMIRIS (RAVULIZUMAB-CWVZ)

BCBSNE-X-131-5053ACE7BD, ULTOMIRIS, PIASKY, UPLIZNA, EMPAVELI, PIASKY,RYSTIGGO, IMAAVY

BCBSNJ-DRUGS-061-2EAD318F66, Eculizumab (Soliris) and Ravulizumab-cwvz (Ultomiris)

HEALTHNET_OR-HNOR-RAVULIZUMAB-CWVZ-ULTOMIRIS-CP-PHAR-415-E20863C6A4, Ravulizumab-cwvz (Ultomiris); CP.PHAR.415

MODA-ULTOMIRIS-CF2F90ABF7, Ultomiris (ravulizumab-cwvz)

IBX-COMMERCIAL-08-00-84M-20FD6F6CEC, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous administration

IBX-MEDICARE-ADVANTAGE-MA08-044L-DB6102C6B3, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous  administration

UMR-POL-UMR-complement-inhibitors, Complement C5 Inhibitors

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-complement-inhibitors, Complement C5 Inhibitors

AMERIHEALTH-COMMERCIAL-08-00-84M-1360D6ACC1, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous administration

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-044L-63881A4CDB, Eculizumab (Soliris) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris) for intravenous  administration

BCBSTN-5230e75895, Ravulizumab-cwvz (Ultomiris)

EVICORE-MEDICAL_DRUG-9FA94F9C939C, Ultomiris (ravulizumab-cwvz) Intravenous Injection

UHC-POL-complement-inhibitors, Complement C5 Inhibitors

OSCAR-ULTOMIRIS-RAVULIZUMAB-CWVZ-PG189-VER-4-48023887C7, Ultomiris (ravulizumab-cwvz) (PG189, Ver. 4)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J1303 Sign up free

`J1303`, Injection, ravulizumab-cwvz, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1303`, Injection, ravulizumab-cwvz, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1303, Injection, ravulizumab-cwvz, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1303, Injection, ravulizumab-cwvz, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1303`, Injection, ravulizumab-cwvz, 10 mg

`J1303`, Injection, ravulizumab-cwvz, 10 mg