MedicaidPrior AuthHigh impact
Ultomiris® (ravulizumab-cwvz) (New)
Humana·OH · Hematology, Nephrology, Neurology +2 more·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 13, 2026
Summary
Humana Ohio Medicaid has implemented a new prior authorization policy for Ultomiris® (ravulizumab-cwvz) effective August 1, 2026, covering four rare conditions: PNH, aHUS, gMG, and NMOSD. Billing teams must now obtain prior authorization before dispensing this medication and ensure patients meet specific clinical criteria for each indication. All claims for Ultomiris will require documented medical necessity and prior approval or face denial.
Action Required
By July 15, 2026: Billing and pharmacy teams must implement prior authorization workflow in their billing system for Ultomiris (HCPCS code J7171). Pharmacy staff must verify patient meets ALL criteria before dispensing: For PNH—document granulocyte/monocyte clone >5%, LDH ≥1.5x upper limit normal, AND either transfusion dependency (Hgb ≤7 or ≤9 with symptoms) OR history of thromboembolism. For aHUS—document diagnosis with STEC-HUS and TTP ruled out. For gMG—document AChR antibody positive status, specialist supervision (neurologist), and prior treatment/intolerance to pyridostigmine AND at least one immunosuppressive agent. For NMOSD—document AQP4 antibody positive AND at least one core clinical characteristic (optic neuritis, acute myelitis, area postrema, brainstem syndrome, narcolepsy, or cerebral syndrome). Providers must submit prior authorization requests with supporting clinical documentation. Update prior auth templates in billing software to capture all four indications separately. Providers and pharmacy staff should reference the policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a59362b before dispensing. NOTE: Ensure patient has meningococcal vaccination at least 2 weeks prior to first dose per black box warning. Claims submitted without prior authorization or incomplete documentation will be denied.