Get the free ULTOMIRIS (ravulizumab) PRIOR AUTHORIZATION FORM

Office of Medical Assistance Programs FeeforService, Pharmacy Division Phone 18005378862 Fax 18663270191ULTOMIRIS (ranibizumab) PRIOR AUTHORIZATION FORM Complement Inhibitors and Quantity Limits/Daily

How to fill out ultomiris ravulizumab prior authorization

How to fill out ultomiris ravulizumab prior authorization

1. To fill out Ultomiris Ravulizumab prior authorization, follow these steps:
2. Obtain the necessary forms or documents required by the insurance company or healthcare provider.
3. Gather all relevant medical information, including the patient's diagnosis and medical history.
4. Complete the patient information section of the prior authorization form, providing necessary personal details such as name, date of birth, and contact information.
5. Provide information about the prescribing physician or healthcare provider, including their name, address, and contact information.
6. Fill out details about the medication Ultomiris Ravulizumab, including the dosage, frequency, and duration of treatment.
7. Include any supporting documentation or medical records that may be required, such as lab test results or clinical notes.
8. Review the completed prior authorization form for accuracy and completeness.
9. Submit the form and any accompanying documents to the insurance company or healthcare provider through the preferred method, such as mail, fax, or online portal.
10. Keep copies of all submitted documents for your records.
11. Follow up with the insurance company or healthcare provider to ensure the prior authorization process is completed and confirmed.

Who needs ultomiris ravulizumab prior authorization?

1. Ultomiris Ravulizumab prior authorization is typically required for patients who wish to have their treatment with Ultomiris covered by their insurance company.
2. The need for prior authorization may be determined by factors such as the patient's insurance policy, formulary restrictions, and the specific medical condition or diagnosis.
3. Patients who have been prescribed Ultomiris for the treatment of paroxysmal nocturnal hemoglobinuria (PNH) or atypical hemolytic uremic syndrome (aHUS) may need to go through the prior authorization process.
4. It is recommended to verify with the insurance company or healthcare provider about their specific requirements for prior authorization and to determine if Ultomiris is covered under the patient's insurance plan.

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