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Ultomiris information includes side effects, interactions and indications. INDICATIONS AND USAGE ULTOMIRIS is a complement inhibitor indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH). Under the ULTOMIRIS REMS, prescribers must enroll in the program (5.1). J1300 has been in effect since 01/01/2008. HCPCS Code: J1303. • J1303 Injection, ravulizumab-cwvz, (Ultomiris), 10 mg REFERENCES • Ultomiris [package insert]. Boston, MA: Alexion Pharmaceuticals, Inc.; October 2019. Ultomiris (ravulizumab-cwvz) injection 10 mg/mL is translucent, slight whitish color solution supplied insingle-dose vials as: 300 mg/30 mL (10 mg/mL) carton containing one vial: NDC 25682-022-01; Store Ultomiris vials refrigerated at 2°C - 8°C (36°F - 46°F) in the original carton to protect from light. code ndc unit qualifier ndc strength number ndc strength unit ndc volume unit ndc volume strength ndc strength ndc generic name cf j0280 ml 250mg/10ml 250 mg ml 10 0.1 aminophylline j0280 ml 500mg/20ml 500 mg ml 20 0.1 aminophylline j0290 500 mg ampicillin 500 mg inj hcpc code ndc unit qualifier ndc strength number ndc strength unit ndc Listing of a code in this policy does not imply that the service described by the code is a covered or non- covered health service. Enrollment in the ULTOMIRIS REMS program and additional information are available by telephone: 1-888-765-4747 or at www.ultomirisrems.com. Do not freeze. Injection, eculizumab, 10 mg. avsola, 10 mg ” for short, used in Medical care . ® & Ultomiris ®) (for Kentucky ... Applicable Codes . • Parker CJ. J1300. ULTOMIRIS is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS). J1303 HCPCS Code | Inj., ravulizumab-cwvz 10 mg | HCPCS Registry | Medical Coding Library | www.HIPAASpace.com © 2021. Ultomiris (ravulizumab-cwvz) is used for the treatment of paroxysmal nocturnal hemoglobinuria (PNH) and hemolytic uremic syndrome. PROCEDURES AND BILLING CODES To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD diagnostic codes. Under the ULTOMIRIS REMS, prescribers must enroll in the program. Do not shake. HCPCS Code Maximum Allowed Brand Generic Soliris eculizumab aHUS 1200 mg J1300 120 HCPCS units (10 mg per unit) MG/NMOSD 1200 mg J1300 120 HCPCS units (10 mg per unit) PNH 900 mg J1300 90 HCPCS units (10 mg per unit) Ultomiris ravulizumab-cwvz 3,600 mg total dose J1303 360 HCPCS units (10 mg per unit) HCPCS Code Description: Injection, ravulizumab-cwvz, 10 mg. HCPCS Code… J1303 Injection, ravulizumab-cwvz, (Ultomiris®) 10 mg (new code effective 10/1/19) Note: CPT codes, descriptions and materials are copyrighted … J1300 is a valid 2021 HCPCS code for Injection, eculizumab, 10 mg or just “ Eculizumab injection ” for short, used in Medical care . Drugs administered other than oral method, chemotherapy drugs. ULTOMIRIS is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS). (1) Enroll in the ULTOMIRIS REMS Click here to complete the ULTOMIRIS REMS Prescriber Enrollment online Or Print and sign the Prescriber Enrollment Form. Q5121 has been in effect since 07/01/2020. Q5121 is a valid 2021 HCPCS code for Injection, infliximab-axxq, biosimilar, (avsola), 10 mg or just “ Inj. 100 mg/mL (11 mL vial): J code, J1303; National Drug Code, NDC 25682-028-01 The ULTOMIRIS 10 mg/mL formulation comes in 1 single-dose vial, 300 mg/30 mL (blue cap), and is a clear to translucent, slight whitish color ULTOMIRIS 10 mg/mL NUMBER OF VIALS NEEDED FOR ULTOMIRIS WEIGHT-BASED DOSING: 10 mg/mL FORMULATION1 Body weight range (kg) ULTOMIRIS The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.

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