What Can I Expect to Pay for ULTOMIRIS®?
Pay as
little as
for ULTOMIRIS
if you have commercial insurance*
Additional eligibility requirements apply; see Terms and Conditions.
If you are starting treatment with ULTOMIRIS, but are concerned about how to pay for it, we may be able to help
Typically, you will pay a copay or coinsurance for the visit when you receive your ULTOMIRIS dose. There may or may not be additional fees for the infusion itself depending on your health plan. The table below outlines out-of-pocket (OOP) expenses by insurance type.
Insurance Types
OOP Expenses |
OOP Maximums |
|---|---|
Private insurance |
|
|
Deductibles and your copayment/ |
Your plan will have an OOP maximum for a plan year. |
Medicare Part B |
|
|
After the annual deductible is paid, you will usually pay 20% of the cost of ULTOMIRIS and 20% for each infusion. However, supplemental insurance such as Medigap will help cover all or a portion of these costs. Over 90% of Medicare patients have some type of supplemental insurance, which reduces OOP costs for infusions. |
No OOP maximum. |
Medicare Part C |
|
|
Your deductible and copayment/ |
Your Medicare plan has an annual OOP maximum. |
Medicare Part D |
|
|
You may have 4 different phases of coverage in Part D, including a deductible, an initial coverage phase, donut hole, and catastrophic coverage. |
There is no true OOP maximum in Part D. Once you get to catastrophic coverage, you may pay 5% for the remainder of the plan year. |
The Alexion OneSource™ CoPay Program helps people pay for eligible out-of-pocket medication and infusion costs
Program Eligibility
Patient enrolled in OneSource
Patient with commercial insurance who has a valid prescription for a US FDA–approved indication for ULTOMIRIS (ravulizumab-cwvz)
Patient must reside and receive treatment with ULTOMIRIS in the United States or its territories
How to Apply for the Alexion OneSource CoPay Program
Fill out the Alexion OneSource Enrollment Form
The Enrollment Form can be found at AlexionOneSource.com
Submit form
Simply fill out the form online, or send the printed form to OneSource at OneSource@Alexion.com. You can always call OneSource at 1-877-464-8586 if you have questions while completing or submitting the form
Receive CoPay ID number from OneSource
You will receive communication from OneSource containing the CoPay ID number
Provide CoPay ID number to site of care
Remember, you can always call OneSource with any questions about the CoPay Program
Navigating your health plan’s approval process for ULTOMIRIS
After you are prescribed ULTOMIRIS, your doctor’s office may research your health plan’s coverage, a process called a Benefits Investigation. OneSource, Alexion’s personalized patient support program, can also conduct a simultaneous Benefits Investigation to make sure that there is complete understanding of your insurance benefits. After a Benefits Investigation, you and your doctor can have a complete picture of ULTOMIRIS coverage and will understand any requirements to access ULTOMIRIS and your OOP costs for ULTOMIRIS.
The Benefits Investigation helps you and your doctor’s office understand:
Current Coverage
Your current coverage for ULTOMIRIS
Approvals
Requirements your insurance company or health plan has to get ULTOMIRIS approved such as a Prior Authorization or a Letter of Medical Necessity
Coverage Restrictions
If there are any coverage restrictions such as the need for a referral or staying within network
Receiving ULTOMIRIS
Whether your insurance company requires you to receive ULTOMIRIS at a particular site of care including: the hospital, doctor’s office, infusion center, or through a home infusion benefit that allows you to receive ULTOMIRIS at home
Medical Exception
If you need to file a request for a Medical Exception
Out-of-Pocket Costs
Your OOP costs and information about your deductible, copayment, coinsurance, and annual OOP maximum with your plan
Want to learn more about savings and affordability with ULTOMIRIS? Download this comprehensive insurance guide
Download the market access brochureWant to learn more about support with OneSource?
Call us at 1-877-GMG-ULTO (877-464-8586)
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