By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by Blue Cross Blue Shield in Michigan: Prior Authorization Forms, Timelines, and Appeals Guide

Answer Box: Quick Path to Ultomiris Approval in Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Ultomiris (ravulizumab) under the medical benefit, with new step therapy requirements as of 2024. For commercial members, you must try an alternative therapy first; Medicare Advantage members need rituximab biosimilar trial for myasthenia gravis. Submit via Availity Essentials portal or the Ultomiris MARF form. Standard approval takes 5-7 business days. If denied, you have 127 days to file an external review with Michigan DIFS.

Start today: Confirm your plan type (commercial vs Medicare Advantage), download the correct PA form, and gather diagnosis documentation with prior therapy history.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Approval Timelines
  7. If You Need More Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps patients and clinicians navigate Blue Cross Blue Shield of Michigan's (BCBSM) prior authorization process for Ultomiris (ravulizumab), a complement inhibitor used to treat paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis, and neuromyelitis optica spectrum disorder (NMOSD).

Ultomiris costs approximately $474,000-$569,000 annually, making prior authorization nearly universal among insurers. BCBSM has specific requirements that vary by plan type and include new step therapy rules implemented in 2024.

Who this helps:

  • Patients prescribed Ultomiris by their specialist
  • Clinicians submitting prior authorization requests
  • Caregivers navigating insurance appeals
  • Anyone switching from Soliris to Ultomiris

Counterforce Health specializes in turning insurance denials into evidence-backed appeals for specialty medications like Ultomiris. Our platform analyzes denial letters and plan policies to create targeted rebuttals that align with payer-specific requirements, helping patients access life-changing treatments faster.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

BCBSM treats Ultomiris differently depending on your specific product:

Plan Type PA Requirements Step Therapy
Commercial BCBSM/BCN Medical benefit PA required Yes (as of July 2024)
Medicare Plus Blue/BCN Advantage Medical drug PA required Yes for MG (rituximab first)
Federal Employee Program (FEP) Separate FEP PA form No standard step therapy
Blue Cross Complete (Medicaid) HCPCS PA list Check current formulary
Tip: Your insurance card should indicate whether you have BCBSM commercial, BCN, Medicare Plus Blue, or another product line.

Step 2: Verify Medical vs. Pharmacy Benefit

Ultomiris is covered under the medical benefit (like other infused medications), not the pharmacy benefit. This means:

  • It's billed using HCPCS code J1303
  • Prior authorization goes through medical drug pathways
  • Cost-sharing follows your outpatient infusion benefits
  • It's not subject to pharmacy formulary tiers

Step 3: Check Network Status

Ensure your prescribing physician and planned infusion site are in-network with BCBSM. Out-of-network providers may require additional authorization or result in higher costs.

Gather Required Documentation

Core Requirements for All Requests

Patient Information:

  • Full name, date of birth, member ID
  • Contact information
  • Insurance card copy

Provider Information:

  • Prescriber name, NPI, specialty
  • Office address and contact information
  • Servicing location for infusions

Clinical Documentation:

  • Confirmed diagnosis with ICD-10 code:
    • PNH: D59.5
    • aHUS: D59.3
    • Myasthenia gravis: G70.00 or G70.01
    • NMOSD: G36.0
  • Recent clinic notes (within 30-60 days)
  • Relevant laboratory results
  • Diagnostic test results (flow cytometry for PNH, complement studies for aHUS)

Step Therapy Documentation (Required for 2024+)

Due to new BCBSM step therapy requirements, you must document:

For Commercial Members (effective July 22, 2024):

  • Trial and failure of at least one clinically appropriate alternative
  • Specific reasons for failure (lack of efficacy, intolerance, contraindications)
  • Dates of prior therapy and outcomes

For Medicare Advantage MG Patients (effective February 3, 2025):

  • Trial of rituximab biosimilar (Ruxience Q5119 or Riabni Q5123) first
  • Documentation of inadequate response or contraindication

Indication-Specific Requirements

PNH:

  • Flow cytometry confirming GPI-anchor deficient clone
  • Evidence of hemolysis: elevated LDH (≥1.5× ULN), low haptoglobin
  • Transfusion history if applicable

aHUS:

  • Microangiopathic hemolytic anemia evidence
  • Negative Shiga toxin testing
  • ADAMTS13 activity >5% (to exclude TTP)
  • Kidney function markers

Myasthenia Gravis:

  • MGFA class II-IV severity
  • Positive anti-AChR antibody results
  • MG-ADL or QMG scores
  • Prior immunosuppressive therapy history

NMOSD:

  • Positive AQP4-IgG by cell-based assay
  • History of NMOSD attacks
  • EDSS or similar disability measures

Safety Requirements

Meningococcal Vaccination:

  • ACWY and serogroup B vaccines completed
  • If starting <2 weeks after vaccination, provide antibiotic prophylaxis plan
  • Documentation of vaccination dates

Submit Your Prior Authorization Request

Commercial BCBSM/BCN Members

Electronic Submission (Preferred):

  1. Log into Availity Essentials
  2. Navigate to Payer Spaces → BCBSM/BCN
  3. Select "Medical/Pharm Drug Benefit Prior Auth (Commercial)"
  4. Complete the Ultomiris-specific questions in NovoLogix
  5. Upload supporting documentation

Paper/Fax Backup:

Medicare Plus Blue/BCN Advantage Members

  • Use the Medicare medical drug prior authorization pathway
  • Submit through NovoLogix or plan's medical drug PA process
  • Use the Global PA/medical drug form rather than the commercial MARF
  • Follow the Medicare medical drug PA list requirements

Federal Employee Program (FEP) Members

Clean Request Packet Checklist

✓ Completed PA form with all required fields
✓ Recent clinic note documenting diagnosis and severity
✓ Laboratory results supporting indication
✓ Prior therapy documentation for step therapy
✓ Vaccination records
✓ Dosing and administration plan
✓ Provider NPI and contact information

Follow-Up and Tracking

When to Call

  • 3-5 business days after submission to confirm receipt
  • If no response within stated timeframe
  • To provide additional information requested

What to Ask

  • Reference number for your PA request
  • Expected decision timeframe
  • Any missing information needed
  • Status of clinical review

Sample Call Script

"I'm calling to check on the status of a prior authorization for Ultomiris for patient [Name], member ID [Number]. The request was submitted on [Date] via [method]. Can you provide the reference number and expected decision date?"

Documentation Tips

  • Keep a log of all calls with dates, times, and representative names
  • Save reference numbers and case IDs
  • Document any verbal commitments or next steps

Typical Approval Timelines

Standard Processing Times

Commercial Plans:

  • Standard PA: 5-7 business days
  • Expedited/urgent: 24-48 hours when clinically appropriate

Medicare Advantage:

  • Standard: Up to 14 days for medical benefit drugs
  • Expedited: 72 hours for urgent requests

What Speeds Decisions

  • Complete documentation submitted initially
  • Clear medical necessity rationale
  • Proper step therapy documentation
  • Electronic submission when available

What Slows Decisions

  • Missing clinical information
  • Incomplete step therapy documentation
  • Need for peer-to-peer review
  • Requests exceeding labeled dosing

If You Need More Information

Common Information Requests

Clinical Clarification:

  • Additional laboratory values
  • More detailed treatment history
  • Specialist consultation notes
  • Updated severity assessments

Administrative Details:

  • Corrected dosing information
  • Site of care confirmation
  • Provider credentialing verification

Handling Medical Necessity Questions

When BCBSM requests additional justification:

  1. Review the specific question in their request letter
  2. Provide targeted responses with clinical evidence
  3. Include relevant guidelines from medical societies
  4. Cite FDA labeling when appropriate
  5. Submit promptly to avoid delays
Note: Counterforce Health can help craft evidence-backed responses to medical necessity questions, using our database of payer-specific criteria and successful appeal strategies.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Step therapy not met Document prior therapy failure/contraindication
Lack of medical necessity Provide additional clinical evidence and guidelines
Dosing exceeds label Justify with clinical rationale or adjust dose
Missing vaccination Submit meningococcal vaccination records
Incomplete documentation Provide requested clinical information

First-Level Appeal Process

Timeline: Submit within 60 days of denial notice

Required Documents:

  • Original denial letter
  • Updated clinical information
  • Medical necessity letter addressing denial reasons
  • Supporting literature or guidelines

Submission: Use BCBSM's standard appeal process or provider portal

Peer-to-Peer Review

If offered a peer-to-peer review:

  • Schedule promptly (usually within 72 hours)
  • Have prescribing physician participate
  • Prepare key clinical points and guideline references
  • Document the conversation outcome

External Review with Michigan DIFS

If internal appeals fail, Michigan offers binding external review:

Eligibility:

  • Received final adverse determination from BCBSM
  • File within 127 days of final denial
  • Service is a covered benefit under the plan

Process:

  • Submit External Review Request to Michigan DIFS
  • Standard review: up to 60 days
  • Expedited review: 72 hours for urgent cases
  • Decision is binding on the insurer

Contact: Michigan DIFS Consumer Hotline at (877) 999-6442

Renewal and Re-Authorization

When to Resubmit

Most BCBSM approvals are for 6-12 months. Calendar renewal dates and submit 30-60 days before expiration.

Documentation for Renewals

Clinical Response Evidence:

  • Laboratory improvements (normalized LDH, stable platelets)
  • Reduced transfusion requirements
  • Improved functional scores (MG-ADL, QMG)
  • Absence of disease progression

Safety Monitoring:

  • No serious adverse events
  • Continued vaccination compliance
  • Regular monitoring results

Ongoing Medical Necessity:

  • Risk of relapse if discontinued
  • Lack of alternative effective treatments
  • Maintained quality of life improvements

Quick Reference Checklist

Before Starting

□ Verify BCBSM plan type and medical benefit coverage
□ Confirm in-network providers
□ Gather diagnosis documentation and ICD-10 codes
□ Document prior therapy for step therapy requirements
□ Ensure meningococcal vaccination completion

Submission

□ Use correct PA form for plan type
□ Submit electronically via Availity when possible
□ Include complete clinical documentation
□ Provide clear medical necessity rationale
□ Follow up within 3-5 business days

If Denied

□ Review denial letter for specific reasons
□ Gather additional evidence addressing concerns
□ Submit first-level appeal within 60 days
□ Consider peer-to-peer review if offered
□ File DIFS external review within 127 days if needed

Renewal

□ Calendar renewal date 30-60 days in advance
□ Document clinical response and continued necessity
□ Submit before current authorization expires

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan terms. Consult your healthcare provider for medical guidance and your insurance plan for specific coverage details.

For additional help with Michigan insurance appeals, contact the Michigan Department of Insurance and Financial Services at (877) 999-6442.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.