Ultomiris Prior Authorization Resources

Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.

Last verified: May 11, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 11, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 11, 2026
California - Uniform Prior Authorization FormCalifornia · Updated May 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated May 11, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated May 11, 2026
Cigna - Ultomiris Prior Authorization Form Cigna Corporation · Updated May 16, 2026

ICD-10 codes for Ultomiris Prior Authorizations

D59.5Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli]
D59.3Hemolytic-uremic syndrome
G70.0Myasthenia gravis
G36.0Neuromyelitis optica [Devic]

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Coverage Authorization Appeals: Generalized Myasthenia Gravis (gMG)Coverage Authorization Appeals: Generalized Myasthenia Gravis (gMG) resource
Letter of Medical Necessity: Generalized Myasthenia Gravis (gMG)Letter of Medical Necessity: Generalized Myasthenia Gravis (gMG) resource
Coverage Authorization Appeals: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)Coverage Authorization Appeals: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD) resource
Letter of Medical Necessity: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)Letter of Medical Necessity: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD) resource
Coverage Authorization Appeals: Atypical Hemolytic Uremic Syndrome (aHUS)Coverage Authorization Appeals: Atypical Hemolytic Uremic Syndrome (aHUS) resource
Letter of Medical Necessity: Atypical Hemolytic Uremic Syndrome (aHUS)Letter of Medical Necessity: Atypical Hemolytic Uremic Syndrome (aHUS) resource
Coverage Authorization Appeals: Paroxysmal Nocturnal Hemoglobinuria (PNH)Coverage Authorization Appeals: Paroxysmal Nocturnal Hemoglobinuria (PNH) resource
Letter of Medical Necessity: Paroxysmal Nocturnal Hemoglobinuria (PNH)Letter of Medical Necessity: Paroxysmal Nocturnal Hemoglobinuria (PNH) resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

Field Reimbursement ManagerField Reimbursement Manager resource
Access and Reimbursement Guide: All IndicationsAccess and Reimbursement Guide: All Indications resource
Reauthorization Guide: All IndicationsReauthorization Guide: All Indications resource
Billing & Coding Guide: Generalized Myasthenia Gravis (gMG)Billing & Coding Guide: Generalized Myasthenia Gravis (gMG) resource
Billing & Coding Guide: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)Billing & Coding Guide: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD) resource
Billing & Coding Guide: Atypical Hemolytic Uremic Syndrome (aHUS)Billing & Coding Guide: Atypical Hemolytic Uremic Syndrome (aHUS) resource
Billing & Coding Guide: Paroxysmal Nocturnal Hemoglobinuria (PNH)Billing & Coding Guide: Paroxysmal Nocturnal Hemoglobinuria (PNH) resource
PA Criteria: Generalized Myasthenia Gravis (gMG)PA Criteria: Generalized Myasthenia Gravis (gMG) resource
PA Criteria: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD)PA Criteria: AQP4 Antibody-Positive Neuromyelitis Optica Spectrum Disorder (NMOSD) resource

Support for Getting Your Patient on Ultomiris

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