Ultomiris (ravulizumab)

Do You Qualify?

Income Limits (500% FPL)

Income threshold is typically 500% FPL; specific eligibility is determined on a case-by-case basis by Alexion.

Based on 2025 HHS Federal Poverty Level guidelines.

# Alexion OneSource Patient Assistance Guide for Ultomiris (ravulizumab)

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Who Qualifies for the Alexion OneSource?

If you have been prescribed Ultomiris (ravulizumab) and cannot afford it, you may be able to get it at little or no cost through the Alexion OneSource patient assistance program. This program is run directly by Alexion, the maker of Ultomiris. For a single-person household, the income limit is typically $75,300 per year. In general, you must be uninsured, underinsured, or have government insurance such as Medicare and be unable to afford your out-of-pocket costs. Eligibility is reviewed on a case-by-case basis, so even if you are not sure you qualify, it is worth applying. The program covers patients with PNH, aHUS, gMG, and NMOSD who have a valid prescription from their doctor.

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About Ultomiris (ravulizumab)

Ultomiris is a complement inhibitor — specifically, a C5 monoclonal antibody — manufactured by Alexion, an AstraZeneca company. It has received FDA approval for four serious conditions: paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized Myasthenia Gravis (gMG), and Neuromyelitis Optica Spectrum Disorder (NMOSD). Ultomiris is administered by intravenous infusion, typically every eight weeks for adults with PNH or aHUS. Because it is a biologic medication with no FDA-approved biosimilar alternatives currently on the market, the list price is extremely high — often hundreds of thousands of dollars per year — making financial assistance programs critical for many patients who need this treatment.

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Income Eligibility: Full Breakdown

Alexion OneSource uses income guidelines set at approximately 500% of the Federal Poverty Level (FPL). The table below shows the maximum annual household income allowed for each household size:

| Household Size | Max Annual Income |

|---|---|

| 1 person | $75,300 |

| 2 persons | $102,200 |

| 3 persons | $129,100 |

| 4 persons | $156,000 |

If your household has more than four people, the income limit increases with each additional member. Contact Alexion OneSource directly at (888) 765-4747 to ask about your specific household size.

Your income is typically verified using your most recent federal tax return, your W-2 forms, or three months of recent pay stubs. If your income has changed significantly since last year — for example, due to job loss — you may be able to use current pay stubs rather than a prior-year tax return.

If your income is above these limits, do not assume you are automatically disqualified. Alexion reviews applications individually, and there may be room for exceptions depending on your medical costs and financial situation. It is still worth calling the program to discuss your options before giving up.

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Insurance Requirements Explained

Your insurance status plays a major role in how the program helps you:

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Step-by-Step: How to Apply

Follow these steps to apply for Alexion OneSource:

1. Gather your documents. You will need a completed OneSource Enrollment Form, proof of household income (such as a recent tax return, W-2, or three months of pay stubs), and a valid prescription for Ultomiris from your doctor.

2. Get the enrollment form. Download it at https://alexiononesource.com/ or call (888) 765-4747 to have one mailed or faxed to you.

3. Have your doctor complete their section. The enrollment form includes a prescriber section. Your doctor or their office staff will need to fill this out and sign it.

4. Choose how to submit your application. You have several options:

- Online: Submit your application at https://alexiononesource.com/

- By phone: Call (888) 765-4747 for guided assistance

- By fax: Send completed documents to (800) 420-5105

5. Confirm receipt. After submitting, follow up with the program to confirm that all documents were received and your application is complete.

6. Wait for a decision. Processing typically takes 7 to 10 business days after a complete application is received.

7. Notify your doctor. Once approved, the medication will be shipped directly to your prescriber's office or infusion center, not to your home.

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What to Expect: Timeline and Delivery

After you submit a complete application, Alexion OneSource typically processes it within 7 to 10 business days. You and your prescriber will be notified of the approval decision. If approved, Ultomiris will be shipped directly to your prescriber or infusion center — not to your home. You do not need to pick it up yourself or arrange shipping. Your doctor's office will coordinate your infusion appointment.

Your enrollment is not permanent. You will need to reauthorize your enrollment once per year to continue receiving the medication. Alexion will typically contact you or your doctor's office before your renewal is due. Be sure to gather updated income documents at that time to avoid any gap in your supply.

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Alternatives If You Don't Qualify

If you do not qualify for Alexion OneSource, here are other options to explore:

1. Biosimilars: There are currently no FDA-approved biosimilar versions of Ultomiris (ravulizumab) on the market. This option is not available at this time.

2. Manufacturer savings card: If you have commercial (private) insurance, Alexion offers a co-pay savings card that may reduce your out-of-pocket costs. You can find this program at https://www.ultomiris.com/onesource/financial-support.

3. State Pharmaceutical Assistance Programs (SPAPs): Many states run their own programs to help residents pay for high-cost medications. These programs vary widely by state. Contact your state's department of health or aging services to ask what is available where you live.

4. NeedyMeds.org: This free, independent website lists hundreds of patient assistance programs, co-pay cards, and disease-specific foundations that may be able to help. Visit www.needymeds.org and search for Ultomiris to see additional resources. There is no cost to use this database.

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*This guide is for informational purposes only and does not constitute medical or legal advice. Eligibility determinations are made solely by Alexion / AstraZeneca. Program terms may change — verify current requirements at [https://www.alexion.com/patients/patient-assistance-programs](https://www.alexion.com/patients/patient-assistance-programs) before applying.*

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