Alexion OneSource Inpatient Support Program

for Neuromyelitis optica spectrum disorder (NMOSD)

The Alexion OneSource Inpatient Support Program (ISP) is a voluntary support program for adult patients with anti-aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD). The Alexion OneSource Inpatient Support Program provides up to 3 doses of ULTOMIRIS® (ravulizumab-cwvz) medication free of charge to eligible patients with anti-AQP4 antibody-positive NMOSD who have a physician-determined urgent medical need to initiate treatment in an inpatient setting. The Program does not assist with infusion-related costs.

Program Eligibility & Information

Download and read the full Inpatient Support Program Terms and Conditions and Inpatient Support Program Guide below for eligibility requirements and program information.

Inpatient Support Program Terms and Conditions

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Inpatient Support Program Guide

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Getting the patient started

1

Inpatient Support Form for Healthcare Provider and Site of Care Pharmacy

The prescribing physician must complete and sign this form.

An additional signature attesting to the program terms and conditions is required on the form from the pharmacy receiving the free product.

Download Icon Download ISP Form

2

OneSource Patient Services Enrollment Form

The patient or their legal representative must complete and sign this form to enroll in OneSource.

OneSource is a complimentary, personalized patient support program offered by Alexion and tailored to the specific needs of adults living with NMOSD.

3

Fax completed forms to OneSource at 1-800-420-5150 or email to OneSource@alexion.com.

Adobe Sign forms will be automatically received upon completion.

Alexion will review the forms and coordinate with you and your patient on next steps to start therapy.

Questions? CONTACT ONESOURCE:

PHONE: 1.888.765.4747

EMAIL: OneSource@Alexion.com