Edaravone Injection (Radicava)

Radicava (edaravone) is covered only for the FDA‑approved indication of ALS and is excluded for non‑ALS uses or for patients who do not meet the policy’s diagnostic, respiratory, or treatment criteria. Coverage requires a definite/probable ALS diagnosis per El Escorial or revised Airlie House criteria, ALSFRS‑R score ≥2 on each item, percent‑predicted FVC ≥80%, diagnosis ≤2 years, prior or concurrent riluzole therapy, prescription by or in consultation with an ALS specialist, adherence to the specified 60 mg IV infusion schedule, initial/renewal approvals limited to 6 months with documented ongoing benefit and no requirement for invasive ventilation.

"Medication history documenting that the individual has received or is currently receiving riluzole (Rilutek or generics), Tiglutik, or Exservan."

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