Edaravone Injection (Radicava)

Covered only for ALS when ALL initial criteria are met—definite/probable ALS per El Escorial/Airlie House, ALSFRS‑R ≥2 on every item, percent‑predicted FVC ≥80%, diagnosis ≤2 years, prior/concurrent riluzole, and prescribed by or in consultation with an ALS specialist; any failure to meet these criteria is excluded. Approvals are 6 months and re‑authorization requires documented ongoing benefit, no invasive ventilation, continued specialist involvement, and submission of diagnostic, ALSFRS‑R, PFT, riluzole, and prescriber documentation.

"For the treatment of amyotrophic lateral sclerosis (ALS) — Initial Authorization: patient must meet ALL of the following: Has a "definite" or "probable" diagnosis of amyotrophic lateral sclerosis (..."

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