Edaravone Injection (Radicava)

Radicava (edaravone) is covered only for patients with a "definite" or "probable" ALS diagnosis per El Escorial or revised Airlie House criteria and is excluded for those with "possible" ALS/other motor neuron diseases, any ALSFRS‑R item <2, FVC <80%, diagnosis >2 years, no prior/current riluzole, or no specialist involvement. Initial and renewal approvals (each up to 6 months) require documentation of the applied diagnostic criteria, ALSFRS‑R scores (each item ≥2), percent‑predicted FVC ≥80%, diagnosis date ≤2 years, receipt of riluzole, specialist prescription/consult note, a dosing plan (60 mg IV per recommended cycle), and for reauthorization evidence of continued benefit and no invasive ventilation.

"For the treatment of amyotrophic lateral sclerosis (ALS) — Initial Authorization: The individual must meet ALL of the following criteria for approval:"

Sign up to see full coverage criteria, indications, and limitations.