Edaravone

Edaravone (Radicava) is covered for treatment of amyotrophic lateral sclerosis (ALS) in adults when prescribed for patients with definite or probable ALS by the revised El Escorial criteria who retain most activities of daily living (ALSFRS‑R ≥2 on each item), have normal respiratory function (FVC ≥80%), and have disease duration ≤2 years. Coverage is limited to uses and dosing consistent with FDA labeling or authoritative compendia (or supported by two peer‑reviewed articles for off‑label uses), requires meeting the policy’s initiation criteria, and is denied when evidence thresholds, dosing recommendations, or plan/state exclusions are not met; Radicava ORS is managed under the pharmacy benefit.

"Drug therapy is covered when it is proven effective for the relevant diagnosis or procedure."

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