edaravone oral suspension — Blue Cross Blue Shield of Illinois

amyotrophic lateral sclerosis (ALS)

Initial criteria

ONE of the following:
A. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
B. ALL of the following:
1. The patient has a diagnosis of amyotrophic lateral sclerosis (ALS) AND
2. The patient has had the diagnosis of ALS for a duration of 2 years or less AND
3. The patient has a baseline percent forced vital capacity (FVC%) or slow vital capacity (SVC) of 80% or greater AND
4. The patient is able to perform most activities of daily living, defined as scores of 2 points or better on each individual item of the ALS Functional Rating Scale – Revised (ALSFRS-R) AND
5. ONE of the following:
A. BOTH of the following:
1. The patient is currently being treated with riluzole AND
2. The patient will continue riluzole in combination with the requested agent OR
B. The patient has an intolerance, hypersensitivity, or FDA-labeled contraindication to riluzole AND
2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist), or has consulted with a specialist in the area of the patient’s diagnosis AND
3. The patient does NOT have any FDA-labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
2. The patient has had clinical benefit with the requested agent AND
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or has consulted with a specialist in the area of the patient’s diagnosis AND
4. The patient does NOT have any FDA-labeled contraindications to the requested agent

6–12 months