Radicava ors — Blue Cross Blue Shield of New Mexico

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:
• • The patient has a diagnosis of amyotrophic lateral sclerosis (ALS)
• • The patient has had the diagnosis of ALS for a duration of 2 years or less
• • The patient has a baseline percent forced vital capacity (FVC%) or slow vital capacity (SVC) of 80% or greater
• • 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)
• • 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
• • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

BCBSIL:12months; others:6months initial,12months renewal