Radicava ors — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 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 ALL of the following:
• Diagnosis of amyotrophic lateral sclerosis (ALS)
• Diagnosis duration ≤ 2 years
• Baseline percent forced vital capacity (FVC%) or slow vital capacity (SVC) ≥ 80%
• Able to perform most activities of daily living (scores ≥ 2 points on each ALSFRS-R item)
• EITHER BOTH of the following: currently treated with riluzole AND will continue riluzole in combination with requested agent OR has intolerance, hypersensitivity, or FDA labeled contraindication to riluzole
• Prescriber is a neurologist or has consulted a specialist in the area of the diagnosis
• No FDA labeled contraindications to requested agent

Reauthorization criteria

• Previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a neurologist or has consulted with a specialist in the area of the diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

6 months (initial); 12 months (renewal)