Radicava ORS (edaravone) — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of ALS (ICD-10: G12.21)
• ALS is classified as 'Definite' or 'Probable' based on the El Escorial revised criteria
• ALS Functional Rating Scale-Revised (ALSFRS-R) score ≥ 2 in all items at initiation of treatment
• baseline forced vital capacity (FVC) ≥ 80%
• member is not dependent on invasive ventilation or tracheostomy
• disease duration less than 2 years when therapy with Radicava or Radicava ORS was initiated

Reauthorization criteria

• prescriber attests member has experienced stability or improvement in symptoms of ALS
• member is not dependent on invasive ventilation or tracheostomy

Approval duration

12 months