Radicava ORS — Medical Mutual

Amyotrophic Lateral Sclerosis

Initial criteria

Patient has diagnosis of clinically definite or probable ALS based on El Escorial revised criteria or Awaji criteria; AND
Patient has a disease duration of 2 years or less; AND
Patient has a percent-predicted forced vital capacity (%FVC) > 80%; AND
Baseline documentation of retained functionality for most activities of daily living [i.e., score of 2 or better on each individual item of ALS Functional Rating Scale-Revised (ALSFRS-R)] [documentation required]; AND
Patient has previously received a riluzole product OR Patient is currently receiving a riluzole product OR Patient will take Radicava ORS concomitantly with a riluzole product; AND
Patient will not use Radicava ORS concomitantly with any other medications containing Edavarone; AND
The medication is prescribed by or in consultation with a neurologist, a neuromuscular disease specialist, or a physician specializing in the treatment of ALS.

Patient does not require invasive ventilation; AND
According to the prescriber, the patient continues to benefit from therapy; AND
The medication is prescribed by or in consultation with a neurologist, a neuromuscular disease specialist, or a physician specializing in the treatment of ALS.

6 months