Tiglutik Kit — Medical Mutual

Preferred products

• generic riluzole oral tablets

Initial criteria

• Patient is age ≥ 18 years; AND
• Baseline ALS Functional Rating Scale-Revised (ALSFRS-R) score measured; AND
• Patient has normal respiratory function (defined as percent-predicted forced vital capacity values ≥ 60%); AND
• Prescribed by or in consultation with a neurologist or physician who specializes in the treatment of ALS; AND
• Patient must have previously tried therapy with generic riluzole oral tablets

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Baseline ALS Functional Rating Scale-Revised (ALSFRS-R) score measured; AND
• Prescribed by or in consultation with a neurologist or physician who specializes in the treatment of ALS; AND
• Patient must have previously tried therapy with generic riluzole oral tablets

Approval duration

initial 6 months; reauth 1 year