Radicava ORS (edaravone) — United Healthcare
amyotrophic lateral sclerosis (ALS)
Initial criteria
- EITHER both of the following:
- (1) Patient has been established on therapy with edaravone for ALS under an active UnitedHealthcare medical benefit prior authorization
- AND (2) All of the following:
- • Diagnosis of ALS
- • Prescribed by, or in consultation with, a neurologist with expertise in the diagnosis of ALS
- • Patient is currently receiving edaravone therapy
- • Patient is not dependent on invasive ventilation
- OR all of the following:
- (1) Submission of medical records (e.g., chart notes, previous medical history, diagnostic testing including imaging, nerve conduction studies, laboratory values) to support the diagnosis of ALS
- AND (2) Prescribed by, or in consultation with, a neurologist with expertise in the diagnosis of ALS
- AND (3) Submission of the most recent ALS Functional Rating Scale-Revised (ALSFRS-R) score confirming that the patient has scores ≥ 2 in all items of the ALSFRS-R criteria at the start of treatment
- AND (4) Submission of medical records (e.g., chart notes, laboratory values) confirming that the patient has a percent forced vital capacity (%FVC) ≥ 80% at the start of treatment
Reauthorization criteria
- Diagnosis of ALS
- Prescribed by, or in consultation with, a neurologist with expertise in the diagnosis of ALS
- Patient is currently receiving Radicava ORS therapy
- Patient is not dependent on invasive ventilation
Approval duration
12 months