Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
Edaravone (Radicava) intravenous infusion may be considered medically necessary when
ALL
of the following criteria are met:
Initial Authorization Criteria:
-
The individual has a diagnosis of amyotrophic lateral sclerosis (ALS);
and
-
The individual has had the diagnosis of ALS for a duration of 2 years or less;
and
-
The individual has a baseline percent forced vital capacity (FVC%) or slow vital capacity (SVC) of 80% or greater;
and
-
The individual is able to perform most activities of daily living, defined as scores of two (2) points or better on each individual item of the ALS Functional Rating Scale - Revised [ALSFRS-R];
and
-
ONE of the following:
-
BOTH of the following:
-
The individual is currently being treated with riluzole;
or
-
The individual will continue riluzole in combination with edaravone (Radicava);
or
-
The individual has an intolerance, hypersensitivity, or FDA labeled contraindication to riluzole;
and
- The prescriber is a specialist in the area of the individual's diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis.
Initial Approval:
Six (6) months
Reauthorization Criteria:
-
The individual has been previously approved for edaravone (Radicava) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
The individual has had documented clinical benefit with edaravone (Radicava);
and
-
The individual is NOT dependent on invasive ventilation or tracheostomy;
and
- The prescriber is a specialist in the area of the individual's diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis.
Reauthorization Approval:
12 months
The use of edaravone (Radicava) is considered experimental/investigational and therefore non-covered for any other indications. Scientific evidence does not support its use for any other indications.
Procedure Code
