CurrentMass General Brigham Health PlanPolicy N/A

Amyotrophic Lateral Sclerosis Agents Radicava (edaravone injection) edaravone vial Effective 05

Defines prior authorization criteria, continuation (reauthorization) requirements, quantity/approval durations, benefit routing (medical vs pharmacy), and specialty/provider requirements for Radicava (edaravone injection) and edaravone vial for treatment of amyotrophic lateral sclerosis (ALS) under Mass General Brigham Health Plan / MassHealth.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAmyotrophic Lateral Sclerosis Agents Radicava (edaravone injection) edaravone vial Effective 05

Policy CodePolicy N/A

Change TypeAdded edaravone and vial; admin and criteria updates

Effective DateMay 12, 2025

Next Review Date

Key ActionPrior authorization is required for Radicava (edaravone injection) and edaravone vial; include prescriber specialty or specialist consult notes, pre-treatment ALSFRS-R with individual domain scores and disease duration, and medical records confirming ALS per El Escorial criteria.

SourceLink

POLICY UPDATE CHANGES

Admin update separating Radicava injection criteria from ALS guideline to create own medical benefit policy while other agents in this class will be on pharmacy benefit; included A-rated generic of Radicava injection.

Clarified that Radicava ORS (edaravone suspension) is only available through the pharmacy benefit.

Updated provider specialty requirement to include neuromuscular specialist or other ALS treating specialists; added specific pre-treatment ALSFRS-R and FVC thresholds and ventilation exclusion to criteria.

Added edaravone and vial to policy; criteria requirements remain the same.

6 monthsApproval Duration

Specialty reqPrescriber Limitation