CurrentMass General Brigham Health PlanPolicy N/A

Tiglutik (riluzole) oral suspension – Pharmacy prior authorization

Pharmacy prior authorization policy for Tiglutik (riluzole) oral suspension for members of Mass General Brigham Health Plan (Commercial/Exchange). Governs initial and reauthorization criteria, limits, and contact information for pharmacy benefit requests.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTiglutik (riluzole) oral suspension – Pharmacy prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and provide documentation of ALS diagnosis, member age ≥18, and inability to swallow oral riluzole tablets (or for new-to-plan members, evidence they are currently receiving the medication).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PharmacyBenefit type

Prior AuthProgram type

≥18Minimum age

24 moApproval duration

Commercial/ExchangeApplicable plan

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

COVERAGE CRITERIA

Authorization may be granted when EITHER of the following is true:

Any of the following pathways

Pathway A - Continuation for new-to-plan members: Member is new to the plan within the past 90 days AND is currently receiving the requested medication (excludes samples and manufacturer's patient assistance programs)
Requires documentation of current therapy
Pathway B - Initial or switch authorization: Member has diagnosis of amyotrophic lateral sclerosis (ALS) AND member is at least 18 years of age AND documentation that member is unable to swallow oral riluzole tablets
All three conditions must be met

Coverage is not granted for members who are new to the plan within the past 90 days unless there is documentation that the member is currently receiving the requested medication. Requests where the medication was obtained as samples or through the manufacturer's patient assistance program are excluded from being considered current therapy for continuity-of-care authorization.

Initial Therapy

Initial authorization criteria

Initial authorization: Member is diagnosed with amyotrophic lateral sclerosis (ALS) AND member is at least 18 years of age AND documentation member is unable to swallow oral riluzole tablets

All conditions required

Continuation Therapy

Continuation for members new to the plan

New-to-plan continuity: Member is new to the plan within the past 90 days AND is currently receiving the requested medication (excluding samples and manufacturer's patient assistance programs)

Documentation required

Provider Actions & Authorization Details

Prior Authorization

Prior Authorization Required

Prior authorization is required for Tiglutik (riluzole) oral suspension under the pharmacy benefit.

Pharmacy benefit prior authorization required
Contact Pharmacy Benefit: Phone 800-711-4555, Fax 844-403-1029

Step Therapy

No step therapy requirement applies for this medication under the plan.

Documentation Required

Required Documentation

Documentation must support the diagnosis and clinical need for the oral suspension formulation.

Definitions

inv-09: Tiglutik (riluzole) oral suspension — Definition / product summary and prescribing information citation

DrugTiglutik (riluzole) oral suspension

IndicationTreatment of amyotrophic lateral sclerosis (ALS)

FormulationOral suspension — for patients unable to swallow oral tablets

Prescribing informationTiglutik (riluzole) [prescribing information], EDW Pharma, Inc; September 2025.

Key supporting referencesBensimon et al., N Engl J Med 1994;330:585; Miller et al., Cochrane Database Syst Rev 2012; Tiglutik PI (2025)

Background

Riluzole is indicated for the treatment of amyotrophic lateral sclerosis (ALS). The oral suspension formulation (Tiglutik) provides an alternative for patients who are unable to swallow oral tablets; coverage decisions follow the plan’s prior authorization criteria requiring documentation of ongoing treatment for new-to-plan members or meeting diagnosis and functional swallowing criteria for new starts.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTiglutik (riluzole) oral suspension – Pharmacy prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

SourceLink

On This Page

Documentation of amyotrophic lateral sclerosis (ALS) diagnosis
Member is at least 18 years of age
Documentation that member is unable to swallow oral riluzole tablets (necessitating suspension formulation)

Documentation Required

New‑to‑Plan Continuity

For members new to the plan within the past 90 days, authorization may be granted when the member is currently receiving the requested medication.

Applies only when member is actively receiving the medication prior to plan enrollment
Does not apply when the product was obtained as samples or through manufacturer patient assistance programs

Denial Risk

Triggers for Denial

Authorizations may be denied if required criteria or documentation are missing or not met.

No documentation of ALS diagnosis
Member is younger than 18 years of age
No documentation that member is unable to swallow riluzole tablets
New-to-plan continuity not met (e.g., medication obtained only as samples or via patient assistance programs)