Edaravone IV (Radicava)

OFFICE ADMINISTRATION / HOME HEALTH

Indications for Prior Authorization:

  • Treatment of amyotrophic lateral sclerosis (ALS)

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by a physician who specializes in ALS, AND
  • 18 years or older, AND
  • Confirmed diagnosis of ALS with disease duration of no more than 2 years, AND
  • Patient is taking or is intolerant to riluzole

Dosing:

  • Initial treatment cycle: 60 mg IV daily for 14 days followed by a 14-day drug-free period
  • Subsequent treatment cycles: 60 mg IV daily for 10 days out of a 14-day period, followed by 14-day drug-free period

Approval:

  • Initial: 6 months
  • Renewal: 1 year