CommercialPrior AuthMedium impact
State and School Employees' Health Insurance Plan - Radicava (edaravone)
Blue Cross & Blue Shield of Mississippi·MS · Neurology·Medical Policy
We identified it
Jun 20, 2026
Summary
This policy establishes criteria for coverage of Radicava (edaravone) for ALS treatment under the State and School Employees' Health Insurance Plan. The policy requires prior authorization with specific clinical criteria including ALS diagnosis within 24 months, normal respiratory function, and specialist prescriber involvement.
Action Required
Immediately: Billing team must ensure prior authorization is obtained before administering Radicava (J1301) for ALS patients. Verify all clinical criteria are met including: patient is 18+ years old, ALS diagnosed within 24 months, baseline ALSFRS-R score ≥2 on all criteria, FVC ≥80% predicted, and prescriber is a neurologist or has neurologist consultation. Update billing system to flag J1301 for prior auth requirement. Claims will be denied without proper authorization.