CommercialPrior AuthHigh impact
Edaravone Injection (CPB 0918, reviewed 2026-07-02)
Aetna·Neurology, Pharmacy·Pharmacy
Effective date
Jul 2, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its Clinical Policy Bulletin for edaravone injection (Radicava and generics) effective 2026-07-02, requiring precertification for all commercial medical plans before administration. The policy covers edaravone only for definite/probable ALS patients with specific functional criteria (ALSFRS-R score ≥2 on all 12 areas) and without continuous invasive ventilation. All other indications remain experimental/investigational.
Action Required
By 2026-07-02, the billing and clinical authorization teams must: (1) Update billing system to require precertification for all edaravone injection claims (HCPCS J1301) for commercial plans BEFORE infusion is administered; (2) Configure system to flag claims with ICD-10 code G12.21 (ALS) to route to precertification workflow using contact numbers (866) 752-7021 or fax (888) 267-3277; (3) Instruct providers that edaravone must be prescribed by or in consultation with a neurologist, neuromuscular specialist, or ALS specialist—add specialty requirement to order entry; (4) Update prior authorization forms to verify: diagnosis of definite/probable ALS, ALSFRS-R score documentation showing ≥2 points on all 12 areas, and confirmation that patient does NOT require continuous invasive ventilation; (5) Communicate to all neurologists and infusion centers that Radicava IV branded formulation distribution/production ends April 1, 2025, with shift to generic formulations; (6) Configure system to deny or route for medical review any claims for non-ALS indications listed as experimental (e.g., stroke, Parkinson's, Alzheimer's, MS). Claims submitted without precertification or missing required ALSFRS-R documentation will be denied.