ph-1183
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Radicava (edaravone) Prior Authorization with Quantity Limit Program Summary

Policy Number: PH-1183

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

POLICY REVIEW CYCLE                                                                                                                                                

Effective Date

Date of Origin   

1/1/2023

FDA APPROVED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Radicava ORS®

(edaravone)

Oral suspension

Treatment of amyotrophic lateral sclerosis (ALS)

 

1

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS) is an idiopathic, fatal neurodegenerative disease.(2) It is characterized by loss of motor neurons in the spinal cord, brainstem, and motor cortex.(3) Age of onset is between 58-63 years for sporadic disease and 47-52 years for familial disease, with rapidly decreased incidence after 80 years. The clinical hallmark of ALS is the presence of upper and lower motor neuron (UMN and LMN) features involving brainstem and multiple spinal cord regions of innervation.(2)

 

ALS is a rapidly progressive disease with 50% of patients dying within 30 months of symptom onset, and about 20% of patients survive between 5 years and 10 years after symptom onset. Older age at symptom onset, early respiratory muscle dysfunction, and bulbar-onset disease are associated with reduced survival, whereas limb-onset disease, younger age at presentation, and longer diagnostic delay are independent predictors of prolonged survival. Dysphagia develops in most patients, with consequent weight loss and malnutrition. Respiratory compromise eventually develops in most cases, leading to exertional dyspnea, orthopnea, hypoventilation with resultant hypercapnia, and early morning headaches. Progressive weakening of the respiratory muscles leads to respiratory failure, often precipitated by pneumonia.(2)

 

Symptomatic treatments remain the cornerstone for management of patients with ALS. Disease modifying treatment options for ALS are limited. Riluzole is the only agent shown to have any impact on survival in ALS. The American Academy of Neurology (AAN) has recommended that riluzole be offered to slow disease progression in patients with ALS.(2) While edaravone has been shown to slow the decline of functional and quality of life ratings in patients with ALS, the short duration of trials did not allow for the assessment of an effect on survival.(6) According to CADTH Common Drug Review (CDR) of Radicava, Radicava should be considered for the majority of newly diagnosed ALS patients with preserved respiratory function and with functional independence. Patients with advanced ALS with severe disability, such as ventilator-dependence with very little limb function, are unlikely to benefit from therapy and should not be offered Radicava.(5)

Efficacy (1,4)

The efficacy of edaravone was evaluated in a post-hoc analysis of a 6-month, phase III randomized, placebo-controlled, double-blind study, in patients aged 20 to 75 years with ALS. All study patients had to meet all of the following criteria at screening:

  1. Functionality retained most activities of daily living (defined as scores of 2 points or better on each individual item of the ALS Functional Rating Scale – Revised [ALSFRS-R])
  2. Normal respiratory function (defined as percent-predicted forced vital capacity [%FVC] values of greater than or equal to 80%)
  3. Definite or probable ALS based on the El Escorial revised criteria
  4. Disease duration of 2 years or less

Patients who met the criteria above (n= 137) were randomized to receive either edaravone 60 mg intravenously (IV) or placebo for 6 cycles (4 weeks per cycle with 2 weeks on, 2 weeks off). 91% of patients in both the edaravone and placebo group were also receiving treatment with riluzole. The primary efficacy endpoint was change in the Revised ALS Functional Rating Scale (ALSFRS-R) score from baseline to 24 weeks or therapy discontinuation (if discontinuation occurred after the third cycle) after randomization. The change in ALSFRS-R score was -5.01 (SE 0.64) and -7.50 (0.66) in the edaravone and placebo group respectively. The trial authors concluded edaravone showed efficacy in a small subset of patients (i.e., those meeting the criteria noted above) and that “there is no indication that edaravone might be effective in a wider population of patients with ALS who do not meet the criteria”.

Safety (1)

Edaravone is contraindicated in patients with history of hypersensitivity to edaravone or any of its inactive ingredients.

REFERENCES                                                                                                                                                              

Number

Reference

1

Radicava prescribing information.  Mitsubishi Tanabe Pharma Corporation. May 2022.

2

Kiernan M. C., Vucic S., Cheah B. C., Turner M. R., Eisen A., Hardiman O., et al. (2011). Amyotrophic lateral sclerosis. Lancet 377 942–955. 10.1016/S0140-6736(10)61156-7.

3

Miller R.G., Jackson C.E., Kasarskis E.J., England J.D., Forshew D., Johnston W., Kalra S., Katz J.S., Mitsumoto H., Rosenfeld J., et al. Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): Report of the Quality Standards Subcommittee of the American of Neurology. Neurology. 2009;73:1227–1233.

4

Koji Abe, Mashashi Aoki, Shoji Tsuji, et al. Safety and efficacy or edaravone in well defined patients with amyotrophic lalteral sclerosis: a randomized double-blind, placebo-controlled trial. Lancet Neurology2017 May 15, S1474-4422(17)30115-1.

5

Clinical Review Report: Edaravone (Radicava): (Mitsubishi Tanabe Pharma Corporation): Indication: For the treatment of amyotrophic lateral sclerosis [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Apr. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542359/.

6

Oskarsson B., Gendron T., Staff N. Amyotrophic Lateral Sclerosis: An Update for 2018. Mayo Clin Proc. 2018;93(11):1617-1628.

 

 

 

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Agent Names

Strength

Targeted MSC

Available MSC

Preferred Status

Effective Date

RADICAVA*edaravone oral susp

105 MG/5ML

M ; N ; O ; Y

N

01-01-2023

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Agent GPI

Agent Names

Strength

QL Amount

Dose Form

Days Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Effective Date

745090300018

RADICAVA ORS (edaravone oral susp )

105 MG/5ML

50.0

MLS

28

Days

70510-2322-01

01-01-2023

745090300018

RADICAVA ORS STARTER KIT (edaravone oral susp )

105 MG/5ML

70.0

MLS

180

Days

70510-2321-01 ; 70510-2321-02

01-01-2023

CLIENT SUMMARY – PRIOR AUTHORIZATION

Agent Names

Strength

Client Formulary

RADICAVA*edaravone oral susp

105 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Agent Names

Strength

Client Formulary

RADICAVA ORS (edaravone oral susp )

105 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

RADICAVA ORS STARTER KIT (edaravone oral susp )

105 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

PRIOR AUTHORIZATION CRITERIA FOR APPROVAL

Initial Evaluation

Target Agent(s) will be approved when ALL of the following are met:

  1. The patient has a diagnosis of amyotrophic lateral sclerosis (ALS) AND
  2. The patient has had the diagnosis of ALS for a duration of 2 years or less AND
  3. The patient has a baseline percent forced vital capacity (FVC%) of 80% or greater AND
  4. The patient is able to perform most activities of daily living, defined as scores of 2 points or better on each individual item of the ALS Functional Rating Scale – Revised [ALSFRS-R] AND   
  5. ONE of the following:
    1. The patient is currently being treated with riluzole OR
    2. The patient has tried and had an inadequate response to riluzole OR
    3. The patient has an intolerance or hypersensitivity to riluzole OR
    4. The patient has an FDA labeled contraindication to riluzole AND
  6. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  7. The patient does NOT have any FDA labeled contraindications to the requested agent

Length of Approval:  6 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

NOTE: For patients initiating therapy with oral suspension, approval will include 70 mL starter kit per 180 days (initial dose) and 50 mL per 28 days for the remainder of the 6 months.

 

 

Renewal Evaluation

Target Agent(s) will be approved when ALL of the following are met:

  1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  2. The patient has had clinical benefit with the requested agent AND
  3. The patient is NOT dependent on invasive ventilation or tracheostomy AND
  4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  5. The patient does NOT have any FDA labeled contraindications to the requested agent

Length of Approval:  12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

PA

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. ALL of the following:
    1. The requested quantity (dose) is greater than the program quantity limit AND
    2. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
    3. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit

Length of Approval:  Initial: 6 months; Renewal: 12 months

NOTE: For patients initiating therapy with oral suspension, approval will include 70 mL starter kit per 180 days (initial dose) and 50 mL per 28 days for the remainder of the 6 months.

 

 This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.  

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.  

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

Commercial _ PS _ Radicava (edaravone) Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023  _ © Copyright Prime Therapeutics LLC. November 2022 All Rights Reserved