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Radicava (edaravone)


Billing

Code: J1301

Description: Injection, edaravone, 1 mg

Unit: 1 mg

Payment: $21.402

Pay quarter: Q3 2023


Medicare history

Dosage and Frequency

Amyotrophic Lateral Sclerosis (ALS)

Initial:
• 60mg IV daily for 14 days
Followed by a 14-day drug-free period

Subsequent:
• 60mg IV daily for 10 out of 14-day periods
Followed by a 14-day drug-free period

Calculate drug reimbursement


Total Reimbursement:

$1,361.17

(ASP: $1,284.12, Margin: $77.05)


Code:

J1301

# Units to bill:

60

Prior Authorization

Prior auth criteria for Radicava may include but is not limited to:


1. The patient must have a confirmed diagnosis of amyotrophic lateral sclerosis (ALS).
2. The patient must be 18 years of age or older.
3. The patient must not have any contraindications as listed in the prescribing information.
4. The patient must not have any other known causes for their ALS symptoms.
5. The patient must have adequate renal function.
6. The patient must not have had a prior reaction or intolerance to edaravone.
7. The patient must have the ability to comply with the recommended dosing schedule.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

70510-2171-02

RADICAVA (MITSUBISHI TANABE PHARMA AMERICA)

60 MG



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