Radicava (edaravone)
Billing
Code: J1301
Description: Injection, edaravone, 1 mg
Unit: 1 mg
Payment: $21.414
Pay quarter: Q1 2023
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
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:
$1,361.93(ASP: $1,284.84, Margin: $77.09)
Code:
J1301# Units to bill:
60Prior 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:
Billable NDCs
70510-2171-02
RADICAVA (MITSUBISHI TANABE PHARMA AMERICA)
60 MG
Resources