edaravone infusion bag

Amyotrophic Lateral Sclerosis (Als) Agents

Also known as: Radicava
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 19 hours, 10 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via Radicava 		Tier 1 - Preferred Generic ✓ — — PA
Liberty Medicare Dual Plan (HMO D-SNP)
via Radicava 		Tier 1 - Preferred Generic ✓ — ✓ 70 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Radicava 		Tier 1 - Preferred Generic ✓ — ✓ 70 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Radicava 		Tier 1 - Preferred Generic ✓ — ✓ 70 per 28 days PA | QL
NHC Advantage (HMO I-SNP)
via Radicava 		Tier 1 - Preferred Generic ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Senior Care (HMO I-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Wellcare Assist Open (PPO)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Dual Access (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Dual Liberty (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Dual Reserve (HMO-POS D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Liberty Medicare Advantage (HMO C-SNP)
via Radicava 		Tier 5 - Specialty ✓ — ✓ 70 per 28 days PA | QL
Wellcare Simple Open (PPO)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Simple (HMO-POS)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Giveback Open (PPO)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Wellcare Dual Liberty Open (PPO D-SNP)
via Radicava 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 19 hours, 10 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 19 hours, 10 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Radicava 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via Radicava 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via Radicava 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
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