Patients’ access to rare neuromuscular disease therapies varies across US private insurers

Table 4 Payer coverage criteria for edaravone for amyotrophic lateral sclerosis

	Plan imposes additional coverage criteria	Japan ALS severity classification grade < 3	≥ 2 points or better on each item of the ALSFRS-R*	Respiratory status^†	Use of El Escorial revised criteria for diagnosis	Disease duration of ≤ 2 years	Prior therapy with riluzole	Prescriber requirement
Plan 1	Yes	No	Yes	Ventilation is not required	No	NA	NA	NA
Plan 2	Yes	Yes	Yes	Normal respiratory function	Yes	Yes	NA	NA
Plan 3	Yes	No	Yes	NA	Yes	Yes	NA	Neurologist
Plan 4	No policy	No policy	No policy	No policy	No policy	No policy	No policy	No policy
Plan 5	Yes	No	No	Normal respiratory function	No	Yes	Yes	Neurologist
Plan 6	Yes	No	Yes	Normal respiratory function	No	Yes	NA	NA
Plan 7	Yes	No	Yes	Normal respiratory function	Yes	Yes	Yes	Neurologist with expertise in ALS
Plan 8	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	NA
Plan 9	Yes	No	Yes	Ventilation is not required	No	NA	NA	NA
Plan 10	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	Neurologist
Plan 11	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	Neurologist
Plan 12	Yes	No	No	NA	No	Yes	Yes	Neurologist with expertise in ALS
Plan 13	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	NA
Plan 14	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	NA
Plan 15	Yes	No	Yes	NA	Yes	Yes	NA	NA
Plan 16	Yes	No	Yes	Normal respiratory function	Yes	Yes	NA	Neurologist
Plan 17	Yes	No	Yes	Normal respiratory function	Yes	NA	NA	Neurologist with expertise in ALS

NA = Payer did not address criterion in their coverage policy; *A measure of patient functioning, ALSFRS-R = ALS Functional Rating Scale-Revised; ^†Normal respiratory function (defined as percent predicted forced vital capacity values of ≥ 80%)
ALS amyotrophic lateral sclerosis, NA not available

ISSN: 1750-1172