Gocovri — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following:
• The requested agent is Gocovri AND ALL of the following:
• - The patient has a diagnosis of Parkinson’s disease AND
• ONE of the following:
• - The requested agent will be used for the treatment of dyskinesia OR
• - The requested agent will be used for the adjunctive treatment in patients experiencing “off” episodes AND
• BOTH of the following:
• - The patient is currently treated with levodopa-based therapy AND
• - The patient will continue levodopa-based therapy in combination with the requested agent
• OR
• The requested agent is Osmolex ER AND ONE of the following:
• - The patient has a diagnosis of Parkinson’s disease OR
• - The patient has a diagnosis of drug-induced extrapyramidal reactions AND the prescriber has assessed and adjusted, if applicable, any medications known to cause extrapyramidal symptoms OR
• - The patient has another FDA approved indication for the requested agent