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Osmolex ER — Blue Cross Blue Shield of Alabama

Parkinson’s disease

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