Gocovri — Cigna

Preferred products

• amantadine immediate-release capsules
• amantadine immediate-release tablets
• amantadine oral solution

Initial criteria

• Patient is experiencing dyskinesia OR Patient is experiencing “off” episodes AND Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa)
• Patient has tried immediate-release amantadine capsules, tablets, or oral solution AND Patient derived benefit from immediate-release amantadine but had intolerable adverse events [documentation required] OR Patient could not achieve a high enough dosage to gain adequate benefit [documentation required]
• Medication is prescribed by or in consultation with a neurologist

Reauthorization criteria

• Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa)
• Patient has tried immediate-release amantadine capsules, tablets, or oral solution AND Patient derived benefit from immediate-release amantadine but had intolerable adverse events [documentation required] OR Patient could not achieve a high enough dosage to gain adequate benefit [documentation required]
• Patient has had a response to therapy (e.g., decrease in dyskinesia, decrease in “off” episodes)
• Medication is prescribed by or in consultation with a neurologist

Approval duration

initial 3 months; reauth 1 year