Osmolex ER — Cigna
Drug-induced extrapyramidal reactions
Preferred products
- amantadine immediate-release capsules
- amantadine immediate-release tablets
- amantadine oral solution
Initial criteria
- 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 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 extrapyramidal reactions)
- Medication is prescribed by or in consultation with a neurologist
Approval duration
initial 3 months; reauth 1 year