Gocovri (amantadine ER) — Highmark
Dyskinesia in Parkinson’s disease
Preferred products
- immediate-release amantadine
Initial criteria
- Diagnosis of Parkinson’s disease (ICD-10: G20)
- For dyskinesia: Member is experiencing dyskinesia
- For dyskinesia: Member is receiving concurrent levodopa-based therapy
- For dyskinesia: Member has experienced therapeutic failure or intolerance to the plan-preferred product, immediate-release amantadine
- For 'off' episodes: Member is experiencing 'off' episodes despite optimized levodopa/carbidopa therapy
- For 'off' episodes: Member is receiving concurrent levodopa/carbidopa therapy
- For 'off' episodes: Member has experienced therapeutic failure or intolerance to the plan-preferred product, immediate-release amantadine
- For 'off' episodes: Member has experienced therapeutic failure, contraindication, or intolerance to two (2) of the following agents: entacapone, pramipexole, rasagiline, ropinirole, or selegiline
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months