Nourianz (istradefylline) — Highmark
Parkinson’s disease with 'off' episodes
Preferred products
- selegiline
- rasagiline
- pramipexole
- ropinirole
- entacapone
Initial criteria
- Diagnosis of Parkinson’s disease (ICD-10: G20) AND experiencing 'off' episodes
- Use as adjunct to levodopa/carbidopa
- Therapeutic failure, contraindication, or intolerance to three of the following: selegiline, rasagiline, pramipexole, ropinirole, entacapone
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months