Osmolex ER (amantadine ER) — Highmark
Drug-induced extrapyramidal reactions
Preferred products
- immediate-release amantadine
Initial criteria
- Diagnosis of Parkinson’s disease (ICD-10: G20) OR drug-induced extrapyramidal reactions (ICD-10: G21.1, G24.0, G25.1, G25.7)
- For drug-induced extrapyramidal reactions: member is age ≥ 18 years
- Member has experienced therapeutic failure or intolerance to the plan-preferred product, immediate-release amantadine
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months