Gocovri — Medica

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 (examples include muscle stiffness, slow movements, or difficulty starting movements)
• Patient is currently receiving levodopa-based therapy (e.g., carbidopa/levodopa)
• Patient has tried immediate-release amantadine capsules, tablets, or oral solution and meets ONE of the following: (a) patient derived benefit from immediate-release amantadine but had intolerable adverse events [documentation required]; OR (b) 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 meets ONE of the following: (a) patient derived benefit from immediate-release amantadine but had intolerable adverse events [documentation required]; OR (b) 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) as determined by the prescriber
• Medication is prescribed by or in consultation with a neurologist

Approval duration

initial 3 months; reauthorization 1 year