Apokyn — Medical Mutual

Initial criteria

• Diagnosis of advanced Parkinson’s disease; AND
• The patient experiences intermittent hypomobility or 'off' episodes; AND
• The patient is currently receiving carbidopa/levodopa therapy; AND
• Patient has previously tried one other treatment for 'off' episodes AND (Patient had significant intolerance, according to the prescriber OR Patient had inadequate efficacy, according to the prescriber); AND
• The patient is not concurrently taking a serotonin 5HT3 antagonist (such as: ondansetron, granisetron, etc.); AND
• Apokyn is being prescribed by, or in consultation with, a neurologist or prescriber specializing in the treatment of Parkinson’s disease.

Reauthorization criteria

• The patient is diagnosed with acute intermittent episodes of Hypomobility ('off' episodes) associated with advanced Parkinson’s disease; AND
• The patient has experienced a positive clinical response to therapy; AND
• The patient is not concurrently taking a serotonin 5HT3 antagonist (such as: ondansetron, granisetron, etc.); AND
• Apokyn is being prescribed by, or in consultation with, a neurologist or prescriber specializing in the treatment of Parkinson’s disease.

Approval duration

1 year initial, 1 year reauth