Nourianz — Medical Mutual

Initial criteria

• Patient age ≥ 18 years; AND
• Patient is experiencing 'off' episodes related to end-of-dose wearing off of levodopa/carbidopa totaling an average of at least 2 hours daily; AND
• Nourianz is prescribed by or in consultation with a neurologist; AND
• Patient has been treated with levodopa/carbidopa for a minimum of 1 year and has been using a stable dose for at least 4 weeks; AND
• Nourianz will be used in combination with levodopa/carbidopa; AND
• Patient is in stage 2-4 of disease as assessed by the Modified Hoehn and Yahr Scale

Reauthorization criteria

• Patient has been using Nourianz for at least 3 months; AND
• Patient has responded to Nourianz therapy, as evidenced by a decrease in 'off' time AND an increase in 'on' time without troublesome dyskinesia; AND
• Nourianz will continue to be used in combination with levodopa/carbidopa; AND
• Nourianz is prescribed by or in consultation with a neurologist

Approval duration

1 year initial, 1 year reauth