Apokyn (apomorphine) injection — United Healthcare

Initial criteria

• Diagnosis of Parkinson’s disease
• Apokyn will be used as intermittent treatment for OFF episodes
• Prescribed by or in consultation with a neurologist or specialist in the treatment of Parkinson’s disease
• Patient is currently on a stable dose of a carbidopa/levodopa-containing medication and will continue receiving treatment with a carbidopa/levodopa-containing medication while on therapy
• Patient continues to experience ≥ 2 hours of OFF time per day despite optimal management of carbidopa-levodopa therapy including BOTH of the following: (1) taking carbidopa/levodopa on an empty stomach or at least one half-hour before or one hour after a meal or avoidance of high protein diet AND (2) dose and dosing interval optimization
• History of failure, contraindication, or intolerance to two anti-Parkinson’s disease therapy from TWO DIFFERENT adjunctive pharmacotherapy classes: (1) Dopamine agonists (e.g., pramipexole, ropinirole), (2) Catechol-O-methyl transferase (COMT) inhibitors (e.g., entacapone), (3) Monoamine oxidase (MAO) B inhibitors (e.g., rasagiline, selegiline)
• History of failure, contraindication, or intolerance to Inbrija (levodopa) inhalation powder

Reauthorization criteria

• Documentation of positive clinical response to Apokyn therapy
• Patient will continue to receive treatment with a carbidopa/levodopa-containing medication

Approval duration

12 months