levodopa inhalation powder — United Healthcare

Initial criteria

• Diagnosis of Parkinson’s disease
• Inbrija 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 or more 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 therapies 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)

Reauthorization criteria

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

Approval duration

12 months