Nourianz (istradefylline) — United Healthcare

Initial criteria

• Diagnosis of Parkinson’s disease
• Used as adjunctive treatment to levodopa/carbidopa in patients experiencing “off” episodes
• History of failure, contraindication, or intolerance to two anti-Parkinson’s disease therapy from two different adjunctive pharmacotherapy classes: Dopamine agonists (e.g., pramipexole, ropinirole), Catechol-O-methyl transferase (COMT) inhibitors (e.g., entacapone), Monoamine oxidase (MAO) B inhibitors (e.g., rasagiline, selegiline)

Reauthorization criteria

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

Approval duration

12 months