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Drug Category: CNS Agents

Medication Class/Individual Agents: Antiparkinsonian Agents

I. Prior-Authorization Requirements

 Antiparkinsonian Agents – Anticholinergic Medications

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

benztropine test  
trihexyphenidyl test  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • There is no universal first choice in the treatment of Parkinson’s disease. Clinical and lifestyle characteristics of the patient should be taken into account.
  • Most patients will develop motor complications over time and will require levodopa therapy. Adjuvant medications may help to reduce motor complications and raise quality of life in late stage Parkinson’s disease.
  • There is no difference in the rate of motor complications between immediate- and extended-release levodopa formulations.
  • Anticholinergics are poorly tolerated in the elderly and should be avoided.
 

 Antiparkinsonian Agents – Catechol-O-Methyl Transferase (COMT) Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

entacapone Comtan PA  
tolcapone Tasmar PA  

 Antiparkinsonian Agents – Dopamine Agonists

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

apomorphine Apokyn test  
bromocriptine 2.5 mg, 5 mg Parlodel # test  
pramipexole Mirapex # test  
pramipexole extended-release Mirapex ER PA  
ropinirole Requip # test  
ropinirole extended-release Requip XL PA  
rotigotine transdermal system Neupro PA  

 Antiparkinsonian Agents – Dopamine Analogues

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

carbidopa Lodosyn # test  
carbidopa / levodopa enteral suspension Duopa PA  
carbidopa / levodopa extended-release capsule Rytary PA  
carbidopa / levodopa extended-release tablet Sinemet CR # test  
carbidopa / levodopa orally disintegrating tablet PA  
carbidopa / levodopa tablet Sinemet # test  

 Antiparkinsonian Agents – Monoamine Oxidase (MAO) Type-B Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

rasagiline Azilect PA  
safinamide Xadago PA  
selegiline capsule, tablet test  
selegiline orally disintegrating tablet Zelapar PA  

 Antiparkinsonian Agents – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amantadine extended-release capsule Gocovri PA  
amantadine extended-release tablet Osmolex ER PA  
amantadine immediate-release capsule, solution, tablet test  
carbidopa / levodopa / entacapone Stalevo PA  
pimavanserin Nuplazid PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Drug-induced extrapyramidal symptoms (Osmolex ER)
  • Parkinson’s disease
  • Parkinson's disease psychosis (Nuplazid)
  • Restless Leg Syndrome (Neupro)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

 

carbidopa/levodopa orally disintegrating tablet

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is unable to swallow pills or use a conventional dosage form; and
    • member is not currently receiving other oral solid dosage forms.

carbidopa/levodopa/entacapone

  • Documentation of the following is required:
    • appropriate diagnosis.

SmartPA: Claims for carbidopa/levodopa/entacapone will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for Parkinson’s disease.†

Duopa

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member has a PEG tube; and
    • medical records documenting an inadequate response, adverse reaction, or contraindication to the generic immediate-release carbidopa/levodopa tablet formulation; and
    • medical records documenting an inadequate response, adverse reaction, or contraindication to the generic extended-release carbidopa/levodopa tablet formulation.

entacapone and tolcapone

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is concurrently taking carbidopa/levodopa; and
    • if request is for tolcapone, an inadequate response, adverse reaction, or contraindication to entacapone.

SmartPA: Claims for entacapone will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for Parkinson’s disease and a history of paid MassHealth pharmacy claims for a carbidopa/levodopa product for at least 90 days within the last 120 days.†

SmartPA: Claims for tolcapone will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for Parkinson’s disease, a history of paid MassHealth pharmacy claims for a carbidopa/levodopa product for at least 90 days within the last 120 days, and a history of paid MassHealth pharmacy claims for entacapone.†

Gocovri

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is experiencing dyskinesia while on levodopa-based therapy; and
    • member is concurrently taking carbidopa/levodopa; and
    • medical necessity for use of amantadine extended-release over amantadine immediate-release; and
    • if request is for the 68.5 mg strength, member has moderate or severe renal impairment; and
    • one of the following:
      • for 68.5 mg strength, request is within the quantity limit of 30 units/month; or
      • for 137 mg strength, request is within the quantity limit of 60 units/month.

Neupro

  • Documentation of the following is required for a diagnosis of Parkinson's disease:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to pramipexole or ropinirole; or
      • member is unable to swallow pills or use a conventional dosage form and member is not currently receiving other oral solid dosage forms; and
    • request is within the quantity limit of 30 patches/month.
  • Documentation of the following is required for a diagnosis of Restless Leg Syndrome:
    • appropriate diagnosis; and
    • request is for the 1, 2, or 3 mg patch OR clinical rationale for a higher dose is provided; and
    • one of the following:
      • inadequate response or adverse reaction to pramipexole and ropinirole; or
      • member is unable to swallow pills or use a conventional dosage form and member is not currently receiving other oral solid dosage forms; and
    • request is within the quantity limit of 30 patches/month.

Nuplazid

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • prescriber is a neurologist or a neurology consult is provided; and
    • one of the following:
      • for 17 mg tablet: quantity limit of 60 units/30 days; or
      • for 34 mg capsule: quantity limit of 30 units/30 days; or
      • for 10 mg tablet, both of the following:
        • requested medication will be used in combination with a strong CYP3A4 inhibitor; and
        • quantity limit of 30 units/30 days.

Osmolex ER

  • Documentation of the following is required for a diagnosis of Parkinson's disease:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to three or contraindication to all of the following:
      • carbidopa/levodopa; or
      • dopamine agonist; or
      • monoamine oxidase-type B inhibitor; or
      • anticholinergic agents; and
    • medical necessity for use of amantadine extended-release over generic amantadine immediate-release (capsules, tablets, oral solution); and
    • request is within the quantity limit of 30 units/month.
  • Documentation of the following is required for a diagnosis of drug-induced extrapyramidal symptoms:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all anticholinergic agents (e.g., benztropine, trihexyphenidyl); and
    • medical necessity for use of amantadine extended-release over generic amantadine immediate-release (capsules, tablets, oral solution); and
    • request is within the quantity limit of 30 units/month.

pramipexole extended-release and ropinirole extended-release

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an adverse reaction or inadequate response to the generic immediate-release preparation with the same active ingredient.

rasagiline

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to selegiline; and
    • request is within the quantity limit of 30 units/month.

Rytary

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to the generic immediate-release carbidopa/levodopa tablet formulation; and
    • medical records documenting an inadequate response or adverse reaction to the generic extended-release carbidopa/levodopa tablet formulation; and
    • medical necessity for use over generic carbidopa/levodopa extended-release tablet (Sinemet CR).

Xadago

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is concurrently taking carbidopa/levodopa; and
    • member is experiencing “off” symptoms with carbidopa/levodopa therapy; and
    • medical records documenting an inadequate response or adverse reaction to selegiline and rasagiline; and
    • request is within the quantity limit of 30 units/month.

Zelapar

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is concurrently taking carbidopa/levodopa; and
    • member is unable to swallow pills or use a conventional dosage form; and
    • member is not currently receiving other oral solid dosage forms; and
    • request is within the quantity limit of 60 units/month.

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 08/2010

Last Revised Date: 08/2019


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Last updated 10/09/19