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Table 56: Alzheimer’s Agents


A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S    T    U    V    W    X    Y    Z


Drug Category: CNS Agents

Medication Class/Individual Agents: Alzheimer’s Agents

I. Prior-Authorization Requirements

 Alzheimer's Agents – Cholinesterase Inhibitors

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

donepezil 10 mg tablet Aricept PA   - < 6 years and PA > 2 units/day #
donepezil 5 mg, 23 mg tablet Aricept PA   - < 6 years and PA > 1 unit/day #
donepezil orally disintegrating tablet PA   - < 6 years and PA > 1 unit/day
galantamine extended-release capsule Razadyne ER PA   - > 1 unit/day #
galantamine solution PA  
galantamine tablet Razadyne PA   - < 18 years and PA > 2 units/day #
rivastigmine capsule PA   - > 2 units/day
rivastigmine patch Exelon PA   - > 1 unit/day #

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.

American Psychiatric Association (APA):1,2

  • There is modest evidence to support the efficacy of cholinesterase inhibitors in mild-to-severe AD and memantine in moderate-to-severe AD.
  • Cholinesterase inhibitors should be considered for patients with dementia with Lewy bodies (DLB).
  • Cholinesterase inhibitors can be considered for patients with mild-to-moderate dementia associated with Parkinson's disease (PDD), although the data is weak.
  • Memantine has not been shown to improve cognition in patients with DLB or PDD.
  • The benefit of memantine for mild-to-moderate AD is unclear. Memantine may provide modest benefits and has few adverse effects; it may be considered for patients with moderate-to-severe AD. 

 

1. Rabins PV, Blacker D, Rovner BW, Rummans T, Schneider LS, Tariot PN, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007 Dec;164(12 Suppl):5-56.

2. Rabins PV, Rovner BW, Rummans T, Schneider LS, Tariot PN. Guideline Watch (October 2014): Practice Guideline for the Treatment of Patients With Alzheimer's Disease and Other Dementias. Focus (Am Psychiatr Publ). 2017 Jan;15(1):110-128. doi: 10.1176/appi.focus.15106. Epub 2017 Jan 11.

 

 Alzheimer's Agents – Combination Products

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

memantine / donepezil extended-release Namzaric PA   - < 6 years and PA > 1 unit/day

 Alzheimer's Agents – NMDA Receptor Antagonists

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

memantine extended-release Namenda XR PA   - < 6 years and PA > 1 unit/day BP
memantine solution PA  
memantine tablet Namenda PA   - < 6 years and PA > 2 units/day #
memantine titration pack Namenda PA   - < 6 years and PA > 49 units/month
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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Alzheimer’s Disease
  • Dementia associated with Parkinson’s Disease (rivastigmine)

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).

 

galantamine solution

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • requested quantity does not exceed 6 mL/day; and
    • one of the following:
      • an inadequate response or adverse reaction to galantamine tablets or galantamine extended-release capsules; or
      • clinical rationale for solution formulation over solid oral formulation.

   

memantine solution

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • requested quantity does not exceed 10 mL/day; and
    • one of the following:
      • an inadequate response or adverse reaction to memantine tablets or memantine extended-release capsules; or
      • clinical rationale for solution formulation over solid oral formulation. 

  

All agents at quantities requested above FDA approved limits

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting titration to doses exceeding FDA-recommendations.

    

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

 

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, modafinil, mood stabilizers, and naltrexone] within a 45-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ three mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for four or less behavioral health medications within the past 45 days and one mood stabilizer agent is identified as being used for seizure only.

  

donepezil and memantine for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.  
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current alpha agonist(s) and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.
   
 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: 07/2011

Last Revised Date: 12/2020


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Last updated 01/11/21

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