- PA Applies
- QL (30 per Rx);
- Parkinson's Disease:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Unspecified
Clinically documented acute, intermittent treatment of hypomobility "off" episodes: No
Concomitant Use of Max Tolerable Dose of levodopa + 1 selegiline,pramipexole,entacapone,rasagiline: No
Use as adjunct therapy: No
Requires concomitant anti-emetic agent: No
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Available through Specialty Pharmacy;
- Available only through Specialty Pharmacy;
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