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Gocovri (amantadine HCl)
Drugs for the Nervous System : Drugs for Parkinson
  • Prior Authorization: Parkinson's Disease:
    Documented Diagnosis: Yes
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Step Therapy: Parkinson's Disease:
    ST Single Generic

  • Parkinson's Disease:
    Duration: 1 plan year
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    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
    Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests

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