- Step Therapy: Parkinson's Disease:
ST Multiple Generics
- Quantity Limit: limit maximum 10 EA PER 1 day(s)
- Prior Authorization: Parkinson's Disease:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Parkinson's Disease:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Appropriate Specialist;Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Unspecified
Clinically documented acute, intermittent treatment of hypomobility "off" episodes: Yes
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: Chart Notes
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