Antiparkinsons Agents
Prior authorization and medical necessity criteria for multiple antiparkinson agents (including Crexont, Gocovri, Inbrija, Neupro, Nourianz, Onapgo, Ongentys, Osmolex ER, Requip XL, Mirapex ER, Rytary, Tolcapone, Vyalev, Xadago, Zelapar and others) for treatment of Parkinson's disease and related indications; includes initial and continuation approval criteria, quantity limits, documentation and prescriber specialty requirements, and billing codes.
Policy reviewed and revised January 2026 with Current Effective Date July 24, 2025.
Coverage Summary
This policy covers multiple antiparkinson agents with medical necessity criteria (covered_with_criteria). Covered products include, among others, Crexont, Gocovri, Inbrija, Neupro, Nourianz, Onapgo, Ongentys, Osmolex ER, Rytary, Tolcapone, Vyalev, Xadago, Zelapar and other branded and generic agents. Prior authorization is required and the policy specifies quantity limits and documentation requirements for each product (examples: Crexont 180 caps/30 days; Gocovri 60 caps/30 days; Inbrija 300 caps/30 days; Neupro 30 patches/30 days).
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