CurrentColorado Rocky Mountain Health PlansPolicy N/A

Nuedexta (dextromethorphan/quinidine) prior authorization

Prior authorization and reauthorization requirements for Nuedexta (dextromethorphan/quinidine) for treatment of pseudobulbar affect (PBA) for Colorado Rocky Mountain Health Plans members using UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyNuedexta (dextromethorphan/quinidine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 16, 2025

Next Review DateSep 1, 2025

Key ActionObtain prior authorization with documented diagnosis of pseudobulbar affect; approvals are issued for 12 months and reauthorization requires documentation of positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

Pseudobulbar affectdiagnosis required

Clinical responsereauthorization need

Prior Authorizationmanagement type

Coverage Criteria for Nuedexta (dextromethorphan/quinidine)

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inv-01: Initial Authorization

Covered when ALL of the following are met

Initial Authorization: Diagnosis of pseudobulbar affect

Authorization issued for 12 months

inv-02: Reauthorization

Covered when ALL of the following are met

Reauthorization: Documentation of positive clinical response to therapy

Authorization issued for 12 months

Coverage for Nuedexta may be affected by external legal and benefit constraints. State mandates, applicable federal regulatory requirements, and the member’s specific benefit plan can modify or limit coverage determinations. Other policies and utilization management programs may also apply and alter coverage outcomes.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Nuedexta (dextromethorphan/quinidine). Initial requests must include documentation of a diagnosis of pseudobulbar affect. Authorization, when approved, will be issued for 12 months.

Diagnosis required: pseudobulbar affect
Initial approval duration: 12 months

Documentation Required

Documentation Required for Reauthorization

Reauthorization requires documentation of a positive clinical response to therapy. Authorizations for reauthorization are issued for 12 months. State mandates, federal regulatory requirements, and the member-specific benefit plan may affect coverage criteria.

Reauthorization requirement: documented positive clinical response
Reauthorization duration: 12 months
Coverage may be impacted by state/federal requirements and member benefit plan

Denial Risk

Denial Triggers

Lack of a documented diagnosis for initial requests or lack of documented positive clinical response for reauthorization may result in denial.

Denial trigger: no documented diagnosis on initial request
Denial trigger: no documented positive clinical response for reauthorization

Step Therapy

Automated Approval / Step Considerations

Automated approval and re-approval processes may be used. UnitedHealthcare may approve initial and reauthorization requests based solely on prior claim/medication history, ICD-10 diagnosis codes, and/or claim logic; use of these automated processes varies by program or therapeutic class.

Automated considerations: prior claim/medication history
Automated considerations: diagnosis codes (ICD-10)
Automated considerations: claim logic may drive approvals

Step	Requirement
1
UnitedHealthcare may use prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic to approve initial and reauthorization requests; use of automated approval and re-approval processes varies by program and therapeutic class.

Background

Nuedexta is a combination product containing dextromethorphan hydrobromide and quinidine sulfate indicated for the treatment of pseudobulbar affect (PBA). PBA is secondary to neurologic conditions and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are disproportionate or inappropriate to the underlying emotional state. This policy establishes prior authorization and reauthorization requirements for Nuedexta for Colorado Rocky Mountain Health Plans members processed through UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Definitions

Pseudobulbar affect — definition

DefinitionPseudobulbar affect (PBA) is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are typically out of proportion to or inappropriate for the underlying emotional state.

EtiologyOccurs secondary to a variety of neurologic conditions (secondary to neurologic disease or injury).

Clinical distinctionPBA is a specific condition distinct from other types of emotional lability seen in neurological disease or injury.

Typical presentationEpisodes are sudden, frequent, and may be inappropriate or disproportionate to the patient’s actual feelings.