CurrentMass General Brigham Health PlanPolicy N/A

Neupro (rotigotine) transdermal system - Prior Authorization (Pharmacy Benefit)

Prior authorization policy for Neupro (rotigotine) transdermal patches under the pharmacy benefit for Commercial/Exchange members; covers use for Parkinson disease (PD) and moderate-to-severe primary restless legs syndrome (RLS).

Policy Summary

PayerMass General Brigham Health Plan

PolicyNeupro (rotigotine) transdermal system - Prior Authorization (Pharmacy Benefit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for Neupro for Commercial/Exchange members; authorization allowed for members new to plan who are currently receiving Neupro or when specified clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36 monthsstandard approval duration

Commercial/Exchangeapplicable plan

Pharmacybenefit type

PD & RLSindications covered

Coverage Criteria for Neupro (rotigotine)

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Authorization criteria

Authorization may be granted for one of the following situations:

Continuing therapy for members new to plan: Member is new to the plan and is currently receiving Neupro (excluding product obtained as samples or via manufacturer's patient assistance programs)

Supports continuation of existing therapy

New initiation with clinical justification

Diagnosis requirement: Member has a diagnosis of Parkinson disease (PD) or restless legs syndrome (RLS)
Supporting clinical reason (ONE of)
- Swallowing disorder: Member has a documented diagnosis of a swallowing disorder or difficulty swallowing tablets
- Oral dopamine agonist intolerance/failure: Member has had a documented side effect, allergy, or treatment failure to a trial of an oral dopamine agonist (e.g., pramipexole or ropinirole)

For members who are new to the plan, continuation of therapy with Neupro may be approved only when the member is currently receiving Neupro. Authorization does not apply if the member’s supply was obtained solely as manufacturer-provided samples or through a manufacturer patient assistance program. Providers should document the current Neupro therapy in the member’s record to support continuation requests.

Provider Requirements and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required under the pharmacy benefit before coverage of Neupro (rotigotine) transdermal system. This requirement applies to commercial/exchange members and other plan members when the pharmacy benefit covers the drug.

Applies to Pharmacy Benefit (see Contact Information for pharmacy benefits).
Program type: Prior Authorization required.

Step Therapy

There is no step therapy requirement for Neupro under this policy.

Documentation Required

Required Clinical Documentation

Documentation must support the diagnosis and reason for using the transdermal system. Provide clinical records showing the member's diagnosis and supporting information.

Documented diagnosis of Parkinson disease (PD) or Restless Legs Syndrome (RLS).
Evidence member is currently receiving Neupro if new to the plan (exception: not granted for product obtained only as samples or via manufacturer assistance programs).
Documentation of a swallowing disorder or difficulty swallowing tablets if that is the rationale, OR documentation of trial and documented side effect, allergy, or treatment failure to an oral dopamine agonist (e.g., pramipexole or ropinirole).

Denial Risk

Denial Triggers

Authorizations may be denied if the member is new to the plan and is not currently receiving Neupro, except in cases meeting the stated criteria (diagnosis plus swallowing disorder OR prior trial with intolerance/failure of an oral dopamine agonist).

Denial risk when member is new to the plan and not currently receiving Neupro (not applicable if prior use documented).
Denial risk if supporting documentation does not show PD or RLS diagnosis and the required rationale (swallowing disorder or documented trial/failure of oral dopamine agonist).

Background

Neupro (rotigotine) is a transdermal dopamine agonist indicated for the treatment of Parkinson disease (PD) and moderate-to-severe primary restless legs syndrome (RLS). The patch formulation provides an alternative route when oral dopamine agonists are not tolerated or when patients have difficulty swallowing tablets, and the policy allows authorization for continuation or initiation when clinical criteria are met.