CurrentMass General Brigham Health PlanPolicy N/A

Nuedexta (dextromethorphan/quinidine) prior authorization and quantity limits

This policy governs prior authorization, coverage criteria, and quantity limits for Nuedexta for treatment of pseudobulbar affect (PBA) for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyNuedexta (dextromethorphan/quinidine) prior authorization and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2023

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis of Pseudobulbar Affect (PBA) due to a qualifying neurological condition or evidence of current Nuedexta treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsstandard approval duration

60/30dquantity limit

ALS, MS, stroke, TBI…PBA indications listed

Coverage Criteria

Covered when one of the following is met:

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Provider Actions & Requirements

Prior Authorization

Prior authorization required for Nuedexta

Prior authorization is required for Nuedexta; authorization may be granted for members currently receiving Nuedexta or for members with a diagnosis/indication for treatment of Pseudobulbar Affect (PBA) due to a neurological condition.

Step Therapy

Step therapy noted — no specific steps defined

Step therapy is indicated as a program type for this product, but this document does not define any specific step therapy requirements.

Documentation Required

Required documentation for authorization

Provide documentation of the diagnosis or indication for PBA due to a qualifying neurological condition (for example, ALS, MS, stroke, traumatic brain injury, Alzheimer’s disease, or Parkinson’s disease) or evidence the member is currently receiving treatment with Nuedexta.

Denial Risk

Denial risk: lack of documented PBA diagnosis

Authorization may be denied if the member does not have a documented diagnosis or indication for treatment of Pseudobulbar Affect (PBA) due to a neurological condition.

Background

Pseudobulbar affect (PBA) is characterized by episodes of sudden, uncontrollable, and inappropriate laughing or crying and typically occurs in people with certain neurological conditions or injuries. Nuedexta is a combination of dextromethorphan hydrobromide and quinidine sulfate indicated for treatment of PBA.

Authorization may be granted for members new to the plan who are currently receiving treatment with Nuedexta or for members with a diagnosis or indication for PBA due to a qualifying neurological condition (for example, ALS, MS, stroke, traumatic brain injury, Alzheimer’s disease, or Parkinson’s disease). Approvals are issued consistent with the policy's coverage criteria and quantity limits.

Definitions

Pseudobulbar affect (PBA)

DefinitionPseudobulbar affect (PBA) is characterized by episodes of sudden, uncontrollable, and inappropriate laughing or crying.

Typical contextTypically occurs in people with certain neurological conditions or injuries that affect how the brain controls emotion.

Associated conditions (examples)Neurologic conditions such as ALS, MS, stroke, traumatic brain injury, Alzheimer’s disease, Parkinson’s disease may be associated with PBA.

Nuedexta (dextromethorphan/quinidine)

Active ingredientsDextromethorphan hydrobromide and quinidine sulfate.

Mechanism notesDextromethorphan: uncompetitive NMDA receptor antagonist and sigma-1 agonist; Quinidine: CYP450 2D6 inhibitor.

IndicationIndicated for the treatment of Pseudobulbar affect (PBA).

FormulationCombination product (Nuedexta).