CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ongentys (opicapone) — Prior Authorization Coverage Criteria

Defines prior authorization criteria for Ongentys (opicapone) as adjunctive treatment to levodopa/carbidopa for Parkinson's disease patients experiencing 'off' episodes for members of Neighborhood Health Plan of Rhode Island (CVS Caremark criteria).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOngentys (opicapone) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis of Parkinson's disease with 'off' episodes and, when required, evidence of trial and inadequate response, intolerance, or contraindication to generic entacapone or generic carbidopa/levodopa/entacapone.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1FDA-approved indication listed

3Alternate trial/exception reasons

1References

Coverage Criteria for Ongentys (opicapone)

Initial prior authorization criteria

Covered when ANY one of the following is met:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOngentys (opicapone) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Adjunctive therapy: The requested drug is prescribed as adjunctive treatment to levodopa/carbidopa in a patient with Parkinson's disease experiencing "off" episodes.

Referenced in coverage criteria.

Inadequate response to alternative: The patient has experienced an inadequate treatment response to a trial of generic carbidopa/levodopa/entacapone or generic entacapone used in combination with a generic levodopa/carbidopa product.

Allows coverage when prior trial failed.

Intolerance to alternative: The patient has experienced an intolerance to generic carbidopa/levodopa/entacapone or generic entacapone used in combination with a generic levodopa/carbidopa product.

Allows coverage for intolerance.

Contraindication to alternative: The patient has a contraindication that would prohibit a trial of generic carbidopa/levodopa/entacapone or generic entacapone used in combination with a generic levodopa/carbidopa product.

Allows coverage if contraindication documented.

Provider Requirements and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required. Ongentys (opicapone) is covered only when prescribed as adjunctive therapy to levodopa/carbidopa for patients with Parkinson's disease experiencing "off" episodes.

Covered when prescribed as adjunctive treatment to levodopa/carbidopa for PD patients with documented "off" episodes.
Prior authorization required.

Step Therapy

Step Therapy / Prior Trial Requirement

A trial of generic entacapone (or a generic fixed‑dose carbidopa/levodopa/entacapone product) is expected prior to approval unless there is documentation of inadequate response, intolerance, or a contraindication.

Documented trial of generic entacapone or generic carbidopa/levodopa/entacapone required.
If trial not possible, must document inadequate response, intolerance, or contraindication to these agents.

Documentation Required

Required Documentation and Indication Requirement

Requests must include documentation confirming the diagnosis and treatment context and will be denied if the indication or trials are not documented.

Confirm diagnosis of Parkinson's disease with clinically significant "off" episodes.
Confirm Ongentys is being used as an adjunct to levodopa/carbidopa.
If no documentation that Ongentys is adjunctive to levodopa/carbidopa, request may be denied.

Denial Risk

Denial Risk — Prior Trial Not Met

Requests may be denied without documentation of an inadequate response, intolerance, or contraindication to generic entacapone (or generic fixed‑dose carbidopa/levodopa/entacapone).

Denial risk if prior trial or exception documentation is not provided.
Specify reasons for exception (inadequate response, intolerance, or contraindication).

OpenPayer

Ongentys (opicapone) — Prior Authorization Coverage Criteria

Coverage Criteria for Ongentys (opicapone)

Provider Requirements and Authorization Rules

Key Definitions

Background