CurrentNeighborhood Health Plan of Rhode IslandPolicy Exelon PA Policy 85-A, 509-A 06-2022

Exelon (rivastigmine) prior authorization

Defines prior authorization coverage criteria for Exelon (rivastigmine) products for treatment of Alzheimer's disease, Parkinson's disease dementia, and dementia with Lewy bodies for members requiring pharmacy benefit authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyExelon (rivastigmine) prior authorization

Policy CodePolicy Exelon PA Policy 85-A, 509-A 06-2022

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization showing a covered diagnosis and either documentation of continued benefit for continuation requests or a validated cognitive assessment within the past 12 months for new starts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3covered indications

12 moassessment lookback

benefit requiredrenewal condition

9references

Coverage Criteria for Exelon (rivastigmine)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization Coverage Criteria

Covered when ALL of the following are met:

Root

Allowed diagnoses: Patient has one of: dementia of the Alzheimer's type; mild to moderate dementia associated with Parkinson's disease; dementia with Lewy bodies
Supports Exelon use
Therapy status requirements
- A: Continuation: Request is for continuation of therapy AND the medication continues to provide benefit to the patient (treatment is not appropriate if slowing cognitive decline is no longer a goal or the patient is rapidly declining)
  Refer to clinical judgment for benefit
- B: New start: Request is NOT for continuation of therapy AND the diagnosis is supported by a validated cognitive assessment performed within the past 12 monthswithin the past 12 months
  Validated cognitive assessment required for new-start requests

ref": "b0_0

title": "Prior Authorization Coverage Criteria"

Covered indications for Exelon (rivastigmine) include: dementia of the Alzheimer’s type (Alzheimer’s disease) — with the transdermal patch indicated for mild, moderate, and severe AD and capsules for mild–moderate AD; mild to moderate dementia associated with Parkinson’s disease (Parkinson’s disease dementia); and dementia with Lewy bodies (compendial indication). No other diagnoses or indications are listed as covered in this policy.

Treatment with rivastigmine is considered no longer appropriate when continuation of therapy no longer provides benefit. Specifically, the policy notes that if slowing decline of cognitive function is no longer a goal or the patient is rapidly declining, continuation of the medication is not appropriate and authorization would not be provided under those circumstances.

Assessment and Coding Requirements

Validated cognitive assessment recency

Validated cognitive assessment recencyMust be performed within the past 12 months

Applies to new (non-continuation) requestsDocumentation of the assessment must support the diagnosis for initial authorization

Assessment typesValidated cognitive assessment (per policy) — specific test name not required in policy text

Indications

Dementia with Lewy bodiesListed as a compendial use for rivastigmine (dementia with Lewy bodies) per policy references

Provider Documentation, Prior Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required. The requested drug (Exelon/rivastigmine) is covered only when the coverage criteria are met and PA is approved.

Drug: Exelon (rivastigmine)
PA Type: Initial or Continuation

Note

Provider Action — New Requests

Submit documentation that shows the diagnosis and, for new requests, include a validated cognitive assessment within 12 months.

Include diagnosis (Alzheimer's-type dementia, Parkinson’s disease dementia, or dementia with Lewy bodies)
New requests: attach validated cognitive assessment (≤ 12 months)

Documentation Required

Assessment Documentation Required

For new (non-continuation) requests, provide objective documentation of the diagnosis with a validated cognitive assessment performed within the past 12 months.

Validated cognitive assessment within 12 months (e.g., MMSE, MoCA)
Documentation linking assessment results to the diagnosis

Documentation Required

Continuation Documentation

For continuation requests, document that the medication continues to provide clinical benefit. If the goal of slowing cognitive decline is no longer appropriate or the patient is rapidly declining, continuation is not appropriate.

Statement of continued benefit or clinical improvement/stabilization
Relevant clinical notes or assessments demonstrating ongoing benefit

Denial Risk

Denial Triggers

Requests may be denied if required documentation is missing or if continuation requests do not demonstrate ongoing benefit.

Missing diagnosis documentation or cognitive assessment for new requests
No evidence of continued benefit for renewal/continuation requests
Treatment goals no longer appropriate (e.g., rapid decline)

Clinical Background

Rivastigmine is available as oral capsules and a transdermal patch. The patch formulation (Exelon Patch) is indicated for dementia of the Alzheimer’s type with demonstrated efficacy in mild, moderate, and severe disease; rivastigmine capsules are indicated for mild to moderate Alzheimer’s disease. Both the patch and capsule formulations are indicated for mild to moderate dementia associated with Parkinson’s disease. Rivastigmine is also used for dementia with Lewy bodies as a compendial indication.