CurrentUnitedHealthcarePolicy N/A

Prior authorization form for Gocovri (amantadine ER) and Osmolex ER

This document is a UnitedHealthcare prescriber prior authorization form that captures beneficiary, prescriber and clinical information to support initial and reauthorization requests for Gocovri and Osmolex ER (extended-release amantadine) including age, diagnosis, contraindications, prior trial of immediate-release amantadine, concurrent levodopa use and symptom improvement documentation.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for Gocovri (amantadine ER) and Osmolex ER

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form and document prior trial/failure of immediate-release amantadine and symptom improvement for reauthorization.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2ER amantadine products referenced

>=18Minimum age requirement

6 monthsInitial approval duration

12 monthsReauthorization duration

Coverage summary

Coverage stance: covered_with_criteria. This PA form applies to extended‑release amantadine products Gocovri and Osmolex ER for dyskinesia in Parkinson's disease and related indications. Beneficiaries must be age ≥18. Prior to approval, there must be a documented trial and failure of or intolerance to immediate‑release amantadine (capsule, tablet, or oral solution). End‑stage renal disease is a contraindication defined as creatinine clearance <15 ml/min/1.73m2. Initial authorizations may be approved for up to 6 months, and reauthorizations for up to 12 months.

Provider actions and documentation requirements

Prior Authorization

Submit prior authorization form

Prescriber must complete and sign the prior authorization form. The form must include beneficiary information, prescriber information, the requested drug and strength, length of therapy, and required clinical questions. Prescriber signature is mandatory and must be dated.

Include beneficiary name, ID, and DOB
Include prescriber NPI and contact information
Specify drug name, strength, quantity, and length of therapy
Answer required clinical questions on the form
Prescriber must sign and date the form (signature mandatory)

Documentation Required

Document prior trial of immediate‑release amantadine

For initial authorization of Gocovri or Osmolex ER, the provider must document a trial and failure of, or intolerance to, immediate‑release amantadine (capsule, tablet, or oral solution).

Documentation Required

Document symptom improvement for reauthorization

For reauthorization requests, the provider must submit documentation showing the beneficiary has had improvement in their symptoms from baseline.

Documentation Required

Assess renal function

Provider must confirm there are no contraindications prior to approval, including end-stage renal disease defined as creatinine clearance <15 ml/min/1.73m2.

Billing Rule

Authorization durations

Authorization durations: initial authorizations can be approved for up to 6 months; reauthorizations can be approved for up to 12 months.

Clinical evidence

No specific clinical‑evidence entries or trial summaries were provided in the brief. Coverage criteria and requirements are based on the prior authorization form fields and questions (age, diagnosis, contraindications, documented trial of immediate‑release amantadine, concurrent levodopa use, and documentation of symptom improvement for reauthorization).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for Gocovri (amantadine ER) and Osmolex ER

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form and document prior trial/failure of immediate-release amantadine and symptom improvement for reauthorization.

On This Page

OpenPayer

Prior authorization form for Gocovri (amantadine ER) and Osmolex ER

Coverage summary

Initial therapy criteria

Reauthorization / continuation criteria

Provider actions and documentation requirements

Applicable codes

Background

Clinical evidence

Gocovri	amantadine extended-release (for dyskinesia in Parkinson's disease)
Osmolex ER	amantadine extended-release (for Parkinson's disease or drug-induced extrapyramidal reactions)
immediate-release amantadine	amantadine capsule, tablet, or oral solution (trial required prior to ER products)