Limited Coverage Drugs - Pramipexole

Generic Name / Strength / Form

pramipexole

Special Authority Criteria Approval Period
For the treatment of idiopathic Parkinson's disease

PLUS

1. Patient cannot tolerate or has contraindications to levodopa and bromocriptine

OR

2. Patient is receiving adjunctive treatment with levodopa and cannot tolerate or has contraindications to bromocriptine.

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Pramipexole for restless leg syndrome is not eligible for PharmaCare coverage.

Special Authority Request Form