Limited Coverage Drugs – levodopa-carbidopa
Generic Name |
levidopa-carbidopa |
|
---|---|---|
Strength |
20 mg/mL levodopa and 5 mg/mL carbidopa monohydrate |
|
Form |
intestinal gel |
Special Authority Criteria |
Approval Period |
---|---|
Initial: For the management of severe cases of advanced idiopathic Parkinson’s Disease (PD) when requested by a neurologist practicing at a movement disorder clinic AND all criteria below are met:
Renewal: The patient continues to benefit from the treatment, including significant reduction in the time spent in the off state and/or in ongoing, bothersome levodopa-induced dyskinesias, along with an improvement in the severity of the disability in the off state. |
First approval: 1 year Renewal: 1 year |
Practitioner Exemptions
- None
Special Notes
- None
Special Authority Request Form(s)