Under some plans, including plans that use an open or closed formulary, Neupro and Zelapar are subject to precertification.   If precertification requirements apply Aetna considers Neupro and Zelapar to be medically necessary for those members who meet the following precertification criteria

According to the manufacturer, Neupro and Zelapar can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of these drugs will be considered medically necessary as indicated in the table below:

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit. Additional quantities of Neupro and Zelapar will be considered medically necessary for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets(Zelapar ONLY ) OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose
  

Under some plans, including plans that use an open or closed formulary, Neupro  is subject to step-therapy.  Aetna considers Neupro to be medically necessary for those members who meet the following step-therapy criteria:

A documented trial of 30 days of carbidopa/levodopa, Mirapex, Requip or Stalevo - covered alternatives on the Aetna Medicare Preferred Drug List.


If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section II below.)

Akineton, Cogentin, Eldepryl, Kemadrin, Larodopa, Lodosyn, Neupro, Parcopa, Parlodel,  Sinemet, Sinemet CR, Symmetrel, Tasmar and Zelapar  are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Akineton, Cogentin, Eldepryl, Kemadrin, Larodopa, Lodosyn, Neupro, Parcopa, Parlodel, Sinemet, Sinemet CR, Symmetrel, Tasmar and Zelapar to be medically necessary for those members who meet any of the following criteria:

For Akineton, Cogentin, Eldepryl, Kemadrin, Larodopa, Lodosyn, Parcopa, Parlodel,  Sinemet, Sinemet CR, Symmetrel, Tasmar and Zelapar     

A.  A documented:

• Contraindication to two covered anti-Parkinson agents OR
• Intolerance to two covered anti-Parkinson agents OR
• Allergy to two covered anti-Parkinson agents OR
• Failure of an adequate trial of one month each of two covered anti-Parkinson agents OR
• Member is unable to use oral medications (Cogentin inj ONLY)

OR

For Akineton, Kemadrin, Laradopa, Lodosyn, Parcopa and Tasmar

B. Transition of Coverage:

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Akineton, Kemadrin, Laradopa, Lodosyn, Parcopa, or Tasmar for 30 days or longer

If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.

If the member has been a Medicare member for 91 days or longer and is not residing in a LTC facility then standard precertification, step-therapy, or medical exception criteria will apply.

For Neupro
A.  A documented:

• Contraindication to one of the following covered alternatives: carbidopa/levodopa, Mirapex, Requip or Stalevo OR
• Intolerance to of the following covered alternatives: carbidopa/levodopa, Mirapex, Requip or Stalevo OR
• Allergy to of the following covered alternatives: carbidopa/levodopa, Mirapex, Requip or Stalevo OR
• Failure of an adequate trial of one month of one of the following covered alternatives: carbidopa/levodopa, Mirapex, Requip or Stalevo OR
• Member has difficulty swallowing (dysphagia) and requires the transdermal dosage form