Subject: Nuedexta PA Policy 870-A, 599-A 04-2022

Drug

NUEDEXTA  (dextromethorphan hydrobromide/quinidine sulfate)

Policy:

FDA-approved Indications
Nuedexta is indicated for the treatment of pseudobulbar affect (PBA).
PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurological disease or injury.

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
    •   The patient has a diagnosis of pseudobulbar affect (PBA)

Place of Service:

Outpatient

The above policy is based on the following references:

1. Nuedexta [package insert]. Aliso Viejo, CA: Avanir Pharmaceuticals, Inc.; June 2019.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed February 18, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed February 18, 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 14, 2022