01Billing team: Before scheduling or billing apomorphine for these members, confirm the request is for Apokyn (apomorphine) and submit prior authorization through the BCBSMS PA process.
02Samples do not count as current or stable therapy.
03Initial requests need documentation that the member is 18 years of age or older, has advanced Parkinson's disease as determined by a board certified neurologist, has documented acute, intermittent hypomobility 'off' episodes (end-of-dose wearing off and unpredictable on/off episodes), is currently on levodopa and at least one other agent (amantadine, entacapone, selegiline or tolcapone), is not taking a 5HT3 antagonist (ondansetron, granisetron, dolasetron, palonosetron or alosetron), has no FDA-labeled contraindication to the requested agent, and has a dosage within program quantity limits.
04Initial approval length is 6 months.
05Renewal requires a prior approval through the BCBSMS PA process, documented clinical improvement in 'off' episodes, no FDA-labeled contraindication, and a dosage within program quantity limits.
06Renewal approval length is 12 months.
07Onapgo (apomorphine) for motor fluctuations is considered not medically necessary when other options covered by the Plan are available.
08Services related to delivery or administration of a medication that has not been approved through the BCBSMS PA review process will be considered not medically necessary.
09For State Health Plan participants, perform the formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required prior authorization requests to the Plan's Pharmacy Benefit Manager.
10Services related to delivery or administration of a self-administered drug are not covered.