Pharmacy Prior Authorization Criteria

Nuedexta (dextromethorphan HBr/quinidine)

Indications for Prior Authorization

Nuedexta (dextromethorphan HBr/quinidine)

• For diagnosis of Pseudobulbar Affect (PBA)
  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.

Criteria

Nuedexta

Prior Authorization (Initial Authorization)

Length of Approval: 3 months [A]

• Diagnosis of pseudobulbar affect (PBA)
AND
• Patient has one of the following conditions: [3]
• Amyotrophic lateral sclerosis
• Multiple sclerosis
• Alzheimer's disease
• Parkinson's disease
• Stroke
• Traumatic brain injury
AND
• There is an absence of a cardiac rhythm disorder documented by a cardiac test (e.g., electrocardiogram)
AND
• Prescribed by or in consultation with one of the following specialists:
• Neurologist
• Psychiatrist

Nuedexta

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-01-30, 2023-12-06, 2023-02-01, 2022-02-03, 2021-02-03, 2020-02-13

References

1. Nuedexta Prescribing Information. Otsuka America Pharmaceuticals, Inc. Rockville, MD. December 2022.
2. Per clinical consultation with neurologist, September 8, 2011 and October 23, 2019.
3. Pseudobulbar affect: prevalence and management. Ther Clin Risk Manag. 2013;9:483-9.

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End Notes

1. Patients should be evaluated for Nuedexta benefit after the initial 3 months of treatment. [2]

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Revision History

• 2024-01-30: Annual review: Background and formatting updates.
• 2023-12-06: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-02-01: Annual review: No updates required.
• 2022-02-03: Annual review: No updates required.
• 2021-02-03: Annual review: Background updated.
• 2020-02-13: Annual review: Updated initial authorization and reauthorization criteria, and background.

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