Pharmacy Prior Authorization Criteria

Inbrija (levodopa) inhalation powder

Indications for Prior Authorization

Inbrija (levodopa inhalation powder)

• For diagnosis of Parkinson's Disease
  Indicated for the intermittent treatment of OFF episodes in patients with Parkinson's disease treated with carbidopa/levodopa.

Criteria

Inbrija

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of Parkinson's disease
AND
• Patient is experiencing intermittent OFF episodes
AND
• Patient is receiving Inbrija in combination with carbidopa/levodopa at a maximally tolerated dose
AND
• Trial and failure, contraindication or intolerance to two of the following: [A]
• MAO-B Inhibitor (e.g., rasagiline, selegiline)
• Dopamine Agonist (e.g., pramipexole, ropinirole)
• COMT Inhibitor (e.g., entacapone)
AND
• Prescribed by or in consultation with a neurologist

Inbrija

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy
AND
• Patient is receiving Inbrija in combination with carbidopa/levodopa

P & T Revisions

2024-05-19, 2023-10-03, 2023-05-08, 2022-05-22, 2021-05-06, 2020-05-05

References

1. Inbrija Prescribing Information. Acorda Therapeutics, Inc. Ardsley, NY. August 2020.
2. Per clinical consult with neurologist, March 27, 2019.

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Revision History

• 2024-05-19: 2024 Annual Review.
• 2023-10-03: Program update to standard reauthorization language. No changes to clinical intent
• 2023-05-08: 2023 Annual Review.
• 2022-05-22: 2022 Annual Review
• 2021-05-06: Annual Review
• 2020-05-05: Annual Review. Removed drug name from first reauthorization criterion.

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