ADLARITY (donepezil hydrochloride patch)

ADLARITY (donepezil hydrochloride patch)

Self-Administration – transdermal

Diagnosis considered for coverage:

• Indicated for the treatment of mild, moderate, and severe dementia of the Alzheimer’s type.

Coverage Criteria:

For diagnosis of Alzheimer dementia:

• Dose does not exceed 10 mg/day patch applied to skin once weekly, AND
• Patient has a medical need for patch and cannot use an oral medication, AND
• Patient has tried and failed rivastigmine patch

Reauthorization Criteria:

For diagnosis of Alzheimer dementia:

• Dose does not exceed 10 mg/day patch applied to skin once weekly, AND
• Patient has a continued medical need for patch and cannot use a daily oral medication.

Coverage Duration: 

•    Initial: 1 year
•    Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.
 

Additional Information: 

• Patients treated with donepezil hydrochloride 5 mg or 10 mg tablets may be switched to Adlarity:
  • A patient who is being treated with a total daily dose of 5 mg of oral donepezil hydrochloride can be switched to the once weekly 5 mg/day Adlarity transdermal system. If a patient has been on 5 mg oral donepezil hydrochloride for at least 4-6 weeks, the patient may be switched immediately to the once weekly 10 mg/day transdermal system.
  • A patient who is being treated with a total daily dose of 10 mg of oral donepezil hydrochloride can be switched to the once weekly 10 mg/day Adlarity transdermal system.
• Instruct patients or caregivers to apply the first transdermal system with the last administered oral dose.
• Each Adlarity transdermal system delivers either 5 mg or 10 mg of donepezil daily for 7 days (one week cycle). At the end of 7 days, the used transdermal system is removed, and a new transdermal system is applied. Only one transdermal system should be applied at a time.

Policy Updates:

• 11/15/2022 – New policy approved by P&T.

References:

1.    Adlarity Prescribing Information. Corium, Inc. Grand Rapids, MI. September 2022