Amantadine Extended-Release (Gocovri)

Amantadine Extended-Release (Gocovri®)

SELF ADMINISTRATION - Oral

Indication for Prior Authorization:

• Indicated for the treatment of dyskinesia in patients with Parkinson's disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications

Patients must meet the following criteria for the indication(s) above:

• Used for the treatment of dyskinesia in patients with Parkinson's disease, confirmed by chart note documentation, AND
• Patient is receiving levodopa-based therapy, with or without concomitant dopaminergic medications, AND
• Patient has tried and failed amantadine immediate-release
• Gocovri® is contraindicated in patients with end stage renal disease.

Dosing:

• Initial: 137 mg once daily at bedtime
• After 1 week, increase to 274 mg (two 137 mg capsules) once daily at bedtime.
• Gocovri® is not interchangeable with other amantadine immediate- or extended-release products.
• Dose adjusted for renal impairment (contraindicated in patients with end stage renal disease)