Parkinson's Disease Drugs, Oral & Topical

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
benztropine mesylate BENZTROPINE MESYLATE TABLET Y    
carbidopa/levodopa SINEMET 25-250 TABLET Y    
carbidopa/levodopa SINEMET 10-100 TABLET Y    
carbidopa/levodopa SINEMET 25-100 TABLET Y    
carbidopa/levodopa CARBIDOPA-LEVODOPA TABLET Y    
carbidopa/levodopa SINEMET CR TABLET ER Y    
carbidopa/levodopa CARBIDOPA-LEVODOPA ER TABLET ER Y    
carbidopa/levodopa/entacapone STALEVO 100 TABLET Y    
carbidopa/levodopa/entacapone CARBIDOPA-LEVODOPA-ENTACAPONE TABLET Y    
carbidopa/levodopa/entacapone STALEVO 75 TABLET Y    
carbidopa/levodopa/entacapone STALEVO 125 TABLET Y    
carbidopa/levodopa/entacapone STALEVO 150 TABLET Y    
carbidopa/levodopa/entacapone STALEVO 50 TABLET Y    
carbidopa/levodopa/entacapone STALEVO 200 TABLET Y    
entacapone COMTAN TABLET Y    
entacapone ENTACAPONE TABLET Y    
pramipexole di-HCl PRAMIPEXOLE DIHYDROCHLORIDE TABLET Y    
pramipexole di-HCl MIRAPEX TABLET Y    
selegiline HCl SELEGILINE HCL CAPSULE Y    
trihexyphenidyl HCl TRIHEXYPHENIDYL HCL ELIXIR Y    
trihexyphenidyl HCl TRIHEXYPHENIDYL HCL TABLET Y    
amantadine HCl GOCOVRI CAP ER 24H N PA Document  
amantadine HCl AMANTADINE CAPSULE N PA Document  
amantadine HCl AMANTADINE SOLUTION N PA Document  
amantadine HCl AMANTADINE TABLET N PA Document  
bromocriptine mesylate BROMOCRIPTINE MESYLATE CAPSULE N PA Document  
bromocriptine mesylate PARLODEL CAPSULE N PA Document  
bromocriptine mesylate PARLODEL TABLET N PA Document  
bromocriptine mesylate BROMOCRIPTINE MESYLATE TABLET N PA Document  
carbidopa LODOSYN TABLET N PA Document  
carbidopa CARBIDOPA TABLET N PA Document  
carbidopa/levodopa RYTARY CAPSULE ER N PA Document  
carbidopa/levodopa CARBIDOPA-LEVODOPA TAB RAPDIS N PA Document  
pramipexole di-HCl PRAMIPEXOLE ER TAB ER 24H N PA Document  
pramipexole di-HCl MIRAPEX ER TAB ER 24H N PA Document  
rasagiline mesylate AZILECT TABLET N PA Document  
rasagiline mesylate RASAGILINE MESYLATE TABLET N PA Document  
ropinirole HCl ROPINIROLE ER TAB ER 24H N PA Document  
ropinirole HCl REQUIP XL TAB ER 24H N PA Document  
ropinirole HCl REQUIP TABLET N PA Document  
ropinirole HCl ROPINIROLE HCL TABLET N PA Document  
rotigotine NEUPRO PATCH TD24 N PA Document  
safinamide mesylate XADAGO TABLET N PA Document  
selegiline HCl ZELAPAR TAB RAPDIS N PA Document  
selegiline HCl SELEGILINE HCL TABLET N PA Document  
tolcapone TOLCAPONE TABLET N PA Document  
tolcapone TASMAR TABLET N PA Document