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 CARBIDOPA-LEVODOPA TABLET Y    
CARBIDOPA/LEVODOPA SINEMET 10-100 TABLET Y    
CARBIDOPA/LEVODOPA SINEMET 25-100 TABLET Y    
CARBIDOPA/LEVODOPA SINEMET CR TABLET ER Y    
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA ER TABLET ER Y    
CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 100 TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 150 TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 50 TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 75 TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 200 TABLET Y    
CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 125 TABLET Y    
ENTACAPONE ENTACAPONE TABLET Y    
ENTACAPONE COMTAN TABLET Y    
PRAMIPEXOLE DI-HCL MIRAPEX TABLET Y    
PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE TABLET Y    
SELEGILINE HCL SELEGILINE HCL CAPSULE Y    
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL ELIXIR Y    
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL TABLET Y    
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 BROMOCRIPTINE MESYLATE TABLET N PA Document  
BROMOCRIPTINE MESYLATE PARLODEL TABLET N PA Document  
CARBIDOPA CARBIDOPA TABLET N PA Document  
CARBIDOPA LODOSYN TABLET N PA Document  
CARBIDOPA/LEVODOPA RYTARY CAPSULE ER N PA Document  
CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA TAB RAPDIS N PA Document  
PRAMIPEXOLE DI-HCL MIRAPEX ER TAB ER 24H N PA Document  
PRAMIPEXOLE DI-HCL PRAMIPEXOLE 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 TASMAR TABLET N PA Document  
TOLCAPONE TOLCAPONE TABLET N PA Document