Part D & Commercial Pharmacy Prior Authorization • Medical Necessity & Prior Authorization

Brand & Specialty Parkinson's Drugs (Rytary, Neupro, Xadago, Gocovri, Apokyn, Nourianz, Nuplazid) — Prior Auth Checklist

Billing & Coverage Codes: Rytary • Neupro (rotigotine) • Xadago (safinamide) • Gocovri (amantadine ER) • Apokyn (apomorphine) • Nourianz (istradefylline) • Nuplazid (pimavanserin)

Important Policy Notice — Not a Guarantee of Approval: Clinical coverage criteria change periodically and your health plan's official Evidence of Coverage and clinical policy determination are final. This checklist summarizes published CMS and commercial payer policies for educational preparation and is never a guarantee of approval.

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Plain-English Clinical Documentation Checklist

What Your Neurologist / Care Team Must Document in the Chart Note

Every Medicare Part D plan and commercial PBM uses Step Therapy and Prior Authorization on brand-name Parkinson's medications. Before your neurologist submits the PA form, make sure the chart note explicitly documents the exact step-therapy prerequisites below:

1Rytary (carbidopa/levodopa ER capsules): Document motor fluctuations ('wearing-off') on immediate-release carbidopa/levodopa AND trial/failure of generic sustained-release carbidopa/levodopa ER tablets.

2Neupro Patch (rotigotine): Document trial/failure or intolerance of at least one oral non-ergot dopamine agonist (generic pramipexole or ropinirole), OR document clinical dysphagia (swallowing impairment) / GI malabsorption preventing reliable oral pill intake.

3Xadago (safinamide) & Nourianz (istradefylline): Document persistent 'OFF' episodes on carbidopa/levodopa AND prior trial/inadequate response to generic rasagiline (and generic entacapone/dopamine agonist for Nourianz).

4Gocovri (amantadine ER bedtime capsules): Document levodopa-induced dyskinesia (and/or OFF episodes) AND prior trial, inadequate response, or intolerance to generic immediate-release amantadine capsules/tablets.

5Apokyn (subcutaneous apomorphine rescue pen): Document sudden/unpredictable 'OFF' episodes refractory to oral medication adjustments AND confirm the patient is NOT taking any 5-HT3 antagonist antiemetic (ondansetron, granisetron, palonosetron).

6Nuplazid (pimavanserin 34 mg): Document a clinical diagnosis of hallucinations and/or delusions associated with Parkinson's disease psychosis (ICD-10 G20 + F06.0 / F06.2) and note that dopamine-blocking antipsychotics are clinically contraindicated due to motor worsening.

Published Clinical Policy Citations

CMS Medicare & Major Commercial Payer Policies

Medicare Part D (All Standalone PDPs & Medicare Advantage MAPDs)Verified Oct 2026

CMS CY 2026 Part D Formulary & Utilization Management Requirements (42 CFR § 423.578 Exceptions Process)

Part D plans must issue a standard coverage determination within 72 hours (or 24 hours for an expedited request when waiting could jeopardize health). Once approved, all out-of-pocket costs count toward the $2,100 CY 2026 Part D cap.

View Official Source Policy (https://www.medicare.gov/drug-coverage-part-d/what-medicare-part-d-drug-plans-cover/how-part-d-drug-plans-work)

Medi-Cal Rx (California Statewide Medicaid Pharmacy Benefit)Verified Oct 2026

CA DHCS Medi-Cal Rx Prior Authorization & Contract Drug List (CDL) Clinical Criteria

Medi-Cal Rx adjudicates all PA requests within 24 hours (California statutory turnaround). Approved brand/specialty medications carry a $0 patient copay.

View Official Source Policy (https://medi-calrx.dhcs.ca.gov/)

Other Parkinson's Medical Necessity Checklists

DBS Surgery (CPT 61885 / 61867)DaTscan SPECT (CPT 78803 + A9584)PT / OT / Speech & LSVT (CPT 97110, 97535, 92507)Home Health Care (CPT 99349 / G0151 / G0153)Duopa (J7340) & Vyalev Infusion Pumps