Inbrija Prior Authorization with Quantity Limit Criteria - Medicare Part D

Inbrija will be approved when ALL of the following are met:

1. The requested medication will be used for intermittent treatment of OFF episodes in patients with Parkinson’s disease AND 
2. The requested medication will be used in combination with carbidopa/levodopa AND 
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND 
4. The patient does NOT have any FDA labeled contraindications to the requested medication AND 
5. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. BOTH of the following: 
      1. The requested quantity (dose) is greater than the program quantity limit AND 
      2. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months