Prior Authorization and Quantity Limit Criteria for Approval

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

1. ONE of the following:
   1. The patient has a diagnosis of pseudobulbar affect
      OR
   2. The patient has an indication that is supported in CMS approved compendia for the requested medication
      AND
2. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
3. 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