ADLARITY (donepezil hydrochloride patch)

Self-Administration – transdermal

Diagnosis considered for coverage:
  • Indicated for the treatment of mild, moderate, and severe dementia of the Alzheimer’s type.
Coverage Criteria:

For diagnosis of Alzheimer dementia:

  • Dose does not exceed 10 mg/day patch applied to skin once weekly, AND
  • Patient has a medical need for patch and cannot use an oral medication, AND
  • Patient has tried and failed rivastigmine patch
Reauthorization Criteria:

For diagnosis of Alzheimer dementia:

  • Dose does not exceed 10 mg/day patch applied to skin once weekly, AND
  • Patient has a continued medical need for patch and cannot use a daily oral medication.
Coverage Duration: 


•    Initial: 1 year
•    Reauthorization: 1 year

Authorization is not covered for the following:


The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.
 

Additional Information: 
  • Patients treated with donepezil hydrochloride 5 mg or 10 mg tablets may be switched to Adlarity:
    • A patient who is being treated with a total daily dose of 5 mg of oral donepezil hydrochloride can be switched to the once weekly 5 mg/day Adlarity transdermal system. If a patient has been on 5 mg oral donepezil hydrochloride for at least 4-6 weeks, the patient may be switched immediately to the once weekly 10 mg/day transdermal system.
    • A patient who is being treated with a total daily dose of 10 mg of oral donepezil hydrochloride can be switched to the once weekly 10 mg/day Adlarity transdermal system.
  • Instruct patients or caregivers to apply the first transdermal system with the last administered oral dose.
  • Each Adlarity transdermal system delivers either 5 mg or 10 mg of donepezil daily for 7 days (one week cycle). At the end of 7 days, the used transdermal system is removed, and a new transdermal system is applied. Only one transdermal system should be applied at a time.
Policy Updates:
  • 11/15/2022 – New policy approved by P&T.
References:


1.    Adlarity Prescribing Information. Corium, Inc. Grand Rapids, MI. September 2022

Last review date: December 1, 2022

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