Pharmacy Prior Authorization Criteria

Inbrija (levodopa) inhalation powder

Indications for Prior Authorization

Inbrija (levodopa inhalation powder)

• For diagnosis of Parkinson's Disease
  Indicated for the intermittent treatment of OFF episodes in patients with Parkinson's disease treated with carbidopa/levodopa.

Criteria

Inbrija

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of Parkinson's disease
AND
• Patient is experiencing intermittent OFF episodes
AND
• Patient is receiving Inbrija in combination with carbidopa/levodopa at a maximally tolerated dose
AND
• Trial and failure, contraindication or intolerance to two of the following: [A]
• MAO-B Inhibitor (e.g., rasagiline, selegiline)
• Dopamine Agonist (e.g., pramipexole, ropinirole)
• COMT Inhibitor (e.g., entacapone)
AND
• Prescribed by or in consultation with a neurologist

Inbrija

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy
AND
• Patient is receiving Inbrija in combination with carbidopa/levodopa

P & T Revisions

1970-01-01, 2025-12-18, 2024-05-19, 2023-10-03, 2023-05-08, 2022-05-22, 2021-05-06, 2020-05-05

References

1. Inbrija Prescribing Information. Acorda Therapeutics, Inc. Ardsley, NY. August 2020.
2. Per clinical consult with neurologist, March 27, 2019.

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End Notes

1. Primary treatment options for patients experiencing intermittent OFF episodes depends on the severity of the episodes. The easiest options include: shortening the dosing interval of levodopa, advising patient to take levodopa on an empty stomach if possible, or crushing the tablet and ingesting it with carbonated water for more predictable and faster absorption. Following the trial of the above options, entacapone, MAO-B Inhibtors or Dopamine Agonists may be added to the patient's therapy to enhance dopamine levels. [2]

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Revision History

• 2025-12-18: no criteria changes, added IL statute operational note
• 2024-05-19: 2024 Annual Review.
• 2023-10-03: Program update to standard reauthorization language. No changes to clinical intent
• 2023-05-08: 2023 Annual Review.
• 2022-05-22: 2022 Annual Review
• 2021-05-06: Annual Review
• 2020-05-05: Annual Review. Removed drug name from first reauthorization criterion.

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