Gocovri™
Drug - Gocovri™ (amantadine extended-release) [Adamas Pharma, LLC.]
July 2018
Therapeutic area - Parkinson’s disease
Approval criteria
- Patient is ≥ 18 years of age AND
- Patient must have dyskinesia associated with Parkinson’s disease AND
- Patient must be on concomitant levodopa-based therapy AND
- Patient has had an adequate trial of or is intolerant to amantadine immediate-release AND
- Patient does not have end-stage renal disease (creatinine clearance < 15 mL/min/1.73 m2)
Renewal criteria
- Patient continues to meet criteria defined for initial approval AND
- Absence of unacceptable toxicity from the drug (e.g., hallucinations, falls, orthostatic hypotension, dizziness, anticholinergic effects, peripheral edema)
Quantity limits
- 68.5 mg: 30 capsules / 30 days
- 137 mg: 60 capsules / 30 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411