Coverage criteria policies

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Duopa requires prior authorization from Pharmacy Administration.

Duopa will generally be approved when (1) prescribed by Neurology; and (2) for the treatment of motor fluctuation in patients with advanced Parkinson’s disease.

Approvals will be provided for one year. Reauthorizations will be provided for patients with continued efficacy.

Additional approvals may be required for associated procedures.

Duopa is a combination of carbidopa (an aromatic amino acid decarboxylation inhibitor) and levodopa (an aromatic amino acid) indicated for the treatment of motor fluctuations in patients with advanced Parkinson’s disease.

Duopa is an enteral suspension that is administered over a 16-hour infusion period into the jejunum via a jejunal tube (PEG-J) with a CADD portable infusion pump.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

NDC Codes:

HCPCS Codes:

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Approved Medical Director Committee 8/17/2015; Annual Review 8/2016, 8/2017

References

1. Duopa™ prescribing information and medication guide. North Chicago, IL: AbbVie Inc.; September 2016