Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Akineton biperiden tablet     Not Applicable APOKYN apomorphine 10 mg/mL Cartridge   $$$$$+ Artane trihexyphenidyl 0.4 mg/mL Elixir     $ Artane trihexyphenidyl 2 mg tablet; 5 mg tablet     $ AZILECT rasagiline 0.5 mg tablet; 1 mg tablet   Not Applicable Cogentin benztropine 2 mg/2 mL Solution     $ Comtan entacapone 200 mg tablet     $$$$ Eldepryl selegiline HCl 5 mg capsule     $$$$ Kemadrin procyclidine tablet     Not Applicable Larodopa Levodopa     $$ Lodosyn carbidopa tablet     Not Applicable Mirapex pramipexole tablet     Not Applicable Mirapex ER pramipexole 3.75 mg tablet extended release 24 hr; 2.25 mg tablet extended release 24 hr; 0.375 mg tablet extended release 24 hr; 0.75 mg tablet extended release 24 hr; 1.5 mg tablet extended release 24 hr; 3 mg tablet extended release 24 hr; 4.5 mg tablet extended release 24 hr   Not Applicable Neupro rotigotine 1 mg/24 hour Patch 24 hr; 3 mg/24 hour Patch 24 hr; 8 mg/24 hour Patch 24 hr; 2 mg/24 hour Patch 24 hr; 6 mg/24 hour Patch 24 hr; 4 mg/24 hour Patch 24 hr   $$$$ Parcopa carbidopa-levodopa tablet,disintegrating     Not Applicable Parlodel bromocriptine 2.5 mg tablet     $$$ Parlodel bromocriptine 5 mg capsule     $$$ Requip ropinirole 1 mg tablet; 3 mg tablet; 5 mg tablet; 0.5 mg tablet; 0.25 mg tablet; 4 mg tablet; 2 mg tablet     $$ Requip XL ropinirole 6 mg tablet extended release 24 hr; 12 mg tablet extended release 24 hr; 2 mg tablet extended release 24 hr; 4 mg tablet extended release 24 hr; 8 mg tablet extended release 24 hr   $$$ Sinemet carbidopa-levodopa 10-100 mg tablet; 25-100 mg tablet; 25-250 mg tablet     $$$ Sinemet CR carbidopa-levodopa 25-100 mg tablet extended release; 50-200 mg tablet extended release     $$$ Stalevo 100 carbidopa-levodopa-entacapone 25-100-200 mg tablet     Not Applicable Stalevo 125 carbidopa-levodopa-entacapone 31.25-125-200 mg tablet     Not Applicable Stalevo 150 carbidopa-levodopa-entacapone 37.5-150-200 mg tablet     Not Applicable Stalevo 200 carbidopa-levodopa-entacapone 50-200-200 mg tablet     Not Applicable Stalevo 50 carbidopa-levodopa-entacapone 12.5-50-200 mg tablet     Not Applicable Stalevo 75 carbidopa-levodopa-entacapone 18.75-75-200 mg tablet     Not Applicable Symmetrel amantadine 100 mg capsule     $ Symmetrel amantadine 100 mg tablet     $ Symmetrel amantadine 50 mg/5 mL Syrup     $ Tasmar tolcapone 100 mg tablet     Not Applicable Zelapar selegiline HCl 1.25 mg tablet,disintegrating   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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