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Austedo — Blue Cross Blue Shield of Alabama

tardive dyskinesia

Initial criteria

  • ONE of the following:
  • The requested agent is Austedo/deutetrabenazine, Austedo XR/deutetrabenazine ER, or Ingrezza/valbenazine AND ONE of the following:
  • The patient has a diagnosis of tardive dyskinesia AND BOTH of the following:
  • ONE of the following:
  • - The patient is not taking any medications known to cause tardive dyskinesia (i.e., dopamine receptor blocking agents) OR
  • - The prescriber has reduced the dose or discontinued any medications known to cause tardive dyskinesia OR
  • - A reduced dose or discontinuation of any medications known to cause tardive dyskinesia is not appropriate AND
  • - The prescriber has evaluated the patient's tardive dyskinesia through clinical examination or via a structured evaluative tool (e.g., Abnormal Involuntary Movement Scale [AIMS], Dyskinesia Identification System: Condensed User Scale [DISCUS]) OR
  • The patient has a diagnosis of chorea associated with Huntington’s disease OR
  • The patient has another FDA labeled indication for the requested agent and route of administration OR
  • The patient has another indication supported in compendia for the requested agent and route of administration
  • OR The requested agent is Xenazine/tetrabenazine AND ONE of the following:
  • - The patient has a diagnosis of chorea associated with Huntington’s disease OR
  • - The patient has another FDA labeled indication for the requested agent and route of administration OR
  • - The patient has another compendia-supported indication for the requested agent and route of administration
  • AND If the request is for one of the following brand agents with an available generic equivalent:
  • Brand: Xenazine; Generic equivalent: tetrabenazine
  • ONE of the following:
  • - The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent OR
  • - The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent OR
  • - There is support for the use of the requested brand agent over the generic equivalent
  • AND If the patient has an FDA labeled indication, then ONE of the following:
  • - The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • - There is support for using the requested agent for the patient’s age for the requested indication
  • AND The prescriber is a specialist in or has consulted with a specialist in the area of the patient’s diagnosis (e.g., psychiatrist, neurologist)
  • AND The patient will NOT be using the requested agent in combination with another VMAT2 inhibitor for the requested indication
  • AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s prior authorization process
  • AND The prescriber is or has consulted with a specialist in the area of the patient’s diagnosis (e.g., psychiatrist, neurologist)
  • AND The patient has had clinical benefit with the requested agent
  • AND If request is for brand agent with available generic equivalent (Brand: Xenazine; Generic: tetrabenazine), ONE of the following:
  • - Intolerance or hypersensitivity to the generic equivalent that is not expected with the brand agent OR
  • - FDA labeled contraindication to the generic equivalent that is not expected with the brand agent OR
  • - Support for the use of the requested brand agent over the generic equivalent
  • AND The patient will NOT be using the requested agent in combination with another VMAT2 inhibitor for the requested indication
  • AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

tardive dyskinesia: 3 months; other indications: 12 months; renewal: 12 months