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tetrabenazine — Blue Cross Blue Shield of Kansas

tardive dyskinesia

Initial criteria

  • 1. ONE of the following:
  • A. The requested agent is Austedo/deutetrabenazine, Austedo XR/deutetrabenazine ER, or Ingrezza/valbenazine AND ONE of the following:
  • 1. The patient has a diagnosis of tardive dyskinesia AND BOTH of the following:
  • A. ONE of the following:
  • 1. The patient is not taking any medications known to cause tardive dyskinesia (dopamine receptor blocking agents) OR
  • 2. The prescriber has reduced the dose or discontinued any medications known to cause tardive dyskinesia OR
  • 3. A reduced dose or discontinuation of causative medications is not appropriate AND
  • B. The prescriber has evaluated the patient's tardive dyskinesia through clinical examination or structured tool (e.g., AIMS or DISCUS) OR
  • 2. The patient has a diagnosis of chorea associated with Huntington’s disease OR
  • 3. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 4. The patient has another indication supported in compendia for the requested agent and route of administration OR
  • B. The requested agent is Xenazine/tetrabenazine and ONE of the following:
  • 1. The patient has a diagnosis of chorea associated with Huntington’s disease OR
  • 2. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 3. The patient has another indication supported in compendia for the requested agent and route of administration AND
  • 2. If the request is for one of the brand agents with an available generic equivalent (Xenazine/tetrabenazine), then ONE of the following:
  • A. The patient has an intolerance or hypersensitivity to the generic equivalent not expected to occur with the brand agent OR
  • B. The patient has an FDA labeled contraindication to the generic equivalent not expected to occur with the brand agent OR
  • C. There is clinical support for the use of the brand agent over the generic equivalent AND
  • 3. If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication AND
  • 4. The prescriber is a specialist in the area of the patient’s diagnosis (psychiatrist, neurologist) or has consulted with a specialist AND
  • 5. The patient will NOT use the requested agent in combination with another VMAT2 inhibitor for the same indication AND
  • 6. The patient does NOT have any FDA labeled contraindications to the requested agent.

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s prior authorization process AND
  • 2. The prescriber is a specialist in the area of the patient’s diagnosis (psychiatrist, neurologist) or has consulted with a specialist AND
  • 3. The patient has had clinical benefit with the requested agent AND
  • 4. If the request is for a brand agent with an available generic equivalent (Xenazine/tetrabenazine), then ONE of the following:
  • A. The patient has an intolerance or hypersensitivity to the generic equivalent not expected to occur with the brand agent OR
  • B. The patient has an FDA labeled contraindication to the generic equivalent not expected to occur with the brand agent OR
  • C. There is clinical support for the use of the brand agent over the generic equivalent AND
  • 5. The patient will NOT use the requested agent in combination with another VMAT2 inhibitor for the requested indication AND
  • 6. 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