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Xenazine — Blue Cross Blue Shield of Montana

chorea associated with Huntington’s disease

Initial criteria

  • 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 such medications is not appropriate
  • AND B. The prescriber has evaluated the patient’s tardive dyskinesia through clinical examination or structured tool (e.g., AIMS, 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
  • 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
  • If the request is for a brand agent with a generic equivalent (Xenazine/tetrabenazine), then ONE of the following:
  • A. BOTH of the following:
  • 1. ONE of the following (stage four advanced, metastatic cancer use criteria as appropriate) AND
  • 2. Use is consistent with best practices and FDA approval OR
  • B. The patient is currently stable on the requested agent OR
  • C. The patient has tried and had an inadequate response to, or discontinued the generic due to lack of efficacy, adverse event, or intolerance OR
  • D. The generic equivalent is expected to be ineffective, cause adherence barrier, worsen comorbid condition, or not in the best interest of the patient OR
  • E. The patient has tried another drug in same class and had inadequate response or adverse event OR
  • F. There is support for the use of the brand agent over the generic equivalent
  • If the patient has an FDA labeled indication, then the patient’s age must be within labeling or there must be support for use at that age
  • The prescriber must be a psychiatrist, neurologist, or consult with one
  • The patient will not use the requested agent in combination with another VMAT2 inhibitor
  • The patient must not have any FDA labeled contraindications to the requested agent
  • Compendia Allowed: AHFS, or DrugDex 1, 2a, or 2b level of evidence

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • The prescriber is a specialist in the area of the patient’s diagnosis (psychiatrist, neurologist) or has consulted with one
  • The patient has demonstrated clinical benefit with the requested agent
  • If the request is for a brand agent with generic equivalent (Xenazine/tetrabenazine), then ONE of the following:
  • — meets same brand versus generic criteria as initial approval

Approval duration

12 months (BCBSIL 12 months; others: tardive dyskinesia 3 months, other indications 12 months)