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Ingrezza — Blue Cross Blue Shield of New Mexico

other FDA labeled indications

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) Reduction or discontinuation 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 OR (4) The patient has another compendia-supported indication for the requested agent and route) 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 OR (3) The patient has another compendia-supported indication for the requested agent and route)
  • If the request is for a brand agent with an available generic equivalent (Xenazine/tetrabenazine), then ONE of the following: (A) BOTH of the following: (1) ONE of the following: (A) The prescriber has stated that the patient has stage four advanced metastatic cancer and the requested agent is being used to treat the cancer OR (B) Documentation supports stage four advanced metastatic cancer and the requested agent is being used to treat an associated condition [chart notes required]) AND (2) The use of the requested agent is consistent with best practices, supported by peer-reviewed evidence, and FDA approved OR (B) The patient is currently stable on the requested agent [chart notes required] OR (C) The patient has tried and had inadequate response to the generic equivalent [chart notes required] OR (D) The generic equivalent was discontinued due to lack of efficacy or adverse event [chart notes required] OR (E) The patient has intolerance or hypersensitivity to the generic equivalent [chart notes required] OR (F) The patient has an FDA labeled contraindication to the generic equivalent [chart notes required] OR (G) The generic equivalent is expected to be ineffective, cause adherence barriers, worsen comorbid condition, reduce function, or cause harm [chart notes required] OR (H) The generic equivalent is not in the best interest of the patient [chart notes required] OR (I) The patient has tried another drug in the same pharmacologic class or mechanism discontinued due to inefficacy or adverse event [chart notes required] OR (J) There is support for the use of the requested brand agent over the generic equivalent) AND (K) If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling OR (B) There is support for use for the patient’s age) AND (L) The prescriber is a specialist or has consulted a specialist (psychiatrist, neurologist) AND (M) The patient will NOT be using another VMAT2 inhibitor concurrently AND (N) The patient has no FDA labeled contraindications to the requested agent
  • If Quantity Limit applies, the following criteria must be met: 1. Requested quantity does not exceed program limit OR 2. If exceeds, criteria A/B/C for higher dose justification as outlined in the policy

Reauthorization criteria

  • Patient has been previously approved for the requested agent
  • Prescriber is a specialist in or has consulted a specialist (psychiatrist, neurologist)
  • Patient has had clinical benefit with the requested agent
  • If request is for brand agent with a generic equivalent (Xenazine/tetrabenazine), then SAME exception criteria as Initial Authorization apply (A–J), including documentation requirements

Approval duration

3–12 months