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Ingrezza — Blue Cross Blue Shield of Oklahoma

other FDA labeled indications

Initial criteria

  • ONE of the following: A. Requested agent is Austedo/deutetrabenazine, Austedo XR/deutetrabenazine ER, or Ingrezza/valbenazine AND ONE of the following:
  • 1. Diagnosis of tardive dyskinesia AND BOTH of the following: (A) ONE of the following: (1) Patient is NOT taking medications known to cause tardive dyskinesia OR (2) Prescriber has reduced or discontinued such medications OR (3) Reduction/discontinuation not appropriate AND (B) Prescriber has evaluated tardive dyskinesia by clinical exam or structured tool (e.g., AIMS, DISCUS) OR
  • 2. Diagnosis of chorea associated with Huntington’s disease OR
  • 3. Another FDA labeled indication for the requested agent and route of administration OR
  • 4. Another indication supported in compendia for the requested agent and route of administration;
  • OR requested agent is Xenazine/tetrabenazine AND ONE of the following:
  • 1. Diagnosis of chorea associated with Huntington’s disease OR
  • 2. Another FDA labeled indication OR
  • 3. Compendia supported indication;
  • If the request is for a brand agent with a generic equivalent (Xenazine/tetrabenazine), ONE of the following:
  • A. BOTH of the following: (1) ONE of the following: (A) Prescriber has stated or documented stage four advanced, metastatic cancer and agent used to treat cancer or associated condition AND (2) Use consistent with best practices and FDA approval OR
  • B. Patient currently treated and stable on requested agent OR
  • C. Tried and inadequate response to generic equivalent OR
  • D. Generic discontinued due to lack of efficacy or adverse event OR
  • E. Intolerance/hypersensitivity to generic not expected with brand OR
  • F. FDA labeled contraindication to generic not expected with brand OR
  • G. Generic expected ineffective, cause barrier to care, worsen comorbidity, reduce functional ability, cause harm OR
  • H. Generic not in patient’s best interest based on medical necessity OR
  • I. Tried another drug in same class/MOA discontinued due to lack of efficacy or adverse event OR
  • J. Support for use of brand over generic;
  • K. If FDA labeled indication, ONE of: (A) Age within label OR (B) Support for off-age use;
  • L. Prescriber specialist in diagnosis area or has consulted with specialist;
  • M. Patient will NOT use with another VMAT2 inhibitor for same indication;
  • N. Patient has no FDA labeled contraindications;
  • Compendia allowed: AHFS, DrugDex 1, 2a, 2b.

Reauthorization criteria

  • Patient previously approved for requested agent via plan's PA process;
  • Prescriber specialist in diagnosis area or has consulted with specialist;
  • Patient has had clinical benefit with requested agent;
  • If brand agent with generic equivalent (Xenazine/tetrabenazine): BOTH of the following: (1) One of stage four metastatic cancer documentation criteria, stability, intolerance, etc., as in initial criteria is met.

Approval duration

tardive dyskinesia - 3 months; all other indications - 12 months; BCBSIL members 12 months