tetrabenazine — CareFirst (Caremark)
Chorea associated with Huntington’s disease
Initial criteria
- Member demonstrates characteristic motor examination features.
- Member meets one of the following conditions:
- Laboratory results indicate an expanded HTT CAG repeat sequence of at least 36 OR member has a positive family history for Huntington’s disease.
Reauthorization criteria
- Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement.
Approval duration
Initial: 6 months; Reauthorization: 12 months