tetrabenazine — CareFirst (Caremark)

Initial criteria

• Member exhibits clinical manifestations of disease.
• Member’s tardive dyskinesia has been assessed through clinical examination or with a structured evaluative tool (e.g., Abnormal Involuntary Movement Scale [AIMS], Dyskinesia Identification System: Condensed User Scale [DISCUS]).

Reauthorization criteria

• Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement.

Approval duration

Initial: 6 months; Reauthorization: 12 months