Xenazine — Cigna
chorea associated with Huntington’s disease
Preferred products
- generic tetrabenazine tablets
Initial criteria
- Patient meets BOTH of the following (A and B):
- A) Patient meets the standard Vesicular Monoamine Transporter Type 2 Inhibitor – Tetrabenazine Prior Authorization Policy criteria; AND
- B) Patient meets BOTH of the following (i and ii):
- i. Patient tried generic tetrabenazine tablets; AND
- ii. Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the generic product which, per the prescribing physician, would result in a significant allergy or serious adverse reaction. [documentation required]
Approval duration
1 year