Xenazine (tetrabenazine) — Highmark

Preferred products

• tetrabenazine (generic)

Initial criteria

• age ≥ 18 years
• diagnosis of chorea associated with Huntington’s disease (ICD-10: G10)
• If the request is for brand Xenazine, the member has experienced therapeutic failure or intolerance to generic tetrabenazine
• The member should not be actively suicidal
• If the member has a diagnosis of depression, the prescriber attests the member is receiving adequate treatment (for example cognitive behavioral therapy, pharmacotherapy)

Reauthorization criteria

• The prescriber attests that the member has experienced positive clinical response to therapy
• If the request is for brand Xenazine, the member has experienced therapeutic failure or intolerance to generic tetrabenazine

Approval duration

12 months