Austedo XR — Medical Mutual

Preferred products

• tetrabenazine tablets

Initial criteria

• Diagnosis of Huntington’s disease is confirmed by genetic testing (for example, an expanded HTT CAG repeat sequence of at least 36)
• Patient is age > 18 years
• The medication is prescribed by or in consultation with a neurologist
• Patient has tried generic tetrabenazine tablets
• 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 prescriber, would result in a significant allergy or serious adverse reaction

Reauthorization criteria

• Clinical response to therapy is required for continuation

Approval duration

1 year