CurrentAvMedPolicy N/A

Xenazine (tetrabenazine) prior authorization

Defines pharmacy prior authorization and step-edit requirements for Xenazine (tetrabenazine) for members, including required prescriber specialty, diagnosis, and step therapy. Applies to AvMed pharmacy benefits and affects prescribers and specialty pharmacies.

Policy Summary

PayerAvMed

PolicyXenazine (tetrabenazine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and provide chart notes documenting neurologist involvement, diagnosis of chorea due to Huntington's disease, and, for Xenazine, documented failure of at least 30 days of tetrabenazine.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Neurologist requiredPrescriber specialty requirement

Diagnosis-specificDiagnosis requirement

Tetrabenazine firstStep therapy

PropriumRxSite of care

Coverage Criteria

Approval Criteria

Covered when ALL of the following are met (per the checked product).

Xenazine approval: Medication is prescribed by or in consultation with a Neurologist; Member must have a diagnosis of chorea associated with Huntington's Disease (chart notes must document diagnostic criteria and symptoms); Member must have tried and failed at least 30 days of tetrabenazine (chart notes must document therapy failure).

All criteria must be met for approval

tetrabenazine approval: Medication is prescribed by or in consultation with a Neurologist; Member must have a diagnosis of chorea associated with Huntington's Disease (chart notes must document diagnostic criteria and symptoms).

All criteria must be met for approval

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Providers should not rely on sample medications as evidence of prior therapy when requesting authorization; previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Policy Summary

PayerAvMed

PolicyXenazine (tetrabenazine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Xenazine and tetrabenazine; all clinical criteria must be met and documented for approval. The prescriber (or consulting Neurologist) must sign the request and include complete member and prescriber information to avoid delays.

Fax requests to 1-305-671-0200
Prescriber signature required (preprinted stamps not valid)
Provide complete phone/fax and contact information

Step Therapy

Step therapy requirement for Xenazine

For approval of Xenazine, the member must have tried and failed at least 30 days of tetrabenazine. Documentation of prior therapy failure (chart notes or pharmacy claims) must be provided.

Step therapy: ≥ 30 days trial of tetrabenazine required before Xenazine will be approved
Documentation: chart notes or paid pharmacy claims showing failure or intolerance

Documentation Required

Required supporting documentation

Chart notes must document diagnostic criteria and symptoms for chorea associated with Huntington's Disease, and all checked clinical criteria must be supported by documentation (lab results, diagnostics, chart notes). Failure to provide required documentation may result in denial.

Chart notes documenting diagnostic criteria and symptoms for Huntington's chorea
Documentation of prior therapy failure for Xenazine (if applicable)
Relevant lab results and diagnostic studies, as applicable

Note

Administrative information

Prescriber must include member and prescriber identifying information, prescriber signature, office contact name, phone and fax numbers, and DEA or NPI. Incomplete, incorrect, or illegible information can delay or cause denial of the authorization.

Member name, AvMed #, DOB
Prescriber name, signature, date, DEA or NPI
Office contact name, phone number, fax number

Denial Risk

Incomplete request risk

Incomplete, incorrect, or illegible information on the request can delay or cause denial of the authorization. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Ensure all fields on the form are complete and legible
Do not rely on sample medication as evidence of prior therapy

Denial Risk

Insufficient documentation

Failure to provide required documentation (lab results, diagnostics, chart notes) to support each checked clinical criterion may result in denial of the request. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Insufficient chart documentation for diagnosis or prior therapy failure = potential denial
Provide supporting pharmacy claims when possible to confirm prior treatment history

Definitions

Chorea associated with Huntington's Disease — definition and documentation requirements

DefinitionChorea associated with Huntington's Disease: clinical diagnosis requiring chart notes documenting diagnostic criteria and symptoms; documentation is required for authorization of Xenazine or tetrabenazine.

Required documentationChart notes must document diagnostic criteria and symptoms to support the diagnosis for authorization.

Prescriber involvementMedication must be prescribed by or in consultation with a Neurologist for either Xenazine or tetrabenazine approval.

Use with XenazineFor Xenazine approval, in addition to the diagnosis and neurologist involvement, member must have tried and failed at least 30 days of tetrabenazine with chart notes documenting therapy failure.

VerificationPrevious therapies may be verified via pharmacy paid claims or submitted chart notes.

Initial Therapy Criteria

Initial therapy - Xenazine

Initial authorization requirements

Xenazine initial: Prescribed by or in consultation with a Neurologist; diagnosis of chorea associated with Huntington's Disease documented; prior failure of at least 30 days of tetrabenazine required.

All criteria must be met for approval

Initial therapy - tetrabenazine

Initial authorization requirements for generic tetrabenazine

tetrabenazine initial: Prescribed by or in consultation with a Neurologist; diagnosis of chorea associated with Huntington's Disease documented.

All criteria must be met for approval

OpenPayer

Xenazine (tetrabenazine) prior authorization

Coverage Criteria

Diagnosis and Billing Codes

Provider Actions and Documentation Requirements

Background

Definitions

Initial Therapy Criteria

Step Therapy Requirements

Site of Care / Dispensing