CurrentCignaPolicy N/A

Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo

Policy governs prior authorization and medical necessity criteria for coverage of deutetrabenazine (Austedo and Austedo XR) under Cigna prescription benefit plans, affecting prescribers and patients seeking coverage for Huntington's chorea or tardive dyskinesia.

Policy Summary

PayerCigna

PolicyVesicular Monoamine Transporter Type 2 Inhibitors - Austedo

Policy CodePolicy N/A

Change TypeClarified wordingadministrative revisions

Effective DateMay 15, 2026

Next Review DateN/A

Key ActionObtain prior authorization; approvals are typically granted for 1 year when coverage criteria are met.

SourceLink

POLICY UPDATE CHANGES

Changed phrasing from 'history of treatment with a dopamine receptor blocking agent' to 'Patient has a history of use of dopamine receptor blocking agent' and moved examples into a Note.

Updated title from 'Deutetrabenazine' to current title and recorded successive effective/review dates.

Conditions Not Covered statement was reworded (no criteria changes across noted review dates).

2FDA-approved indications listed

1 yearTypical approval duration

≥18Minimum age

Neurologist/PsychiatristPrescriber specialty

Medical Necessity Criteria

Chorea Associated with Huntington's Disease

Austedo/Austedo XR are considered medically necessary when ONE of the following is met (1 or 2):

A: Patient is >= 18 years of age
B: Diagnosis of Huntington's disease is confirmed by genetic testing (for example, an expanded HTT CAG repeat sequence of at least 36)
C: The medication is prescribed by or in consultation with a neurologist

Tardive Dyskinesia

Tardive dyskinesia coverage requires ALL of the following (A, B, and C):

Policy Summary

PayerCigna

PolicyVesicular Monoamine Transporter Type 2 Inhibitors - Austedo

Policy CodePolicy N/A

Change TypeClarified wordingadministrative revisions

Effective DateMay 15, 2026

Next Review DateN/A

Key ActionObtain prior authorization; approvals are typically granted for 1 year when coverage criteria are met.

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.

Prescriber and Billing Actions

Prior Authorization

Prior Authorization Required

Prior Authorization is required for prescription benefit coverage of Austedo/Austedo XR. Approvals are provided for the duration noted (typically 1 year) when the patient meets the applicable medical necessity criteria. Because evaluation and monitoring require specialized skills, Austedo/Austedo XR must be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., neurologist for Huntington's disease; neurologist or psychiatrist for tardive dyskinesia).

Approvals: typically 1 year when criteria are met
Prescriber requirement: specialist or in consultation with specialist

Step Therapy

No step therapy requirements are specified in this policy for Austedo/Austedo XR.

Documentation Required

Required Clinical Documentation

Prescriptions must be accompanied by documentation supporting the diagnosis and criteria for the indication requested. Examples: genetic testing confirming Huntington's disease (e.g., expanded HTT CAG repeat ≥ 36) for chorea associated with Huntington's disease; documented history of use of a dopamine receptor blocking agent for tardive dyskinesia. Documentation should also identify the specialist prescriber or consultation with a specialist.

Huntington's disease: genetic testing (expanded HTT CAG repeat ≥ 36)
Tardive dyskinesia: history of dopamine receptor blocking agent use; examples include antipsychotics, metoclopramide, prochlorperazine

Billing Rule

Coding and Claim Submission

Claims submitted without a covered diagnosis or procedure code supporting medical necessity will be denied. When billing, providers must use the most appropriate codes as of the date of service. Receipt of sample product does not satisfy documentation or criteria requirements for coverage.

Claims missing covered diagnosis/procedure codes will be denied
Use most appropriate codes for date of service
Sample product does not satisfy criteria

Key Definitions and Terms

History of use of dopamine receptor blocking agent

DefinitionPrior exposure to agents that block dopamine receptors (policy term: 'history of use of dopamine receptor blocking agent').

Examples provided in policy NoteAntipsychotics; metoclopramide; prochlorperazine; (policy also lists dopamine agonists such as pramipexole and ropinirole as examples).

Context of useRequired as part of the tardive dyskinesia coverage criteria — patient must have a history of use of a dopamine receptor blocking agent to meet criteria for Austedo/Austedo XR approval for TD.

Age requirement when appliedMust be ≥ 18 years of age when using this history to qualify for tardive dyskinesia coverage.

Prescriber requirement when appliedMedication must be prescribed by or in consultation with a neurologist or psychiatrist for tardive dyskinesia cases referencing this history.

OpenPayer

Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo

Medical Necessity Criteria

Prescriber and Billing Actions

Clinical Background

Key Definitions and Terms