CurrentCignaPolicy N/A

tetrabenazine_prior_authorization_policy

Defines prior authorization and preferred specialty management for tetrabenazine products (generic tetrabenazine tablets as Preferred Product and Xenazine as Non-Preferred Product) including exception criteria for coverage of the non-preferred brand. Applies to Cigna-administered health benefit plans as noted.

Policy Summary

PayerCigna

Policytetrabenazine_prior_authorization_policy

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionRequests for tetrabenazine require meeting the standard VMAT2 prior authorization criteria; approvals are provided for 1 year.

POLICY UPDATE CHANGES

Annual revisions on 06/07/2023, 04/10/2024, and 04/02/2025 noted with 'No criteria changes.'

1Preferred Product (generic)

1Non-Preferred Product (brand Xenazine) - conditional

Coverage Summary

Tetrabenazine is a reversible VMAT2 inhibitor indicated for treatment of chorea associated with Huntington's disease. This policy implements a Preferred Specialty Management program encouraging use of the Preferred Product (generic tetrabenazine tablets) and requires that all tetrabenazine requests follow the standard Vesicular Monoamine Transporter Type 2 (VMAT2) prior authorization criteria. The policy directs that the Preferred Product should be tried first and that Non-Preferred Products (brand Xenazine) are covered only when the specified exception criteria are met. This policy applies to Cigna-administered health benefit plans as noted in the instructions for use.

Initial / Standard Prior Authorization Criteria

Standard Prior Authorization Criteria (Vesicular Monoamine Transporter Type 2 Inhibitors)

Patient must meet the standard Vesicular Monoamine Transporter Type 2 Inhibitors prior authorization policy criteria (referenced).

Patient meets the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine prior authorization policy criteria

See referenced standard VMAT2 prior authorization policy for detailed clinical criteria

Preferred Product Selection / Specialty Management

Preferred Specialty Management / Product Selection

All medications require meeting the standard VMAT2 prior authorization criteria; Preferred Product should be tried first unless exception criteria for Non-Preferred Product are met.

If patient meets standard VMAT2 prior authorization criteria but has not tried a Preferred Product, approval for a Preferred Product (generic tetrabenazine tablets) will be authorized

All approvals are provided for 1 year

Preferred ProductNDC|HCPCS|mixedCovered

generic tetrabenazine tablets

Preferred product (generic tetrabenazine tablets) — specific NDCs not listed in policy

Non-Preferred Product Exception Criteria (Xenazine)

Xenazine (brand) is covered as medically necessary only when the following exception criteria are met. Any other exception is not medically necessary.

ALL of the following

A and B: A) Patient meets the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine prior authorization policy criteria
B) i and ii
- i and ii: i. Patient tried generic tetrabenazine tablets
  Documentation required (e.g., chart notes, prescription claims records, prescription receipts, other information)
- i and ii: 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 (e.g., chart notes, prescription claims records, prescription receipts, other information)

Fallback if exception not met: If patient meets standard VMAT2 prior authorization criteria but has NOT met exception criteria for Xenazine, approve generic tetrabenazine tablets

Non-Preferred ProductmixedCovered

Xenazine

Non-Preferred product (brand tetrabenazine) — covered only if exception criteria are met (patient meets standard VMAT2 prior authorization criteria, tried generic tetrabenazine tablets, and has documented inability to use the generic due to inactive ingredient-related significant allergy or serious adverse reaction)

Provider Actions

Prior Authorization

Prior authorization required

Requests for tetrabenazine (preferred and non-preferred) require meeting the standard VMAT2 prior authorization policy criteria; approvals are provided for 1 year.

Documentation Required

Documentation for exception

When requesting Xenazine as a non-preferred product, provide documentation that the patient tried generic tetrabenazine tablets and that a clinically significant allergy or serious adverse reaction to inactive ingredient differences would occur per the prescribing physician.

Chart notes
Prescription claims records
Prescription receipts

Clinical Evidence & Definitions

Xenazine tablets prescribing information, Lundbeck; November 2019.

Merative Micromedex search for tetrabenazine (accessed March 26, 2025).

Preferred Product: Generic tetrabenazine tablets — the plan's preferred product for VMAT2 inhibitor therapy.

Non-Preferred Product: Xenazine (brand tetrabenazine) — covered only when the policy's exception criteria are met (patient must meet standard VMAT2 prior authorization criteria, have tried generic tetrabenazine tablets, and have a documented inability to continue the preferred medication due to a clinically significant allergy or serious adverse reaction to inactive ingredient differences).

Revision History

2023-06-07annual_revision

Annual revision on 06/07/2023 noted with "No criteria changes."

2024-04-10annual_revision

Annual revision on 04/10/2024 noted with "No criteria changes."

2025-04-02annual_revisionLatest

Annual revision on 04/02/2025 noted with "No criteria changes."