POLICY: Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo Prior Authorization Policy
Defines prior authorization requirements and medical necessity criteria for Austedo (deutetrabenazine) and Austedo XR for prescription benefit coverage under Cigna-administered health benefit plans, including FDA-approved indications and exclusions.
Austedo XR was added to the policy.
Annual reviews in 2023, 2024, and 2025 noted; 2023 and 2024 recorded 'No criteria changes.'
Coverage Summary
Defines prior authorization requirements and medical necessity criteria for Austedo (deutetrabenazine) and Austedo XR for prescription benefit coverage under Cigna-administered health benefit plans, including FDA-approved indications and exclusions. Austedo and Austedo XR are indicated in adults for chorea associated with Huntington's disease and tardive dyskinesia. Coverage stance: covered_with_criteria (Prior Authorization recommended under the Vesicular Monoamine Transporter Type 2 Inhibitors - Austedo Prior Authorization Policy for Cigna-administered plans).