CurrentCignaPolicy N/A

Vesicular Monoamine Transporter Type 2 Inhibitors Preferred Specialty Management Policy · Xenazine (tetrabenazine tablets)

Defines prior authorization and preferred-product management for tetrabenazine products for Cigna-administered health benefit plans; affects prescribers and payers handling requests for generic tetrabenazine and Xenazine. Applies to coverage determinations under Cigna plans.

Policy Summary

PayerCigna

PolicyVesicular Monoamine Transporter Type 2 Inhibitors Preferred Specialty Management Policy · Xenazine (tetrabenazine tablets)

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateN/A

Next Review DateApr 2, 2025

Key ActionPrescriber must document trial of generic tetrabenazine and, if requesting Xenazine, document that inactive-ingredient differences would cause a significant allergy or serious adverse reaction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration

Preferred productpreferred therapy

Exception criteriaexception pathway

Requireddocumentation

Huntington choreaindication

Policy Summary

PayerCigna

PolicyVesicular Monoamine Transporter Type 2 Inhibitors Preferred Specialty Management Policy · Xenazine (tetrabenazine tablets)

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateN/A

Next Review DateApr 2, 2025

SourceLink

On This Page

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Coverage Criteria for Tetrabenazine and Xenazine

Xenazine (non-preferred) exception criteria

Xenazine (brand) is covered as medically necessary only when the following are met:

Xenazine exception: Patient meets BOTH of the following (A and B)

From policy

A: Patient meets the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine Prior Authorization Policy criteria

See referenced prior authorization policy

B: Patient meets BOTH of the following (i and ii)

Documentation required for both i and ii

i: Patient has tried generic tetrabenazine tablets

[documentation required]

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, according to the prescriber, would result in a significant allergy or serious adverse reaction

[documentation required]

Preferred product approval when exception not met

If the patient meets the standard prior authorization criteria but has not met the Xenazine exception (trial/intolerance), then:

Fallback approval: Approve generic tetrabenazine tablets

Policy states approval of preferred product when exception not met; approvals provided for 1 year per prior authorization policy

Any use of a non-preferred product (brand Xenazine) without meeting the specified exception criteria is considered not medically necessary. The policy requires adherence to the Preferred Specialty Management program: patients must meet the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine prior authorization criteria and, unless the brand exception is met, the preferred product (generic tetrabenazine tablets) will be authorized.

Requests for Xenazine that do not meet the exception criteria will be considered not medically necessary. To qualify for Xenazine under the exception pathway the patient must meet BOTH: (A) the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine prior authorization criteria; and (B) both (i) a documented trial of generic tetrabenazine tablets and (ii) documentation from the prescriber that the patient cannot continue the preferred medication because of a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) that would cause a significant allergy or serious adverse reaction. Documentation may include chart notes, prescription claims records, prescription receipts, or other patient-specific records as noted in the policy.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

All tetrabenazine (VMAT2 inhibitor) requests require prior authorization under the VMAT2 Prior Authorization Policy. Approvals are provided for up to 1 year.

Applies to both Preferred (generic tetrabenazine tablets) and Non-Preferred (Xenazine) products.
Prior authorization decisions follow the standard Vesicular Monoamine Transporter Type 2 Inhibitor - Tetrabenazine Prior Authorization criteria.

Step Therapy

Preferred Product Trial Required

Step therapy requires that patients try the Preferred Product (generic tetrabenazine tablets) before coverage of the Non-Preferred product (Xenazine) will be authorized, unless a documented exception is met.

If PA criteria are met but the patient has not tried the Preferred Product, approval will be authorized for the Preferred Product.
Non-Preferred product (Xenazine) will be approved only if the Non-Preferred Product Exception Criteria are met (see documentation requirements).

Step Therapy Requirements

Step	Requirement	Documentation / Operational details
1
Prescriber must document a trial of the preferred product (generic tetrabenazine tablets) prior to approval of the non-preferred product (Xenazine), unless the Xenazine exception criteria are met.
Documentation of the trial is required and may include chart notes, prescription claims records, prescription receipts, or other patient-specific records. All tetrabenazine requests (preferred and non-preferred) require prior authorization; approvals are provided for 1 year.

Background

Tetrabenazine is a reversible vesicular monoamine transporter type 2 (VMAT2) inhibitor indicated for the treatment of chorea associated with Huntington's disease. This clinical context underlies the policy’s focus on product selection between generic tetrabenazine tablets and brand Xenazine, and the requirement to document intolerance to inactive ingredients when requesting the non-preferred product.

Definitions

Tetrabenazine — definition

Generic nameTetrabenazine

Mechanism of actionReversible vesicular monoamine transporter type 2 (VMAT2) inhibitor

IndicationTreatment of chorea associated with Huntington's disease

Formulation noteAvailable as tetrabenazine tablets (generic) and brand product Xenazine