Criteria for Prior Authorization: VMAT2 Inhibitors (deutetrabenazine, tetrabenazine, valbenazine)
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Prior authorization criteria for vesicular monoamine transporter 2 (VMAT2) inhibitor medications (deutetrabenazine, tetrabenazine, valbenazine) for Kansas Medicaid; governs initial and renewal PA requirements for prescribers and coverage conditions.
No material clinical or coverage changes in this revision.
Coverage Criteria for VMAT2 Inhibitors
Initial Prior Authorization
Covered when ALL of the following are met
Length of approval (initial): 6 months
Renewal Prior Authorization
Covered when ALL of the following are met
Length of approval (renewal): 12 months
Treatment of chorea associated with Huntington's disease is contraindicated in patients who are suicidal or who have a history of untreated or inadequately treated depression unless those issues have been addressed prior to initiating therapy. The policy requires documentation that the patient does not meet these exclusion conditions before coverage will be approved.
For tardive dyskinesia, baseline measurement with the Abnormal Involuntary Movement Scale (AIMS) must be provided; for Huntington's chorea, a baseline Total Maximal Chorea Score is required. Missing these baseline assessments is a clinical caveat that may lead to denial of prior authorization.
Requests that fail to meet any of the specified initial or renewal requirements are not consistent with coverage. Specifically, the request must meet the FDA-approved indication, age, and dosing limits listed in Table 1; use a preferred PDL agent when required unless non-preferred PDL PA criteria are met; and be prescribed by or in consultation with a neurologist or psychiatrist.
Required documentation must be included with the request: for tardive dyskinesia, the prescriber must provide the patient's baseline AIMS rating; for Huntington's chorea, the prescriber must provide the baseline Total Maximal Chorea Score. For requests for tetrabenazine at >50 mg daily, CYP2D6 genotyping results confirming intermediate or extensive metabolizer status must be submitted. Failure to supply the required age, dosing, prescriber specialty, or documentation will render the request inconsistent with coverage and may be considered not medically necessary.
Drug Agents, Dosing Limits, and Age Restrictions
| deutetrabenazine | Austedo®, Austedo® XR - VMAT2 inhibitor |
| tetrabenazine | Xenazine® - VMAT2 inhibitor |
| valbenazine | Ingrezza®, Ingrezza® Sprinkle - VMAT2 inhibitor |
Prior Authorization, Documentation, and Denial Triggers
Prior authorization required for all listed VMAT2 inhibitors
Prior authorization is required for all current and future dose forms of deutetrabenazine, tetrabenazine, and valbenazine. Initial approvals are granted for 6 months; renewals are handled separately (see renewal criteria and length).
Preferred PDL drug required when available
If a preferred PDL drug that treats the PA indication is available, the preferred agent must be used unless the patient meets the non-preferred PDL PA criteria.
Required baseline and renewal documentation (AIMS, Total Maximal Chorea Score, CYP2D6 when applicable)
Prescribers must submit baseline movement scores at initial request and objective improvement data at renewal: baseline AIMS for tardive dyskinesia and baseline Total Maximal Chorea Score for Huntington's chorea; at renewal, documented improvement of ≥2 points from baseline on the relevant scale is required. For tetrabenazine doses >50 mg/day, provide CYP2D6 genotyping confirming intermediate or extensive metabolizer.
- Initial: baseline AIMS rating (for TD) and baseline Total Maximal Chorea Score (for Huntington's chorea).
- Renewal: improvement (reduction) of ≥2 points from baseline on AIMS (TD) or Total Maximal Chorea Score (Huntington's chorea).
- If tetrabenazine >50 mg/day: CYP2D6 genotype results showing intermediate or extensive metabolizer.
Common triggers for PA denial
Prior authorization may be denied if the request does not meet required indications, age, dosing limits, prescriber specialty/consultation, required baseline or renewal documentation, or preferred-drug requirements.
- Not meeting the indication, minimum age (≥18 years), or dosing limits in Table 1 (e.g., exceeding listed max daily doses).
- Failure to use a preferred PDL drug when required and not meeting non-preferred PDL PA criteria.
- Not prescribed by or in consultation with a neurologist or psychiatrist.
- Missing baseline AIMS (for TD) or baseline Total Maximal Chorea Score (for Huntington's chorea), or lack of documented ≥2-point improvement at renewal.
- For tetrabenazine requests >50 mg/day: missing CYP2D6 genotyping confirming intermediate or extensive metabolizer.
- For Huntington's chorea: patient is suicidal or has untreated/inadequately treated depression.
Background
Vesicular monoamine transporter 2 (VMAT2) inhibitors included in this policy (deutetrabenazine, tetrabenazine, and valbenazine) are used for the management of hyperkinetic movement disorders, specifically chorea associated with Huntington's disease and tardive dyskinesia. The policy requires objective baseline and follow-up movement scale scores to document response: AIMS for tardive dyskinesia and the Total Maximal Chorea Score for Huntington's chorea.
Prior authorization is required for these agents, and initial approvals are issued for 6 months with renewal conditions based on documented clinical improvement. Additional safety-related requirements include exclusion of patients who are suicidal or have untreated/inadequately treated depression when treating Huntington's chorea, and CYP2D6 genotyping for higher tetrabenazine dosing (>50 mg/day).
Clinical Definitions and Rating Scales
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