CurrentMass General Brigham Health PlanPolicy N/A

Ingrezza (valbenazine) prior authorization and quantity limits

Rules governing prior authorization, quantity limits, specialty pharmacy requirement, and coverage criteria for valbenazine (Ingrezza) for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyIngrezza (valbenazine) prior authorization and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and ensure fill at a contracted specialty pharmacy; provide required documentation for continuation demonstrating clinical improvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsinitial approval duration

12 monthsreauthorization duration

specialtydesignated fill location

2 indicationsFDA-indicated conditions

AII Plansprior auth phone

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Coverage Criteria for Valbenazine (Ingrezza)

inv-01: Initial therapy — diagnosis criteria

Authorization may be granted when the following diagnosis-specific criteria are met:

Covered indications: Member has one of the following diagnoses: (A) Chorea associated with Huntington's disease; OR (B) Tardive dyskinesia.

See Coverage Guidelines and indication-specific entries.

inv-02: Continuation Therapy

Continuation of therapy (reauthorization)

Improvement required: Documentation that the member's condition has improved is required for reauthorization.

Continuation of Therapy section: reauthorization contingent on documented improvement.

New-to-plan allowance: For members new to the plan within the past 90 days who are currently receiving the requested medication, authorization may be granted, excluding products obtained as samples or via other non-covered means.

See Coverage Guidelines regarding new-to-plan continuation.

For members who are new to the plan within the past 90 days, prior authorization may be granted to continue an ongoing valbenazine (Ingrezza) regimen. Products obtained as samples or via other non-standard distribution channels are excluded from this new-to-plan continuation allowance and therefore are not eligible for this exception to initial-therapy requirements.

Provider Requirements and Authorization Rules

Prior Authorization

Prior Authorization and Specialty Pharmacy

Prior authorization is required. This medication has been designated specialty and must be filled at a contracted specialty pharmacy. Contact information: All Plans Phone: 877-519-1908 Fax: 855-540-3693. Non-specialty medications contact: All Plans Phone: 800-711-4555 Fax: 844-403-1029.

Specialty designation: must be filled at a contracted specialty pharmacy
All Plans (specialty) Phone: 877-519-1908; Fax: 855-540-3693
Non-specialty medications Phone: 800-711-4555; Fax: 844-403-1029

Step Therapy

Step Therapy (Program Type)

Step therapy is indicated as a program type in the policy header. Specific step requirements (which agents or prior trials are required before approval) are not detailed in the criteria and should be confirmed with the plan prior to submission.

Documentation Required

Continuation Documentation

For continuation or reauthorization, documentation that the member's condition has improved is required. Reauthorization may be granted when the plan's continuation criteria are met.

Documentation that the member's condition has improved is required for continuation/reauthorization

Note

New-to-Plan Continuation

Authorization may be granted for members new to the plan within the past 90 days who are currently receiving treatment with the requested therapy, excluding when the product was obtained as samples.

Applies to members new to the plan within the past 90 days
Excludes therapy received only as samples

Background and Indication Summary

Valbenazine (Ingrezza) is available as capsules and a sprinkle capsule formulation and is indicated in adults for the treatment of tardive dyskinesia and chorea associated with Huntington's disease. The policy references the product labeling and clinical guidance as the basis for these FDA‑labeled indications.