CurrentNeighborhood Health Plan of Rhode IslandPolicy Reference number(s) 2266-A

tetrabenazine (Xenazine) coverage for movement disorders

Defines prior authorization coverage criteria, required documentation, and authorization durations for tetrabenazine (Xenazine) for FDA-approved and compendial indications including chorea associated with Huntington's disease, tic disorders, tardive dyskinesia, hemiballismus, and chorea not due to Huntington's disease. Specifies investigational status for other indications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policytetrabenazine (Xenazine) coverage for movement disorders

Policy CodePolicy Reference number(s) 2266-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization and submit required documentation including AIMS items 1-7 for tardive dyskinesia and, for Huntington's chorea, evidence of characteristic motor features plus either HTT CAG repeat >=36 or positive family history.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

5Covered Indications (listed)

1Not covered category (other indications)

6 moTypical initial authorization duration

12 moContinuation authorization duration when improved/stable

Scope: This policy (Reference number(s) 2266-A) defines prior authorization coverage criteria, required documentation, and authorization durations for tetrabenazine (Xenazine) for FDA-approved and compendial indications. Covered indications include: treatment of chorea associated with Huntington's disease (FDA-approved); and compendial uses for tic disorders, tardive dyskinesia, hemiballismus, and chorea not associated with Huntington's disease. Authorization durations are typically 6 months for initial therapy, with potential 12-month continuation approvals when improvement or stabilization is documented.

Coverage stance: tetrabenazine (Xenazine) is covered with criteria when all applicable approval criteria and documentation requirements are met and the member has no exclusions to the prescribed therapy. All other indications not listed above are considered experimental/investigational and not medically necessary. Policy status: CURRENT.

Key thresholds and authorization durations

HTT CAG repeat threshold>= 36 repeats

AIMS items required (baseline & response)Items 1 to 7 of the Abnormal Involuntary Movement Scale (baseline required; decrease from baseline required for TD continuation)

Typical initial authorization duration6 months (for Huntington's chorea, non‑Huntington's chorea, tic disorders, tardive dyskinesia initial, hemiballismus)

Continuation/renewal authorization duration12 months when improved or stabilized (12 months for TD with decreased AIMS items 1–7; 12 months for other indications with improvement/stabilization)

Number of listed covered indications5

Continuation / Renewal Criteria

Criteria to qualify for extended authorization periods

ANY of the following

A. Tardive dyskinesia continuation: Authorization of 12 months may be granted when the member's tardive dyskinesia symptoms have improved as indicated by a decreased AIMS score (items 1 to 7) from baseline
Documentation of decreased AIMS items 1-7 from baseline required
B. Other indications continuation: Authorization of 12 months may be granted for treatment of all other indications listed in Section III when the member has experienced improvement or stabilization
Improvement or stabilization must be documented

Not Covered / Exclusions

Not Covered

Indications considered not medically necessary

All other indications not listed in Section I (FDA-approved and compendial uses) are considered experimental/investigational and not medically necessary

Standard plan exclusions apply: coverage for the listed indications is contingent on the member having no plan exclusions to the prescribed therapy as stated in the policy.

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required with indication-specific documentation

Providers must obtain prior authorization. For Huntington's chorea, submit documentation of characteristic motor examination features AND either laboratory evidence of expanded HTT CAG repeat >= 36 OR a positive family history. For tardive dyskinesia, include baseline AIMS items 1-7 as part of the required documentation.

Prior authorization required
Huntington's chorea: motor features + (HTT CAG repeat >= 36 OR positive family history)
Tardive dyskinesia: baseline AIMS items 1-7 required

Documentation Required

AIMS scoring documentation

For initial prior authorization for tardive dyskinesia, submit the baseline AIMS score for items 1 to 7. For continuation/renewal of tardive dyskinesia treatment, document a decreased AIMS score (items 1 to 7) from the baseline to demonstrate improvement.

Baseline AIMS items 1-7 required for initial PA
Continuation requires decreased AIMS items 1-7 from baseline

Clinical Evidence & References

Evidence: References cited in the policy include the Xenazine (tetrabenazine) package insert (November 2019) and the Apotex tetrabenazine package insert (September 2018), the American Academy of Neurology guideline on pharmacologic treatment of chorea in Huntington disease (Armstrong & Miyasaki, 2012), and additional drug information sources such as Micromedex and AHFS Drug Information. The policy notes tetrabenazine is used for hyperkinetic movement disorders including chorea in Huntington's disease and the listed compendial uses.

Definitions

AIMS items 1-7: Items 1 to 7 of the Abnormal Involuntary Movement Scale are used to assess baseline severity and response for tardive dyskinesia; baseline scoring of items 1-7 is required for initial authorization and documentation of a decreased items 1-7 score from baseline is required for 12-month continuation for tardive dyskinesia.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policytetrabenazine (Xenazine) coverage for movement disorders

Policy CodePolicy Reference number(s) 2266-A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

tetrabenazine (Xenazine) coverage for movement disorders

Coverage Summary

Initial Therapy Criteria

Continuation / Renewal Criteria

Not Covered / Exclusions

Prior Authorization & Documentation Requirements

Applicable Codes

Clinical Evidence & References

Definitions

Revision History