CurrentNeighborhood Health Plan of Rhode IslandPolicy 1746-A

deutetrabenazine (Austedo/Austedo XR) coverage for Huntington disease chorea and tardive dyskinesia

Defines prior authorization, documentation, and coverage criteria for deutetrabenazine (Austedo and Austedo XR) for Huntington disease chorea and tardive dyskinesia for members of the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policydeutetrabenazine (Austedo/Austedo XR) coverage for Huntington disease chorea and tardive dyskinesia

Policy CodePolicy 1746-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit chart notes documenting characteristic motor exam features for Huntington chorea or clinical assessment/AIMS or DISCUS documentation for tardive dyskinesia.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2FDA-approved indications covered

6 moInitial authorization duration

12 moContinuation authorization duration

>=36HTT CAG repeat threshold

Coverage Criteria for Deutetrabenazine (Austedo / Austedo XR)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial coverage: Huntington disease chorea

Authorization of 6 months may be granted when ALL of the following are met:

Chorea HD initial criteria: Member demonstrates characteristic motor examination features.

Supportive diagnostic evidence: Laboratory results indicate an expanded HTT CAG repeat sequence of at least 36HTT CAG >=36

Supportive diagnostic evidence: Member has a positive family history for Huntington's disease

Initial coverage: Tardive dyskinesia

Authorization of 6 months may be granted when ALL of the following are met:

Tardive dyskinesia initial criteria: Member exhibits clinical manifestations of disease.

Assessment requirement: Tardive dyskinesia has been assessed through clinical examination or with a structured evaluative tool (e.g., AIMS, DISCUS).

Continuation therapy

Continuation of therapy — Authorization of 12 months may be granted when ALL of the following are met:

Continuation criteria: Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement.

Authorization of 12 months may be granted.

All uses of deutetrabenazine (Austedo/Austedo XR) outside the FDA‑approved indications listed below are considered experimental/investigational and are not covered.

Use of deutetrabenazine for indications other than chorea associated with Huntington disease in adults and tardive dyskinesia in adults is not medically necessary and may be denied.

Drug Products and Coding

Covered drug productsNDC | brandCovered

Austedo	deutetrabenazine (brand)
Austedo XR	deutetrabenazine extended release (brand)

inv-07: HTT CAG repeat — threshold supporting Huntington disease diagnosis

HTT CAG repeat threshold>= 36 CAG repeats indicating expanded HTT allele supporting Huntington disease diagnosis

Clinical contextUsed as supportive diagnostic evidence for chorea associated with Huntington disease when laboratory results indicate expansion

Alternative supportive evidencePositive family history for Huntington disease may substitute when HTT CAG result not available

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization duration and renewal

Prior authorization is required. Initial approvals may be granted for 6 months when criteria are met; continuation approvals may be granted for 12 months for members experiencing benefit (disease stability or improvement).

Initial approval duration: up to 6 months
Continuation approval duration: up to 12 months

Note

Provider action required

Submit documentation to initiate prior authorization review for initial requests as specified below.

Documentation Required

Initial request documentation

For initial requests, submit chart notes or medical record documentation specific to the indication: characteristic motor examination features for chorea associated with Huntington's disease, or clinical manifestations of tardive dyskinesia.

Chorea (Huntington's disease): chart notes documenting characteristic motor examination features; supportive laboratory evidence such as HTT CAG repeat >= 36 or positive family history may be used per coverage criteria.
Tardive dyskinesia: chart notes documenting clinical manifestations of TD.

Documentation Required

Assessment documentation for tardive dyskinesia

Documentation for tardive dyskinesia must include assessment via clinical examination or a structured evaluative tool (e.g., AIMS or DISCUS).

Acceptable tools: Abnormal Involuntary Movement Scale (AIMS), Dyskinesia Identification System: Condensed User Scale (DISCUS)

Denial Risk

Non‑covered indications

Requests for indications other than treatment of chorea associated with Huntington's disease in adults or treatment of tardive dyskinesia in adults are not covered.

Non‑covered: Any use outside the two FDA‑approved adult indications

Key Definitions

inv-14: Expanded HTT CAG repeat — Laboratory result indicating an expanded HTT CAG repeat sequence of at least 36

DefinitionLaboratory result indicating an expanded HTT CAG repeat sequence of at least 36

PurposeSupports diagnosis of Huntington disease as part of coverage criteria for chorea associated with Huntington disease

Context in policyListed as one of the required supportive diagnostic evidences for initial authorization of 6 months

inv-15: Structured evaluative tools for tardive dyskinesia — Examples include AIMS and DISCUS

ExamplesAbnormal Involuntary Movement Scale (AIMS) and Dyskinesia Identification System: Condensed User Scale (DISCUS)

UseStructured evaluative tools or clinical examination must be used to assess tardive dyskinesia for initial authorization of 6 months

Policy requirementAssessment with a structured tool is listed alongside clinical examination as necessary documentation for coverage