CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Tetrabenazine coverage for hyperkinetic movement disorders

Defines coverage, clinical criteria, and authorization limits for tetrabenazine for Medicaid members of Neighborhood Health Plan of Rhode Island for FDA-approved and specified compendial uses.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTetrabenazine coverage for hyperkinetic movement disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective Date6/2018

Next Review DateN/A

Key ActionObtain prior authorization; when criteria are met, authorization of 6 months may be granted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsauthorization duration granted when criteria met

12.5 mgspecified tablet strength in quantity limit

Reviewed: 3/2025document review history

Medicaidapplicability

Coverage Criteria for Tetrabenazine

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.

Chorea associated with Huntington's disease - Initial authorization

Motor features: Member demonstrates characteristic motor examination features.
Genetic/family evidence: Member has EITHER a positive family history for Huntington's disease OR laboratory results indicating an expanded HTT CAG repeat sequence of at least 36.

Chorea not associated with Huntington's disease: Authorization of 6 months may be granted for treatment of chorea not associated with Huntington's disease.

No additional specific diagnostic criteria listed in document.

Tic disorders: Authorization of 6 months may be granted for treatment of tic disorders.

No additional specific diagnostic criteria listed in document.

Tardive dyskinesia - Initial authorization

Specialist involvement: Must be prescribed by or in consultation with a neurologist or psychiatrist.
Causation: Documented diagnosis of tardive dyskinesia secondary to a centrally acting dopamine receptor-blocking agent (DRBA).
Assessment may include clinical examination or structured evaluative tool (e.g., AIMS, DISCUS).

Hemiballismus: Authorization of 6 months may be granted for the treatment of hemiballismus.

Assessment of dyskinesia using clinical exam or structured evaluative tool (e.g., AIMS, DISCUS) is referenced.

Continuation/renewal criteria: Authorization of 6 months may be granted for treatment continuation when there is written documentation of a positive clinical response as evidenced by disease stability or improvement.

Applies to tardive dyskinesia and other listed indications per document sections.

All indications for tetrabenazine that are not listed as either the FDA-approved indication (chorea associated with Huntington’s disease) or the enumerated compendial uses (tic disorders, tardive dyskinesia, hemiballismus, and chorea not associated with Huntington’s disease) are considered experimental/investigational and not medically necessary.

Use of tetrabenazine is covered only for the FDA-approved chorea indication and the specified compendial uses listed in this policy (tic disorders, tardive dyskinesia, hemiballismus, and chorea not associated with Huntington’s disease). Requests for any other, non‑FDA and non‑compendial uses will be denied as experimental/investigational and not medically necessary.

Provider Requirements and Authorization

Prior Authorization

Prior authorization required; 6-month approvals when criteria met

Prior authorization is required for tetrabenazine; when the coverage criteria are met, an authorization of 6 months may be granted for indicated uses including chorea associated with Huntington's disease, chorea not associated with Huntington's disease, tic disorders, tardive dyskinesia, and hemiballismus.

Authorization duration when criteria met: 6 months

Step Therapy

Specialist prescribing requirement for tardive dyskinesia

For requests to treat tardive dyskinesia with tetrabenazine, the medication must be prescribed by or in consultation with a neurologist or psychiatrist.

Documentation Required

Required clinical documentation and diagnostic evidence

Documentation must include diagnostic evidence of the covered condition and, for Huntington's disease chorea, characteristic motor examination features plus either a positive family history or laboratory confirmation of an expanded HTT CAG repeat ≥36; for tardive dyskinesia, document a diagnosis secondary to a centrally acting dopamine receptor-blocking agent (DRBA); continuation/renewal requires written documentation of a positive clinical response (stability or improvement).

Huntington's chorea: characteristic motor exam findings AND (positive family history OR HTT CAG repeat ≥36)
Tardive dyskinesia: documented diagnosis secondary to a centrally acting DRBA
Continuation/renewal: written documentation of positive clinical response (disease stability or improvement)

Denial Risk

Unlisted indications are experimental/investigational and will be denied

Requests for indications not listed in the policy (outside the FDA-approved indication and the enumerated compendial uses) are considered experimental/investigational and are not medically necessary; such requests will be denied.

Background

Tetrabenazine is a pharmacologic agent used in the management of hyperkinetic movement disorders. It is utilized for the treatment of chorea (including the FDA‑approved indication of chorea associated with Huntington’s disease) and for several compendial indications such as tic disorders, tardive dyskinesia, hemiballismus, and chorea not due to Huntington’s. Clinical evaluation and documentation of the diagnosis and therapeutic response are required for coverage of these indications.

Definitions

Huntington's disease chorea — definition and diagnostic criteria

DefinitionChorea associated with Huntington's disease: involuntary, rapid, irregular movements characterized by characteristic motor examination features.

Diagnostic criteriaMember demonstrates characteristic motor examination features AND meets one of: positive family history for Huntington's disease OR laboratory confirmation of expanded HTT CAG repeat ≥ 36.

Authorization durationWhen criteria met, authorization of 6 months may be granted for treatment.

Tardive dyskinesia — definition and assessment guidance

DefinitionTardive dyskinesia: dyskinesia secondary to a centrally acting dopamine receptor-blocking agent (DRBA).

Assessment guidanceDocumented diagnosis of tardive dyskinesia secondary to a centrally acting DRBA; assessment should include clinical examination or a structured tool (e.g., AIMS, DISCUS).

Authorization duration & prescriber requirementWhen criteria met, authorization of 6 months may be granted; for tardive dyskinesia, tetrabenazine must be prescribed by or in consultation with a neurologist or psychiatrist.