CurrentUnitedHealthcarePolicy N/A

Movement Disorder Agents (Ingrezza) prior authorization form

Prior authorization form and clinical criteria checklist for initiation or continuation of valbenazine (Ingrezza) for movement disorders including Huntington's chorea and tardive dyskinesia; collects patient, provider, diagnosis, prior therapy, assessment scales, and documentation requirements for coverage determination.

Policy Summary

PayerUnitedHealthcare

PolicyMovement Disorder Agents (Ingrezza) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvider must complete entire form (Sections A-E), sign, include prescriber specialty and date, and fax to 866-940-7328 with chart notes attached; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Primary Indications Listed

1Required prior VMAT2 trial

12Minimum trial duration specified (weeks)

Coverage Summary

This is a UnitedHealthcare prior authorization form for valbenazine (Ingrezza) with a mixed coverage stance: requests may be approved when the form documents required clinical and administrative items. Primary indications listed are Chorea associated with Huntington's disease and Tardive dyskinesia. The prior authorization form is used to collect information needed for coverage determination and to confirm prior therapy and specialist involvement.

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Clinical Criteria for Approval

General Coverage Criteria for Ingrezza Prior Authorization

Coverage/approval considered when ALL of the following are documented:

Request includes completed patient and provider information (Section A and B) and prescriber signature, specialty, date, and chart notes are attached

Form explicitly states 'CHART NOTES ARE REQUIRED WITH THIS REQUEST'

Indication specified: Indication is specified as one of: Chorea associated with Huntington's disease; Tardive dyskinesia; or Other (specified)

Section C asks to indicate diagnosis and ICD-10 code

Continuation documentation: If continuation of therapy: documentation of clinical benefit or disease stability (e.g., reduction in involuntary movements, decrease in total maximal chorea score, or improvement in AIMS or CGI-TD score)

Section asks for evidence of disease stability/positive clinical response

Prescriber specialty: Prescribed by or in consultation with a psychiatrist or neurologist

Checkbox required in Section C

Baseline assessments: Documentation of baseline assessment with relevant rating scales as appropriate (e.g., UHDRS sections, AIMS, CGI-TD)

Section C question 4 requests which baseline assessments completed

Pregnancy status: Documentation of pregnancy status (pregnant yes/no) if applicable

Section C includes pregnancy question

Concomitant MAOI/VMAT2 use: Documentation of concomitant MAOI or other VMAT2 inhibitor use (yes/no) and specification if applicable

Section C question 5

Prior VMAT2 therapy requirement (either one applies)

TD antipsychotic strategy alternatives: For TD: documentation that patient continues to have persistent TD after trying one of the following unless contraindicated, not tolerated, or would risk psychiatric stability: switching from a 1st generation to a 2nd generation antipsychotic; OR trial of two 2nd generation antipsychotics; OR history of discontinuation or dose modification of the offending medication with continued symptoms
Section specifically lists these alternatives for TD
Deutetrabenazine 12-week trial: Documentation that patient had treatment (minimum of 12 weeks) with deutetrabenazine or deutetrabenazine ER that was ineffective, not tolerated, or contraindicatedminimum of 12 weeks
Section C question 6

Attach prior medication trial details: Attach chart notes supporting diagnosis, prior medication trials (dates, reasons for failure/discontinuation), and clinical assessments

Section D captures previous medication trials and reasons; chart notes required

Administrative / Documentation Requirements

Requests will be reviewed only when ALL administrative items are provided:

Completed Sections A-E: Completed prior authorization form with Sections A-E fully filled

Form instructions: complete entire form and fax

Attach chart notes with prior medication trials/details: Attach chart notes supporting diagnosis, prior medication trials (dates, reasons for failure/discontinuation), and clinical assessments

Section D captures previous medication trials and reasons; chart notes required

Continuation: start date and evidence of benefit: If continuation: include start date of therapy and evidence of benefit

Section A asks if continuation and start date

Actions Required of Providers

Prior Authorization

Submit completed prior authorization form and chart notes

Complete and sign the prior authorization form (Sections A–E). Include prescriber specialty and date. Attach chart notes supporting the request and fax the entire packet to 866-940-7328. Allow at least 24 hours for review.

Complete Sections A–E
Include prescriber specialty and date
Attach chart notes
Fax to 866-940-7328
Allow at least 24 hours for review

Documentation Required

Document baseline and follow-up assessments

Document baseline assessment using the appropriate movement disorder scales (e.g., UHDRS sections as relevant, AIMS, CGI-TD). For continuation requests, provide documentation of clinical improvement or disease stability (for example: reduction in involuntary movements, decrease in total maximal chorea score, or improvement in AIMS or CGI-TD).

Baseline assessments: UHDRS (specify section[s] completed), AIMS, CGI-TD as applicable
For continuation: show clinical benefit or stability (e.g., reduced involuntary movements, lower chorea score, improved AIMS/CGI-TD)

Documentation Required

Document prior medication trials and reasons for failure

List prior medication trials with medication name, strength, directions, dates of therapy, and reason for failure or discontinuation. For tardive dyskinesia, document trials of antipsychotic adjustments (e.g., switch from 1st to 2nd generation, trials of two 2nd generation antipsychotics, or history of dose modification/discontinuation) or state contraindications/intolerance.

Include medication name, strength, directions, dates, and reason for failure/discontinuation
For TD: document antipsychotic switch/trials or history of dose change/discontinuation, or contraindication/intolerance

Documentation Required

Confirm specialist involvement

Ensure the prescriber is a psychiatrist or neurologist or attach documentation of consultation with a psychiatrist or neurologist. Include prescriber signature, specialty, and date on the form.

Prescriber must be a psychiatrist or neurologist or provide consultation documentation
Include prescriber signature, specialty, and date

Background

This UnitedHealthcare prior authorization form applies to Movement Disorder Agents (Ingrezza/valbenazine) and is intended to support coverage decisions for treatment of Huntington's chorea and tardive dyskinesia. The form instructs providers to complete all sections, fax the form and attached chart notes, and allow at least 24 hours for review.

The form emphasizes documentation of prior therapy trials (including listing previous medications, dates, and reasons for failure/discontinuation), confirmation that the prescriber is a psychiatrist or neurologist (or that consultation occurred), and the use of standardized movement disorder rating scales for baseline and follow-up assessments (UHDRS sections, AIMS, CGI-TD). For tardive dyskinesia, the form specifically asks for evidence of antipsychotic management steps (e.g., switching antipsychotic class or trials of second-generation agents) unless contraindicated. Chart notes and prescriber signature/specialty/date are required with the request.

AIMS: Abnormal Involuntary Movement Scale — a standardized scale to assess involuntary movements.

CGI-TD: Clinical Global Impression of Change - Tardive Dyskinesia — a clinician-rated measure of change in TD.

UHDRS: Unified Huntington's Disease Rating Scale — includes motor, cognitive, behavioral, functional assessment, independence scale, and total functional capacity sections.

MAOI: Monoamine oxidase inhibitor — examples listed include isocarboxazid, phenelzine, tranylcypromine, reserpine.

VMAT2 inhibitor: Vesicular monoamine transporter 2 inhibitor — examples listed include tetrabenazine and deutetrabenazine.

OpenPayer

Movement Disorder Agents (Ingrezza) prior authorization form

Coverage Summary

Clinical Criteria for Approval

Actions Required of Providers

Diagnosis Coding

Background

Revision History