CurrentUnitedHealthcarePolicy N/A

Ingrezza (North Carolina) Prior Authorization Form - Community Planopen_in_new

A prescriber-completed prior authorization form used by UnitedHealthcare North Carolina Community Plan to request initial or continuation coverage for Ingrezza (a VMAT2 inhibitor) for beneficiaries with moderate to severe tardive dyskinesia, capturing demographics, clinical criteria, prior trials, concomitant therapy, baseline rating scale scores, and treatment duration.

Policy Summary

PayerUnitedHealthcare

PolicyIngrezza (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateOct 15, 2025

Key ActionPrescriber must complete and sign the Ingrezza prior authorization form including beneficiary info, prescriber NPI, clinical questions, AIMS or ESRI score, prior trial information, concomitant therapy status, and desired duration.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered Indication (Tardive Dyskinesia)

1Required Baseline Scales (AIMS or ESRI)

18+Minimum Age

Coverage Summary

This is a prescriber-completed prior authorization form used by UnitedHealthcare North Carolina Community Plan to request initial or continuation coverage for Ingrezza (valbenazine), a VMAT2 inhibitor, for beneficiaries with moderate to severe tardive dyskinesia; the form captures demographics, prescriber NPI, clinical criteria, prior trials, concomitant therapy, baseline rating scale scores (AIMS or ESRI), and desired treatment duration. Coverage stance: covered_with_criteria. Status: CURRENT.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prescriber must submit completed PA form

Prescriber must complete and sign the Ingrezza prior authorization form. The form requires beneficiary identifying information, prescriber NPI, responses to clinical questions, either an AIMS or ESRI score, prior trial information, concomitant therapy status, desired duration of therapy, and the prescriber signature (mandatory).

Beneficiary information (name, ID, DOB, gender)
Prescriber NPI and requester contact information
Clinical questions (diagnosis, age, prior trial, concomitant therapy)
AIMS or ESRI score (baseline scale result)
Prior trial information (yes/no)
Concomitant therapy status (dual VMAT2, MAOI/reserpine)
Desired duration/length of therapy (selected interval)
Prescriber signature (mandatory)

Documentation Required

Baseline and follow-up rating scales required

Document baseline movement assessment using either the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRI). For continuation requests, attach documentation that shows improvement in symptoms from the documented baseline.

Document baseline AIMS or ESRI score
Continuation requests must include documentation showing improvement from baseline

Denial Risk

Potential denial for missing required info

Requests missing required information may be denied or processed incompletely. Missing prescriber signature, missing baseline rating scores (AIMS/ESRI), or lack of documentation of improvement for continuation requests are examples of information that may trigger denial or incomplete processing.

Missing prescriber signature may result in denial
Missing baseline AIMS or ESRI scores may result in denial
Missing documentation of improvement for continuation may result in denial or incomplete processing

Billing Rule

Pharmacy PA contact

For pharmacy prior authorization inquiries, contact the Pharmacy PA Call Center.

Pharmacy PA Call Center: 1-855-258-1593

Background & Definitions

This UnitedHealthcare Community Plan prior authorization request form is for Ingrezza (valbenazine), a vesicular monoamine transporter 2 (VMAT2) inhibitor indicated for tardive dyskinesia; it collects clinical and administrative information necessary to evaluate both initial and continuation therapy requests, including drug name/strength/quantity, length of therapy options, prescriber NPI and contact, and signature.

Term	Definition
AIMS	Abnormal Involuntary Movement Scale — a baseline evaluation tool queried on the form.
ESRI	Extrapyramidal Symptom Rating Scale — alternative baseline evaluation tool queried on the form.
VMAT2	Vesicular monoamine transporter 2 — class of drugs including valbenazine (Ingrezza).

Policy Summary

PayerUnitedHealthcare

PolicyIngrezza (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review DateOct 15, 2025

SourceLink

On This Page

OpenPayer

Ingrezza (North Carolina) Prior Authorization Form - Community Planopen_in_new

Coverage Summary

Initial and Continuation Therapy Criteria

Provider Actions & Prior Authorization Requirements

Applicable Codes

Background & Definitions

Clinical Evidence

Revision History