CurrentUnitedHealthcarePolicy 2025 P 2138-9

Austedo® (deutetrabenazine), Austedo® XR (deutetrabenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Defines UnitedHealthcare commercial plan prior authorization and medical necessity criteria for initiation and reauthorization of Austedo and Austedo XR for (1) tardive dyskinesia and (2) chorea associated with Huntington's disease, including prescriber requirements and authorization duration.

Policy Summary

PayerUnitedHealthcare

PolicyAustedo® (deutetrabenazine), Austedo® XR (deutetrabenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Policy CodePolicy 2025 P 2138-9

Change TypeClarified; Added (Austedo XR)

Effective DateJul 1, 2025

Next Review Date

Key ActionPrior authorization is required for Austedo and Austedo XR; authorization will be issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Annual review with no change to clinical criteria in 4/2025; references updated.

Added coverage criteria for Austedo XR formulation per prescribing information in 4/2023.

2Covered Indications

12 moAuthorization Duration

Neurologist/PsychiatristPrescriber Requirement

Coverage Summary

Defines UnitedHealthcare commercial plan prior authorization and medical necessity criteria for initiation and reauthorization of Austedo and Austedo XR for tardive dyskinesia and chorea associated with Huntington's disease, including prescriber requirements (must be prescribed by or in consultation with a Neurologist or Psychiatrist) and an authorization duration of 12 months.

Key Policy Facts

Policy number2025 P 2138-9

Effective date2025-07-01

Last review2025-04-01

Authorization duration12 months

Covered indications (count)2

Covered indications (names)Tardive dyskinesia; Chorea associated with Huntington's disease

Initial Authorization — Tardive Dyskinesia

Initial Authorization - Tardive Dyskinesia

Covered when ALL of the following are met:

ALL of the following

Diagnosis of moderate to severe tardive dyskinesia.
ONE of
- Patient has persistent symptoms of tardive dyskinesia despite a trial of dose reduction, tapering, or discontinuation of the offending medication.
- Patient is not a candidate for a trial of dose reduction, tapering, or discontinuation of the offending medication (e.g., unacceptable clinical risk, contraindication, or inability to safely discontinue the offending agent).
Prescriber requirement
- Prescribed by or in consultation with a Neurologist.
- Prescribed by or in consultation with a Psychiatrist.

Prior Authorization

Provider Actions at Initiation and Reauthorization

Prior authorization is required for initiation. Document required clinical information and follow-up when submitting the request; authorization, when approved, is issued for 12 months.

Prior authorization required for Austedo or Austedo XR (initiation).
Prescriber specialty: documentation that the medication is prescribed by or in consultation with a Neurologist or Psychiatrist must be provided.
Evidence of prior trial: documentation of a trial of dose reduction, tapering, or discontinuation of the offending medication OR documentation of why the patient is not a candidate for such a trial (e.g., contraindication, unacceptable risk) must be provided.
For reauthorization: document positive clinical response to therapy (clinical improvement in tardive dyskinesia signs/symptoms).

Reauthorization — Tardive Dyskinesia

Reauthorization - Tardive Dyskinesia

Reauthorization will be approved when:

Documentation of positive clinical response to therapy

Documentation Required

Reauthorization — Tardive dyskinesia

For reauthorization for tardive dyskinesia, providers must document a positive clinical response to therapy. UnitedHealthcare may also approve reauthorization automatically based on claims/medication history, diagnosis codes, and/or claim logic.

Initial Authorization — Chorea Associated with Huntington's Disease

Initial Authorization - Chorea associated with Huntington's disease

Austedo or Austedo XR will be approved based on both of the following criteria:

ALL of the following

Diagnosis of chorea associated with Huntington's disease
Prescriber
- Prescribed by or in consultation with a Neurologist
- Prescribed by or in consultation with a Psychiatrist

Authorization will be issued for 12 months.

Documentation Required

Prescriber and authorization requirements — Chorea (Huntington's disease)

Prior authorization is required for Austedo and Austedo XR for chorea associated with Huntington's disease; when criteria are met, authorization is issued for 12 months.

Prescriptions must be by or in consultation with a Neurologist or Psychiatrist.

Reauthorization — Chorea Associated with Huntington's Disease

Reauthorization - Chorea associated with Huntington's disease

Reauthorization will be approved when:

Documentation of positive clinical response to therapy

Documentation Required

Reauthorization — Chorea (Huntington's disease)

For reauthorization for chorea associated with Huntington's disease, providers must document a positive clinical response to therapy. UnitedHealthcare may also approve reauthorization automatically based on claims/medication history, diagnosis codes, and/or claim logic.

Background

Austedo and Austedo XR are VMAT2 inhibitors indicated in adults for the treatment of chorea associated with Huntington's disease and for the treatment of tardive dyskinesia. The policy aligns coverage to those indications and requires prescriber specialty (prescribed by or in consultation with a Neurologist or Psychiatrist) and documentation of positive clinical response for reauthorization.

Policy Summary

PayerUnitedHealthcare

PolicyAustedo® (deutetrabenazine), Austedo® XR (deutetrabenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Policy CodePolicy 2025 P 2138-9

Change TypeClarified; Added (Austedo XR)

Effective DateJul 1, 2025

Next Review Date

Key ActionPrior authorization is required for Austedo and Austedo XR; authorization will be issued for 12 months when criteria are met.

SourceLink

On This Page

OpenPayer

Austedo® (deutetrabenazine), Austedo® XR (deutetrabenazine) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Coverage Summary

Initial Authorization — Tardive Dyskinesia

Reauthorization — Tardive Dyskinesia

Initial Authorization — Chorea Associated with Huntington's Disease

Reauthorization — Chorea Associated with Huntington's Disease

Provider Actions & Authorization Rules

Applicable Codes

Clinical Evidence & References

Background

Revision History