CurrentUnitedHealthcarePolicy N/A

Ingrezza (valbenazine) prior authorization

Defines UnitedHealthcare prior authorization and medical necessity criteria for Ingrezza (valbenazine) for adults with tardive dyskinesia and chorea associated with Huntington's disease; applies to providers and members under UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerUnitedHealthcare

PolicyIngrezza (valbenazine) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, prescriber specialty or consultation, and trial of dose reduction/taper (or rationale why not a candidate).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization period

Adultsindicated population

TD; choreaapproved indications

Neuro/Psychprescriber specialty

Coverage Criteria for Ingrezza (valbenazine)

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Initial Therapy - Tardive Dyskinesia

Covered when ALL of the following are met:

TD initial criteria: (1) Diagnosis of moderate to severe tardive dyskinesia

TD initial criteria - treatment trial: (2) One of the following: (a) Patient has persistent symptoms of tardive dyskinesia despite a trial of dose reduction, tapering, or discontinuation of the offending medication (b) Patient is not a candidate for a trial of dose reduction, tapering, or discontinuation of the offending medication

Refer to documentation requirements for rationale when patient is not a candidate

TD initial criteria - prescriber: (3) Prescribed by or in consultation with one of the following: neurologist or psychiatrist

Authorization issued for 12 months

Initial Therapy - Chorea (Huntington's disease)

Covered when ALL of the following are met:

Chorea initial criteria: (1) Diagnosis of chorea associated with Huntington's disease

Chorea initial criteria - prescriber: (2) Prescribed by or in consultation with one of the following: neurologist or psychiatrist

Authorization issued for 12 months

Coverage is subject to state mandates, federal requirements, and the member's specific benefit plan. UnitedHealthcare may use prior claims/medication history, diagnosis codes, and automated program logic to approve initial or reauthorization requests. In addition, other medical or pharmacy policies, utilization management programs, and supply limits may affect coverage determinations.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and will be approved when the specified diagnostic, treatment-trial (or rationale), and prescriber specialty criteria are met. For tardive dyskinesia: initial authorization requires diagnosis of moderate to severe tardive dyskinesia, documentation of a trial of dose reduction/tapering/discontinuation of the offending agent unless the patient is not a candidate for such a trial, and that the medication is prescribed by or in consultation with a neurologist or psychiatrist. For chorea associated with Huntington's disease: initial authorization requires diagnosis of chorea and that the medication is prescribed by or in consultation with a neurologist or psychiatrist. Authorization (when approved) will be issued for 12 months.

Tardive dyskinesia: diagnosis of moderate to severe tardive dyskinesia required
Tardive dyskinesia: documentation of trial of dose reduction, tapering, or discontinuation of offending medication OR documentation that patient is not a candidate for such trial
Chorea: diagnosis of chorea associated with Huntington's disease required
Prescriber: prescribed by or in consultation with a neurologist or psychiatrist
Authorization duration when approved: 12 months

Documentation Required

Dose Reduction / Taper Requirement

For the tardive dyskinesia indication, a trial of dose reduction, tapering, or discontinuation of the offending medication is required and must be documented unless clinically contraindicated or the patient is not a candidate for such a trial. If the patient is not a candidate, documentation explaining why a dose-reduction/taper is not appropriate is required.

Required unless clinically contraindicated or patient not a candidate
If not performed, provide clinical rationale and supporting documentation

Documentation Required

Required Clinical Documentation

Documentation must include the diagnosis (moderate to severe tardive dyskinesia or chorea associated with Huntington's disease), history and results of treatment trials or a clear rationale if trials are not applicable (including dose-reduction/taper efforts or why not attempted), evidence of positive clinical response for reauthorization, and prescriber specialty or consultation notes (neurology or psychiatry).

Include diagnosis and severity (where applicable)
Include documentation of dose-reduction/taper trial or rationale if not performed
Include prescriber specialty or consultation notes (neurologist or psychiatrist)
For reauthorization, document positive clinical response to therapy

Denial Risk

Denial Triggers for Tardive Dyskinesia

Denial may occur for tardive dyskinesia requests if documentation does not demonstrate the diagnosis of moderate to severe tardive dyskinesia, if there is no documentation of a trial of dose reduction/tapering/discontinuation of the offending agent (and no documented rationale why such a trial was not appropriate), or if the request is not prescribed by or in consultation with a neurologist or psychiatrist.

Missing or insufficient documentation of diagnosis/severity
No documentation of dose-reduction/taper trial and no clinical rationale provided
Prescriber is not a neurologist or psychiatrist and no consultation is documented

Denial Risk

Denial Triggers for Chorea

Denial may occur for chorea requests if documentation does not demonstrate a diagnosis of chorea associated with Huntington's disease, or if the request is not prescribed by or in consultation with a neurologist or psychiatrist. Lack of prescriber specialty/consultation documentation or missing evidence of benefit on reauthorization may result in denial.

Missing documentation of chorea associated with Huntington's disease
Prescriber not a neurologist or psychiatrist and no consultation documented
For reauthorization: lack of documented positive clinical response

Initial Authorization Rules

Initial Therapy — Initial authorization rules for covered indications

Initial authorization rules for covered indications:

Initial - Tardive Dyskinesia: Diagnosis of moderate to severe tardive dyskinesia; AND trial of dose reduction, tapering, or discontinuation of the offending medication with persistent symptoms, OR documentation that the patient is not a candidate for such a trial; AND prescribed by or in consultation with a neurologist or psychiatrist

Authorization period: 12 months

Initial - Chorea: Diagnosis of chorea associated with Huntington's disease; AND prescribed by or in consultation with a neurologist or psychiatrist

Authorization period: 12 months

Reauthorization and Continuation Criteria

Reauthorization/Continuation — Reauthorization requires documentation of clinical benefit

Reauthorization requires documentation of clinical benefit:

Reauthorization/Continuation: Documentation of positive clinical response to Ingrezza therapy is required for reauthorization

Authorization period: 12 months

Step	Requirement
1	Document a trial of dose reduction, tapering, or discontinuation of the offending medication (patient has persistent symptoms despite such trial).
1	OR document why the patient is not a candidate for a trial of dose reduction, tapering, or discontinuation of the offending medication.

Definitions and Terminology

VMAT2 inhibitor — definition of mechanism class

TermVMAT2 inhibitor (vesicular monoamine transporter 2 inhibitor)

Mechanism class exampleValbenazine (Ingrezza) is classified as a VMAT2 inhibitor

Indicated population (from policy background)Adults with tardive dyskinesia and chorea associated with Huntington's disease

Moderate to severe tardive dyskinesia — required diagnostic severity for approval

Required diagnostic severityDiagnosis of moderate to severe tardive dyskinesia

Context for requirementThis severity level is the stated diagnostic criterion for initial authorization of Ingrezza for TD

Related authorization noteAuthorization will be issued for 12 months when criteria are met

Background

Ingrezza (valbenazine) is a VMAT2 inhibitor indicated for the treatment of adults with tardive dyskinesia and for chorea associated with Huntington's disease. The policy requires an appropriate documented diagnosis and prescriber specialty involvement (neurologist or psychiatrist), and reauthorization is contingent on documentation of a positive clinical response.

Policy Summary

PayerUnitedHealthcare

PolicyIngrezza (valbenazine) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, prescriber specialty or consultation, and trial of dose reduction/taper (or rationale why not a candidate).

SourceLink

On This Page

OpenPayer

Ingrezza (valbenazine) prior authorization

Coverage Criteria for Ingrezza (valbenazine)

Provider Actions and Documentation Requirements

Initial Authorization Rules

Reauthorization and Continuation Criteria

Step Therapy / Trial Requirements

Definitions and Terminology

Background