CurrentUnitedHealthcarePolicy N/A

Ingrezza (North Carolina) Prior Authorization Form - Community Planopen_in_new

Prior authorization form for Ingrezza (a VMAT2 inhibitor) for treatment of moderate to severe tardive dyskinesia for UnitedHealthcare Community Plan (North Carolina). Captures beneficiary, prescriber, drug, clinical eligibility, baseline assessment, prior therapy, concomitant therapy, and continuation requirements.

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 Date

Key ActionPrescriber must complete and sign the Ingrezza prior authorization form including beneficiary, prescriber, drug, and clinical information; prescriber signature is mandatory and dated.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Required Baseline Assessment (AIMS/ESRI)

18+Minimum Age

1Mandatory Prescriber Signature

Coverage Summary

Prior authorization form for Ingrezza (valbenazine) for treatment of moderate to severe tardive dyskinesia for UnitedHealthcare Community Plan - NC; coverage stance: covered_with_criteria. The form captures beneficiary and prescriber details, drug information (name/strength/quantity/length of therapy), clinical eligibility (diagnosis, age >= 18), baseline assessment using AIMS or ESRI (numeric score requested), prior therapy history, concomitant therapy checks (dual VMAT2 therapy and concurrent MAOI/reserpine), and requirements for continuation of therapy including documentation of symptomatic improvement and re-answering clinical questions.

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Provider Actions & Prior Authorization Requirements

Prior Authorization

Submit prior authorization form

Prescriber must complete and sign the Ingrezza prior authorization form including beneficiary, prescriber, drug, and clinical information; prescriber signature is mandatory and dated.

Complete beneficiary, prescriber, drug, and clinical sections on the prior authorization form
Ensure prescriber signature is provided and dated

Documentation Required

Baseline movement disorder assessment required

Provider must document a baseline movement disorder assessment on the form using either the Abnormal Involuntary Movement Scale (AIMS) or the Extrapyramidal Symptom Rating Scale (ESRI). Include the numeric AIMS or ESRI score in the space provided on the form.

Indicate that baseline AIMS or ESRI was completed (Yes/No)
Record the numeric AIMS score or ESRI score in the designated field

Documentation Required

Continuation requires evidence of improvement

For continuation requests, attach documentation showing the beneficiary has had improvement in symptoms from baseline and re-answer clinical questions 1–6 on the form (diagnosis, age, baseline AIMS/ESRI, prior therapy, VMAT2 dual therapy, MAOI/reserpine use).

Attach objective or clinical documentation demonstrating symptom improvement from baseline
Re-answer clinical questions 1–6 on the form for continuation requests

Denial Risk

Concurrent contraindicated medications

The form queries concurrent use of MAOI (monoamine oxidase inhibitor) or reserpine; concurrent use is a contraindication/important safety check and may result in claim denial or referral for safety review if present without justification.

Question 6 asks whether the beneficiary is concurrently using a MAOI or reserpine (Yes/No)
Concurrent MAOI or reserpine use may trigger denial or safety review

Background & Definitions

This document is a payer prior authorization request template for Ingrezza (valbenazine) used to capture clinical eligibility for treatment of moderate to severe tardive dyskinesia and to support initial and continuation coverage decisions by collecting diagnosis, age, baseline AIMS/ESRI score, prior therapy, current concomitant medications (VMAT2 inhibitors, MAOI/reserpine), and prescriber attestation.

Term	Definition
AIMS	Abnormal Involuntary Movement Scale - a baseline evaluation tool requested on the form.
ESRI	Extrapyramidal Symptom Rating Scale - alternative baseline evaluation tool requested on the form.
VMAT2 inhibitor	Vesicular monoamine transporter 2 inhibitor; Ingrezza is a VMAT2 inhibitor and the form queries concurrent use of other VMAT2 inhibitors.