CurrentUnitedHealthcarePolicy 2026 P 1238-9

Tetrabenazine (Xenazine®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy Summary

PayerUnitedHealthcare

PolicyTetrabenazine (Xenazine®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2026 P 1238-9

Change TypeClarified placement of exclusion footnotereferences updated

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required for tetrabenazine; initial approvals are issued for 12 months when diagnosis criteria are met.

SourceLink

POLICY UPDATE CHANGES

Updated placement of footnote for exclusion statement for Xenazine brand tablets without change to intent.

Annual review and updates to background and references occurred across prior years without changes to clinical coverage criteria.

2Covered Indications (diagnoses)

12 moAuthorization Duration

XenazineBrand tablets typically excluded

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UnitedHealthcare prior authorization/notification policy for tetrabenazine (Xenazine) for UnitedHealthcare Commercial Plans specifying initial authorization and reauthorization clinical criteria, authorization durations, exclusions for brand tablets, and operational rules. Effective 2026-05-01; last review 2026-02. Initial authorization is approved for diagnoses of chorea associated with Huntington's disease and tardive dyskinesia when criteria are met, with authorizations issued for 12 months. Reauthorization requires documentation of a positive clinical response to therapy and is issued for 12 months. Note: Xenazine brand tablets are typically excluded from coverage (refer to plan specifics). UnitedHealthcare may use automated approval processes per program rules.

Initial Authorization - Chorea associated with Huntington's disease

Tetrabenazine will be approved based on the following criterion:

Diagnosis of chorea associated with Huntington's disease

Authorization will be issued for 12 months.

Reauthorization - Chorea associated with Huntington's disease

Reauthorization criteria:

Documentation of positive clinical response to tetrabenazine therapy

Authorization will be issued for 12 months.

Initial Authorization - Tardive dyskinesia

Tetrabenazine will be approved based on the following criterion:

Diagnosis of tardive dyskinesia

Authorization will be issued for 12 months.

Reauthorization - Tardive dyskinesia

Reauthorization criteria:

Documentation of positive clinical response to tetrabenazine therapy

Authorization will be issued for 12 months.

Applicable Codes & Brand Exclusions

Brand exclusion notemixedNot Covered

Xenazine brand tablets

Xenazine brand tablets are typically excluded from coverage; tried/failed criteria may be in place. Refer to plan specifics to determine exclusion status.

UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic using automated approval processes; these are acceptable forms of evidence for automated approval. Check member-specific benefit plans and state mandates for supply limits, NDC/quantity restrictions, and plan-specific brand exclusions (for example, Xenazine brand tablets) before submitting requests.

Provider Actions & Operational Rules

Prior Authorization

Prior authorization required

Prior authorization/notification is required for tetrabenazine; initial approvals are issued for 12 months when diagnosis criteria are met.

Documentation Required

Reauthorization documentation

For reauthorization, submit documentation of positive clinical response to tetrabenazine therapy; reauthorizations are issued for 12 months.

Documentation Required

Acceptable evidence for automated approval

UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic using automated approval processes.

Billing Rule

Supply limits and plan-specific exclusions

Supply limits may be in place and member-specific benefit plan coverage or state mandates may impact coverage; check plan specifics for brand exclusions and quantity limits.

Background

Tetrabenazine is a vesicular monoamine transporter 2 (VMAT2) inhibitor indicated for the treatment of chorea associated with Huntington's disease and is recommended by the American Academy of Neurology and the American Psychiatric Association for consideration in the management of tardive dyskinesia.

Key summary facts

Covered Indications (diagnoses)2

Authorization Duration12 months

Brand tablets typically excludedXenazine

Policy Summary

PayerUnitedHealthcare

PolicyTetrabenazine (Xenazine®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2026 P 1238-9

Change TypeClarified placement of exclusion footnotereferences updated

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required for tetrabenazine; initial approvals are issued for 12 months when diagnosis criteria are met.

SourceLink

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OpenPayer

Tetrabenazine (Xenazine®) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Coverage Summary

Applicable Codes & Brand Exclusions

Provider Actions & Operational Rules

Clinical Evidence & References

Background

Revision History