CurrentUnitedHealthcarePolicy N/A

Pharmacy prior authorization form for VMAT2 inhibitors (tardive dyskinesia and Huntington's chorea)

This document is a UnitedHealthcare pharmacy prior authorization request form used by prescribers to request coverage for vesicular monoamine transporter 2 (VMAT2) inhibitor medications for Tardive Dyskinesia or Huntington's Disease-related chorea. It collects beneficiary, prescriber, drug, and clinical information required to evaluate medical necessity and continuation requests.

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy prior authorization form for VMAT2 inhibitors (tardive dyskinesia and Huntington's chorea)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form and include required clinical documentation; for continuation requests attach documentation showing improvement from baseline (AIMS or ESRS).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Indications listed on form (Tardive Dyskinesia; Huntington's Disease chorea)

6Required baseline/continuation questions for Tardive Dyskinesia

6Required baseline/continuation questions for Huntington's Disease

Authorization Criteria for VMAT2 Inhibitors

Tardive Dyskinesia - Initial or Continuation Authorization

Coverage considered when ALL of the following are met (for continuation, documentation of improvement from baseline is additionally required):

ALL of the following

Beneficiary has a diagnosis of moderate to severe Tardive Dyskinesia
Checkbox on form
Beneficiary is age 18 years or older>= 18 years
Checkbox on form
Provider has completed baseline evaluations using either the Abnormal Involuntary Movement Scale (AIMS) or Extrapyramidal Symptom Rating Scale (ESRS)
Form requests AIMS or ESRI/ESRS score

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy prior authorization form for VMAT2 inhibitors (tardive dyskinesia and Huntington's chorea)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Huntington's Disease (Chorea) - Initial or Continuation Authorization

Coverage considered when ALL of the following are met (for continuation, documentation of improvement from baseline is additionally required):

ALL of the following

Beneficiary has a diagnosis of Huntington's Disease and is experiencing signs and symptoms of chorea
Checkbox on form
Beneficiary is age 18 years or older>= 18 years
Checkbox on form
Beneficiary is not receiving dual therapy with other VMAT2 inhibitors
Form asks about dual therapy
Beneficiary is not concurrently using a monoamine oxidase inhibitor (MAOI) or reserpine
Concurrent MAOI or reserpine use is queried
Provider has documented history of depression or suicidal ideation status
Form asks whether history exists; may impact safety assessment
Beneficiary is receiving treatment and/or is stable
Form asks if receiving treatment/stable; for continuation, improvement from baseline must be attached

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title": "Huntington's Disease (Chorea) - Initial or Continuation Authorization

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What the Prescriber Must Do

Prior Authorization

Complete and sign prior authorization form

Prescriber must complete the pharmacy prior authorization form, providing beneficiary and prescriber information, the requested drug details, answers to the clinical questions, and the prescriber’s signature and date; incomplete or unsigned forms may delay review.

Include beneficiary name, ID, DOB, and gender.
Provide prescriber NPI and requester contact information.
Record drug name, strength, quantity, length of therapy, and check initial vs continuation.
Sign and date the form (Prescriber Signature Mandatory).

Documentation Required

Attach baseline and follow-up symptom assessments for continuation

For continuation requests, attach documentation demonstrating improvement in symptoms from baseline; for tardive dyskinesia this specifically requests baseline and follow‑up AIMS or ESRS/ESRI scores.

For Tardive Dyskinesia: include baseline AIMS or ESRI/ESRS score and follow‑up scores showing improvement.
For Continuation of Therapy (both indications): answer the form questions and attach documentation of symptom improvement from baseline.

Denial Risk

Concurrent contraindicated medications or dual VMAT2 therapy

The form specifically asks whether the beneficiary is concurrently using a MAOI or reserpine or is receiving dual therapy with another VMAT2 inhibitor; affirmative responses are queried as part of appropriateness and may render the request inappropriate or be denied.

For Tardive Dyskinesia: question 5 (dual VMAT2 therapy) and question 6 (MAOI or reserpine) must be answered.
For Huntington’s Disease: question 9 (dual VMAT2 therapy) and question 10 (MAOI or reserpine) must be answered.

Clinical and Form Purpose

This prior authorization form is used to request coverage for VMAT2 inhibitors for two primary indications: moderate to severe tardive dyskinesia and Huntington's disease chorea. The form collects beneficiary, prescriber, drug, and clinical information necessary to evaluate medical necessity, including prescriber signature and date for certification of accuracy.

For tardive dyskinesia requests the form asks whether the beneficiary has a diagnosis of moderate to severe tardive dyskinesia; confirms the beneficiary is age ≥ 18 years; documents whether baseline evaluations were completed using the AIMS or ESRS/ESRI and requests the actual score; asks whether there has been a previous trial of an alternative management method; queries if the beneficiary is receiving dual therapy with other VMAT2 inhibitors; and asks whether the beneficiary is concurrently using a MAOI or reserpine. For continuation requests the same questions must be answered and documentation showing improvement from baseline must be attached.

For Huntington's disease (chorea) requests the form asks whether the beneficiary has the diagnosis and is experiencing chorea; confirms the beneficiary is age ≥ 18 years; queries dual VMAT2 therapy and concurrent use of a MAOI or reserpine; asks whether the beneficiary has a history of depression or suicidal ideation; and asks whether the beneficiary is receiving treatment and/or is stable. As with tardive dyskinesia, continuation requests require answers to these items plus attached documentation demonstrating improvement from baseline.

OpenPayer

Pharmacy prior authorization form for VMAT2 inhibitors (tardive dyskinesia and Huntington's chorea)

Authorization Criteria for VMAT2 Inhibitors

What the Prescriber Must Do

Clinical and Form Purpose

Key Terms and Scales

Form Metrics