ModifiedWashington State Health Care AuthorityPolicy 62.38.00.AA-2

Movement Disorder Agents: Valbenazine (Ingrezza)

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 62.38.00.AA-2 alerts

Get alerted when Policy 62.38.00.AA-2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Prior authorization and medical-necessity coverage for valbenazine (Ingrezza) to treat Huntington disease chorea and tardive dyskinesia in Apple Health members, including clinical criteria, reauthorization, prescriber qualifications, exclusions, step therapy, and quantity limits.

Policy Summary

PayerWashington State Health Care Authority

PolicyMovement Disorder Agents: Valbenazine (Ingrezza)

Policy CodePolicy 62.38.00.AA-2

Change TypeModified

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization documentation showing the applicable diagnosis, baseline assessment, required prior treatment, and absence of prohibited concomitant therapy.

SourceLink

POLICY UPDATE CHANGES

Prescribing requirements were updated to allow nurse practitioners and physician assistants who specialize in mental health to prescribe or consult on valbenazine therapy.

2Covered indications

12 monthsInitial authorization

12 monthsReauthorization

18+Minimum age

30/30 daysQuantity limit

Coverage Criteria Overview

Initial therapy: chorea associated with Huntington disease

Covered when ALL of the following are met:

Huntington disease chorea initial therapy

ALL of the following
- Patient is 18 years of age or older.Age >=18
- Valbenazine is prescribed by, or in consultation with, a provider who specializes in treating serious mental illness.
- The patient has a diagnosis of Huntington disease.
- ONE baseline UHDRS section completed
  - Baseline assessment using the Motor section of the Unified Huntington's Disease Rating Scale (UHDRS) has been completed.
  - Baseline assessment using the Cognitive section of the UHDRS has been completed.
  - Baseline assessment using the Behavioral section of the UHDRS has been completed.
  - Baseline assessment using the Functional Assessment section of the UHDRS has been completed.
  - Baseline assessment using the Independence Scale section of the UHDRS has been completed.
  - Baseline assessment using the Total Functional Capacity section of the UHDRS has been completed.
- Valbenazine will not be used in combination with another VMAT2 inhibitor, such as tetrabenazine, or with a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
- Treatment with deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated.Minimum trial: 12 weeks

Initial therapy: tardive dyskinesia

Covered when ALL of the following are met:

Tardive dyskinesia initial therapy

ALL of the following
- Patient is 18 years of age or older.Age >=18
- Valbenazine is prescribed by, or in consultation with, a provider who specializes in treating serious mental illness.
- The patient has a diagnosis of tardive dyskinesia (TD).
- ONE baseline assessment completed
  - A baseline Abnormal Involuntary Movement Scale (AIMS) assessment has been completed.
  - A baseline Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD) assessment has been completed.
- Valbenazine will not be used in combination with another VMAT2 inhibitor, such as tetrabenazine, or with a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
- ALL of the following
  - ONE eligible treatment approach
    Switching from a first-generation to a second-generation antipsychotic.
    A trial of two second-generation antipsychotics.
    Discontinuation or dose modification of the offending medication, with continued symptoms.

Continuation and reauthorization

Covered when ALL of the following are met:

The applicable ongoing treatment-exclusion criterion from the initial authorization criteria continues to be met; specifically, valbenazine is not used in combination with another VMAT2 inhibitor or a monoamine oxidase inhibitor.
Documentation demonstrates disease stability or a positive clinical response.
Examples include reduced involuntary movements, decreased total maximal chorea score, improved AIMS score, or improved CGI-TD score.

Valbenazine must not be used in combination with another VMAT2 inhibitor, such as tetrabenazine, or with a monoamine oxidase inhibitor (MAOI), including isocarboxazid, phenelzine, tranylcypromine, or reserpine.

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for valbenazine (Ingrezza). New-to-market drugs in this class are non-preferred under the Apple Health Preferred Drug List and require documentation of inadequate response or intolerance to preferred therapy.

Non-preferred agents require inadequate response or documented intolerance due to severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent is available in the class, document inadequate response to that one preferred agent.
If criteria are not met, a clinical reviewer may approve a medically necessary request on a case-by-case basis; new FDA indications are also reviewed case by case.

Step Therapy

Deutetrabenazine Step Therapy

For Huntington disease–associated chorea, document that deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated before requesting valbenazine.

An ineffective or not-tolerated trial requires a minimum of 12 weeks.
The requirement applies unless deutetrabenazine or deutetrabenazine ER is contraindicated.

Documentation Required

Prior Antipsychotic Management

For tardive dyskinesia, document persistent symptoms after at least one eligible antipsychotic-management approach, unless the approach is contraindicated, not tolerated, or would place psychiatric stability at risk.

Switch from a first-generation to a second-generation antipsychotic.
Trial of two second-generation antipsychotics.
Discontinuation or dose modification of the offending medication with continued symptoms.

Documentation Required

Huntington Disease Initial Documentation

For Huntington disease–associated chorea, submit documentation that the patient is at least 18 years old, has Huntington disease, and is prescribed by or in consultation with a provider specializing in serious mental illness. Include a baseline assessment using at least one applicable section of the Unified Huntington’s Disease Rating Scale (UHDRS).

Acceptable UHDRS sections include Motor, Cognitive, Behavioral, Functional Assessment, Independence Scale, or Total Functional Capacity.
Document that valbenazine will not be used with another VMAT2 inhibitor or a monoamine oxidase inhibitor (MAOI).

Documentation Required

Tardive Dyskinesia Initial Documentation

For tardive dyskinesia, submit documentation that the patient is at least 18 years old, has a TD diagnosis, and is prescribed by or in consultation with a provider specializing in serious mental illness. Include a baseline assessment and documentation of persistent TD despite an eligible treatment approach.

Acceptable baseline assessments are the Abnormal Involuntary Movement Scale (AIMS) or Clinical Global Impression of Change–Tardive Dyskinesia (CGI-TD).
Document that valbenazine will not be used with another VMAT2 inhibitor or an MAOI.
Document the applicable prior antipsychotic-management approach and any contraindication, intolerance, or psychiatric-stability exception.

Documentation Required

Reauthorization Documentation

Reauthorization requests may be approved for 12 months when ongoing exclusion criteria remain satisfied and documentation demonstrates disease stability or a positive clinical response.

Document continued nonuse with another VMAT2 inhibitor or MAOI.
For Huntington disease, provide evidence such as reduced involuntary movements or a decreased total maximal chorea score.
For tardive dyskinesia, provide evidence such as reduced involuntary movements, an improved AIMS score, or an improved CGI-TD score.

Denial Risk

Failure to Meet Clinical Criteria

A request may be denied when required clinical criteria are not met or cannot be verified. This includes failure to satisfy age, diagnosis, prescriber-specialty, baseline-assessment, concomitant-medication, or treatment-history requirements.

The patient is younger than 18 years of age.
The required Huntington disease or tardive dyskinesia diagnosis is not documented.
The prescriber is not a specialist in serious mental illness and there is no documented consultation with one.
The required UHDRS, AIMS, or CGI-TD baseline assessment is absent.
Valbenazine would be combined with another VMAT2 inhibitor or an MAOI.
Required deutetrabenazine step therapy for Huntington disease, or required prior antipsychotic management for tardive dyskinesia, is not documented and no applicable exception is established.

Denial Risk

Insufficient Reauthorization Documentation

Reauthorization may be denied when ongoing eligibility or treatment benefit is not documented. Requests require continued compliance with the applicable exclusion criteria and evidence of disease stability or positive clinical response.

No documentation that valbenazine remains uncombined with another VMAT2 inhibitor or MAOI.
No documented disease stability or positive clinical response.
For Huntington disease, no evidence such as reduced involuntary movements or decreased total maximal chorea score.
For tardive dyskinesia, no evidence such as reduced involuntary movements, improved AIMS score, or improved CGI-TD score.

Clinical Background

Huntington disease is an inherited, progressive neurodegenerative disorder associated with choreiform movements, psychiatric problems, and dementia. Treatment is symptomatic and supportive, with clinical assessment of motor and other functional effects used to guide care.

Tardive dyskinesia is a medication-induced hyperkinetic movement disorder caused by dopamine receptor-blocking agents, most often antipsychotic drugs, and may persist after the offending medication is discontinued. Valbenazine is a VMAT2 inhibitor used for chorea associated with Huntington disease and for tardive dyskinesia when the applicable coverage criteria are met.

Definitions

Huntington disease

DefinitionAn inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric problems, and dementia.

CauseCaused by a cytosine-adenine-guanine (CAG) trinucleotide repeat expansion in the huntingtin (HTT) gene on chromosome 4p.

InheritanceInherited in an autosomal dominant pattern.

Clinical featuresChoreiform movements, psychiatric problems, and dementia.

Tardive dyskinesia

DefinitionA medication-induced hyperkinetic movement disorder.

CauseCaused by exposure to dopamine receptor-blocking agents, most often antipsychotic drugs.

PersistencePersists for at least a month after discontinuation of the offending agent.

Baseline assessment

Huntington disease instrumentUnified Huntington's Disease Rating Scale (UHDRS).

UHDRS domainsMotor, Cognitive, Behavioral, Functional Assessment, Independence Scale, or Total Functional Capacity.

Tardive dyskinesia instrumentsAbnormal Involuntary Movement Scale (AIMS) or Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD).

Initial Therapy Criteria

Initial therapy: Huntington disease chorea

Valbenazine may be approved for Huntington disease chorea when ALL clinical criteria are met:

Huntington disease chorea

Patient is 18 years of age or older.Age >=18
Treatment is prescribed by, or provided in consultation with, a provider who specializes in treating serious mental illness.
Huntington disease is diagnosed.
ONE baseline UHDRS section completed
- Motor section
- Cognitive section
- Behavioral section
- Functional Assessment section
- Independence Scale section
- Total Functional Capacity section
Valbenazine is not used in combination with another VMAT2 inhibitor, such as tetrabenazine, or a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
Deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated after a minimum 12-week trial.Minimum prior trial: 12 weeks

Initial therapy: tardive dyskinesia

Valbenazine may be approved for tardive dyskinesia when ALL clinical criteria are met:

Tardive dyskinesia

Patient is 18 years of age or older.Age >=18
Treatment is prescribed by, or provided in consultation with, a provider who specializes in treating serious mental illness.
Tardive dyskinesia (TD) is diagnosed.
ONE baseline assessment completed
- Abnormal Involuntary Movement Scale (AIMS) assessment
- Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD) assessment
Valbenazine is not used in combination with another VMAT2 inhibitor, such as tetrabenazine, or a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
ALL of the following
- ONE eligible approach
  - Switch from a first-generation to a second-generation antipsychotic.
  - Trial of two second-generation antipsychotics.
  - Discontinuation or dose modification of the offending medication with continued symptoms.

Continuation and Reauthorization

Reauthorization

Valbenazine may be approved for reauthorization when ALL continuation criteria and documentation requirements are met:

The applicable ongoing treatment-exclusion criterion from the initial authorization criteria continues to be met; specifically, valbenazine is not used in combination with another VMAT2 inhibitor or a monoamine oxidase inhibitor.
Documentation demonstrates disease stability or a positive clinical response.
Examples include reduced involuntary movements, decreased total maximal chorea score, improved AIMS score, or improved CGI-TD score.

Required Prior Therapies

Step	Required prior treatment	Duration / outcome
1	Trial of deutetrabenazine or deutetrabenazine ER for Huntington disease chorea	Minimum 12-week trial when attempted; treatment must be contraindicated, ineffective, or not tolerated. The requirement does not apply when contraindicated.

Step	Eligible treatment approach for tardive dyskinesia	Required outcome / exceptions
1	Switch from a first-generation to a second-generation antipsychotic	Persistent TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.
1	Trial of two second-generation antipsychotics	Persistent TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.
1	Discontinue or modify the dose of the offending medication	Continued TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.

Quantity Limits

Quantity limit

DrugValbenazine (Ingrezza) 40 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 40 mg capsule sprinkles.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 60 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 60 mg capsule sprinkles.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 80 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Policy Summary

PayerWashington State Health Care Authority

PolicyMovement Disorder Agents: Valbenazine (Ingrezza)

Policy CodePolicy 62.38.00.AA-2

Change TypeModified

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization documentation showing the applicable diagnosis, baseline assessment, required prior treatment, and absence of prohibited concomitant therapy.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedWashington State Health Care AuthorityPolicy 62.38.00.AA-2

Movement Disorder Agents: Valbenazine (Ingrezza)

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 62.38.00.AA-2 alerts

Get alerted when Policy 62.38.00.AA-2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWashington State Health Care Authority

PolicyMovement Disorder Agents: Valbenazine (Ingrezza)

Policy CodePolicy 62.38.00.AA-2

Change TypeModified

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization documentation showing the applicable diagnosis, baseline assessment, required prior treatment, and absence of prohibited concomitant therapy.

SourceLink

POLICY UPDATE CHANGES

Prescribing requirements were updated to allow nurse practitioners and physician assistants who specialize in mental health to prescribe or consult on valbenazine therapy.

2Covered indications

12 monthsInitial authorization

12 monthsReauthorization

18+Minimum age

30/30 daysQuantity limit

Coverage Criteria Overview

Initial therapy: chorea associated with Huntington disease

Covered when ALL of the following are met:

Huntington disease chorea initial therapy

ALL of the following
- Patient is 18 years of age or older.Age >=18
- Valbenazine is prescribed by, or in consultation with, a provider who specializes in treating serious mental illness.
- The patient has a diagnosis of Huntington disease.
- ONE baseline UHDRS section completed
  - Baseline assessment using the Motor section of the Unified Huntington's Disease Rating Scale (UHDRS) has been completed.
  - Baseline assessment using the Cognitive section of the UHDRS has been completed.
  - Baseline assessment using the Behavioral section of the UHDRS has been completed.
  - Baseline assessment using the Functional Assessment section of the UHDRS has been completed.
  - Baseline assessment using the Independence Scale section of the UHDRS has been completed.
  - Baseline assessment using the Total Functional Capacity section of the UHDRS has been completed.
- Valbenazine will not be used in combination with another VMAT2 inhibitor, such as tetrabenazine, or with a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
- Treatment with deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated.Minimum trial: 12 weeks

Initial therapy: tardive dyskinesia

Covered when ALL of the following are met:

Tardive dyskinesia initial therapy

ALL of the following
- Patient is 18 years of age or older.Age >=18
- Valbenazine is prescribed by, or in consultation with, a provider who specializes in treating serious mental illness.
- The patient has a diagnosis of tardive dyskinesia (TD).
- ONE baseline assessment completed
  - A baseline Abnormal Involuntary Movement Scale (AIMS) assessment has been completed.
  - A baseline Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD) assessment has been completed.
- Valbenazine will not be used in combination with another VMAT2 inhibitor, such as tetrabenazine, or with a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
- ALL of the following
  - ONE eligible treatment approach
    Switching from a first-generation to a second-generation antipsychotic.
    A trial of two second-generation antipsychotics.
    Discontinuation or dose modification of the offending medication, with continued symptoms.

Continuation and reauthorization

Covered when ALL of the following are met:

The applicable ongoing treatment-exclusion criterion from the initial authorization criteria continues to be met; specifically, valbenazine is not used in combination with another VMAT2 inhibitor or a monoamine oxidase inhibitor.
Documentation demonstrates disease stability or a positive clinical response.
Examples include reduced involuntary movements, decreased total maximal chorea score, improved AIMS score, or improved CGI-TD score.

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Non-preferred agents require inadequate response or documented intolerance due to severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent is available in the class, document inadequate response to that one preferred agent.
If criteria are not met, a clinical reviewer may approve a medically necessary request on a case-by-case basis; new FDA indications are also reviewed case by case.

Step Therapy

Deutetrabenazine Step Therapy

For Huntington disease–associated chorea, document that deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated before requesting valbenazine.

An ineffective or not-tolerated trial requires a minimum of 12 weeks.
The requirement applies unless deutetrabenazine or deutetrabenazine ER is contraindicated.

Documentation Required

Prior Antipsychotic Management

Switch from a first-generation to a second-generation antipsychotic.
Trial of two second-generation antipsychotics.
Discontinuation or dose modification of the offending medication with continued symptoms.

Documentation Required

Huntington Disease Initial Documentation

Acceptable UHDRS sections include Motor, Cognitive, Behavioral, Functional Assessment, Independence Scale, or Total Functional Capacity.
Document that valbenazine will not be used with another VMAT2 inhibitor or a monoamine oxidase inhibitor (MAOI).

Documentation Required

Tardive Dyskinesia Initial Documentation

Acceptable baseline assessments are the Abnormal Involuntary Movement Scale (AIMS) or Clinical Global Impression of Change–Tardive Dyskinesia (CGI-TD).
Document that valbenazine will not be used with another VMAT2 inhibitor or an MAOI.
Document the applicable prior antipsychotic-management approach and any contraindication, intolerance, or psychiatric-stability exception.

Documentation Required

Reauthorization Documentation

Reauthorization requests may be approved for 12 months when ongoing exclusion criteria remain satisfied and documentation demonstrates disease stability or a positive clinical response.

Document continued nonuse with another VMAT2 inhibitor or MAOI.
For Huntington disease, provide evidence such as reduced involuntary movements or a decreased total maximal chorea score.
For tardive dyskinesia, provide evidence such as reduced involuntary movements, an improved AIMS score, or an improved CGI-TD score.

Denial Risk

Failure to Meet Clinical Criteria

The patient is younger than 18 years of age.
The required Huntington disease or tardive dyskinesia diagnosis is not documented.
The prescriber is not a specialist in serious mental illness and there is no documented consultation with one.
The required UHDRS, AIMS, or CGI-TD baseline assessment is absent.
Valbenazine would be combined with another VMAT2 inhibitor or an MAOI.
Required deutetrabenazine step therapy for Huntington disease, or required prior antipsychotic management for tardive dyskinesia, is not documented and no applicable exception is established.

Denial Risk

Insufficient Reauthorization Documentation

No documentation that valbenazine remains uncombined with another VMAT2 inhibitor or MAOI.
No documented disease stability or positive clinical response.
For Huntington disease, no evidence such as reduced involuntary movements or decreased total maximal chorea score.
For tardive dyskinesia, no evidence such as reduced involuntary movements, improved AIMS score, or improved CGI-TD score.

Clinical Background

Definitions

Huntington disease

DefinitionAn inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric problems, and dementia.

CauseCaused by a cytosine-adenine-guanine (CAG) trinucleotide repeat expansion in the huntingtin (HTT) gene on chromosome 4p.

InheritanceInherited in an autosomal dominant pattern.

Clinical featuresChoreiform movements, psychiatric problems, and dementia.

Tardive dyskinesia

DefinitionA medication-induced hyperkinetic movement disorder.

CauseCaused by exposure to dopamine receptor-blocking agents, most often antipsychotic drugs.

PersistencePersists for at least a month after discontinuation of the offending agent.

Baseline assessment

Huntington disease instrumentUnified Huntington's Disease Rating Scale (UHDRS).

UHDRS domainsMotor, Cognitive, Behavioral, Functional Assessment, Independence Scale, or Total Functional Capacity.

Tardive dyskinesia instrumentsAbnormal Involuntary Movement Scale (AIMS) or Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD).

Initial Therapy Criteria

Initial therapy: Huntington disease chorea

Valbenazine may be approved for Huntington disease chorea when ALL clinical criteria are met:

Huntington disease chorea

Patient is 18 years of age or older.Age >=18
Treatment is prescribed by, or provided in consultation with, a provider who specializes in treating serious mental illness.
Huntington disease is diagnosed.
ONE baseline UHDRS section completed
- Motor section
- Cognitive section
- Behavioral section
- Functional Assessment section
- Independence Scale section
- Total Functional Capacity section
Valbenazine is not used in combination with another VMAT2 inhibitor, such as tetrabenazine, or a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
Deutetrabenazine or deutetrabenazine ER is contraindicated, ineffective, or not tolerated after a minimum 12-week trial.Minimum prior trial: 12 weeks

Initial therapy: tardive dyskinesia

Valbenazine may be approved for tardive dyskinesia when ALL clinical criteria are met:

Tardive dyskinesia

Patient is 18 years of age or older.Age >=18
Treatment is prescribed by, or provided in consultation with, a provider who specializes in treating serious mental illness.
Tardive dyskinesia (TD) is diagnosed.
ONE baseline assessment completed
- Abnormal Involuntary Movement Scale (AIMS) assessment
- Clinical Global Impression of Change—Tardive Dyskinesia (CGI-TD) assessment
Valbenazine is not used in combination with another VMAT2 inhibitor, such as tetrabenazine, or a monoamine oxidase inhibitor, including isocarboxazid, phenelzine, tranylcypromine, or reserpine.
ALL of the following
- ONE eligible approach
  - Switch from a first-generation to a second-generation antipsychotic.
  - Trial of two second-generation antipsychotics.
  - Discontinuation or dose modification of the offending medication with continued symptoms.

Continuation and Reauthorization

Reauthorization

Valbenazine may be approved for reauthorization when ALL continuation criteria and documentation requirements are met:

The applicable ongoing treatment-exclusion criterion from the initial authorization criteria continues to be met; specifically, valbenazine is not used in combination with another VMAT2 inhibitor or a monoamine oxidase inhibitor.
Documentation demonstrates disease stability or a positive clinical response.
Examples include reduced involuntary movements, decreased total maximal chorea score, improved AIMS score, or improved CGI-TD score.

Required Prior Therapies

Step	Required prior treatment	Duration / outcome
1	Trial of deutetrabenazine or deutetrabenazine ER for Huntington disease chorea	Minimum 12-week trial when attempted; treatment must be contraindicated, ineffective, or not tolerated. The requirement does not apply when contraindicated.

Step	Eligible treatment approach for tardive dyskinesia	Required outcome / exceptions
1	Switch from a first-generation to a second-generation antipsychotic	Persistent TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.
1	Trial of two second-generation antipsychotics	Persistent TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.
1	Discontinue or modify the dose of the offending medication	Continued TD symptoms after the approach, unless contraindicated, not tolerated, or likely to put psychiatric stability at risk.

Quantity Limits

Quantity limit

DrugValbenazine (Ingrezza) 40 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 40 mg capsule sprinkles.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 60 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 60 mg capsule sprinkles.

Quantity limit30 capsules.

Limit periodPer 30 days.

Quantity limit

DrugValbenazine (Ingrezza) 80 mg capsules.

Quantity limit30 capsules.

Limit periodPer 30 days.

Policy Summary

PayerWashington State Health Care Authority

PolicyMovement Disorder Agents: Valbenazine (Ingrezza)

Policy CodePolicy 62.38.00.AA-2

Change TypeModified

Effective DateJun 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization documentation showing the applicable diagnosis, baseline assessment, required prior treatment, and absence of prohibited concomitant therapy.

SourceLink

On This Page