Anthem Blue Cross (HMO, PPO, EPO) |
Austedo TD Titratn Pk (Wk 1-2) (deutetrabenazine) |
Drugs for the Nervous System : Drugs for the Nervous System |
- Quantity Limits Apply
- Tardive Dyskinesia (TD):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
AIMS Score: N/A
Patient Must Not Have Congenital LQTS or Arrhythmias Associated with Prolonged QT Interval: No
Patient Must Not Have Risk of Suicidal Behavior and Unstable Psychiatric Symptoms: No
Concomitant Use With Other VMAT inhibitors Prohibited: No
Supporting Documentation Requirements: 1 of Lab Tests;Medication History
- Prior Authorization: Tardive Dyskinesia (TD):
Documented Diagnosis: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
- Step Therapy: Tardive Dyskinesia (TD):
ST Multiple Generics
|