| Anthem Blue Cross (HMO, PPO, EPO) |
| Ingrezza (valbenazine) |
| Drugs for the Nervous System : Drugs for the Nervous System |
- 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
- Available only through Specialty Pharmacy; Limited access; Dose Optimization - 1 capsule per day
For details on drug coverage click HERE;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Step Therapy: Tardive Dyskinesia (TD):
ST Multiple Generics
- PA Applies
|