Anthem Blue Cross (HMO, PPO, EPO)
Austedo 12Mg Start Titr(Wk1-4) (deutetrabenazine)
Drugs for the Nervous System : Drugs for the Nervous System
  • Quantity Limits Apply
  • Chorea in Huntington's Disease:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    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: Chorea in Huntington's Disease:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Tardive Dyskinesia (TD):
    Documented Diagnosis: Yes
    Duration: 1 year(s)
    Reauthorization Required: Yes

  • Step Therapy: Chorea in Huntington's Disease:
    ST Single Generic

    Tardive Dyskinesia (TD):
    ST Multiple Generics

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