- Quantity Limits Apply
- Prior Authorization: Chorea in Huntington's Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Tardive Dyskinesia (TD):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Chorea in Huntington's Disease:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Tardive Dyskinesia (TD):
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Psychiatrist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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: Yes
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests;Medical Tests;Medication History
Reauthorization Supporting Documentation Requirements: 3 of Improvement in AIMS Score;Meet initial criteria;Successful response to therapy
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