Anthem Blue Cross (HMO, PPO, EPO) |
Austedo (deutetrabenazine) |
Drugs for the Nervous System : Drugs for the Nervous System |
- Step Therapy: Chorea in Huntington's Disease:
ST Single Generic
Tardive Dyskinesia (TD): ST Multiple Generics
- 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
- Quantity Limit: 4 tablets per 1 day(s).
- PA Applies
- Available only through Specialty Pharmacy;
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;
- 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
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