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Drug Category: VMAT2 Inhibitors

Medication Class/Individual Agents: VMAT2 Inhibitors

I. Prior-Authorization Requirements

 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

deutetrabenazine Austedo PA  
tetrabenazine Xenazine BP PA  
valbenazine Ingrezza PA  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 
Table Footnotes
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • chorea associated with Huntington’s disease
  • tardive dyskinesia

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

 

Austedo

  • Documentation of all of the following is required for a diagnosis of Huntington’s disease:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to tetrabenazine; and
    • one of the following:
      • requested dose is ≤ 36 mg/day; or
      • requested dose is > 36 mg/day and ≤ 48 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
    • request is within quantity limit of 120 units/30 days.
  • Documentation of all of the following is required for a diagnosis of tardive dyskinesia:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • persistent, disabling, or intrusive tardive dyskinesia; and
    • one of the following:
      • requested dose is ≤ 36 mg/day; or
      • requested dose is > 36 mg/day and ≤ 48 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer; and
    • request is within quantity limit of 120 units/30 days.

 

Ingrezza

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • persistent, disabling, or intrusive tardive dyskinesia; and
    • requested dose is ≤ 80 mg/day; and
    • request is within quantity limit of 30 units/30 days.

 

tetrabenazine

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • requested dose is ≤ 50 mg/day; or
      • requested dose is > 50 mg/day and ≤ 100 mg/day, and member has been genotyped for the drug metabolizing enzyme CYP2D6 to determine that the member is not a poor metabolizer.

SmartPA: Claims for tetrabenazine at a dose of ≤ 100 mg/day will usually process at the pharmacy without a prior authorization request if the member is ≥ 18 years of age, has a history of MassHealth medical claims for Huntington’s disease with chorea, and has a history of paid claims for tetrabenazine for at least 90 out of the last 120 days.†
 
 

  
Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 02/2018

Last Revised Date: 08/2019


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Last updated 11/25/19