Medical Policy

Effective Date:04/01/2016 Title:Xenazine (Tetrabenazine)
Revision Date: Document:BI499:00
CPT Code(s):None
Public Statement
Effective Date: a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Tetrabenazine requires prior authorization. 2) Only the generic product is covered; brand Xenazine is not covered. 3) Tetrabenazine is used to treat chorea associated with Huntington’s Disease. 4) Tetrabenazine is an oral specialty drug and must be obtained through a specialty pharmacy.
Medical Statement

Tetrabenazine is considered medically necessary when members meet the following criteria:

1)    Member 18 years of age or older AND

2)    Diagnosis of chorea associated with Huntington’s Disease  AND

3)    For doses greater than 50mg/day, must be genotyped to demonstrate CYP2D6 expression AND

4)    Must be enrolled in the REMS program

5)    Initial approval will be for 3 months.

 

Criteria for renewal include:

1)    Signs and symptoms of chorea must be decreased AND

2)    Patient exhibiting no signs of worsening depression

Limits

1)    As a specialty drug, Tetrabenazine is limited to a maximum 30 day supply per fill

2)    Tetrabenazine must be obtained through a specialty pharmacy

Reference

1)    Xenazine Prescribing Information.  Lundbeck. Deerfield, IL.  June 2015.

2)    Clinical Pharmacology.  Accessed online 12/3/2015.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.