Prior Authorization and Quantity Limit Criteria for Approval

Tetrabenazine will be approved when ALL of the following are met:

1. ONE of the following:
   1. The patient has a diagnosis of chorea associated with Huntington’s disease
      OR
   2. The patient has an indication that is supported in CMS approved compendia for the requested medication
      AND
2. ONE of the following:
   1. The patient does NOT have a current diagnosis of depression
      OR
   2. The patient has a current diagnosis of depression and is being treated for depression
      AND
3. ONE of the following:
   1. The patient does NOT have a diagnosis of suicidal ideation and/or behavior
      OR
   2. The patient has a diagnosis of suicidal ideation and/or behavior and must NOT be actively suicidal
      AND
4. The patient will NOT be using the requested medication in combination with a monoamine oxidase inhibitor (MAOI)
   AND
5. The patient will NOT be using the requested medication in combination with reserpine
   AND
6. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
7. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has submitted information in support of therapy with a higher dose for the requested indication
         

Length of Approval: 12 months