Subject: Ingrezza 1750-A SGM P2022

Drug

INGREZZA  (valbenazine)

Policy:

I.    INDICATIONS 

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy. 

FDA-Approved Indication
Treatment of adults with tardive dyskinesia

All other indications are considered experimental/investigational and not medically necessary. 

II.  DOCUMENTATION 

Submission of the following information is necessary for both initial approval and continuation of therapy prior authorization reviews: Documentation of score of items 1 to 7 of the Abnormal Involuntary Movement Scale (AIMS). 

III. CRITERIA FOR INITIAL APPROVAL 

Tardive dyskinesia
Authorization of 6 months may be granted for treatment of tardive dyskinesia when the baseline AIMS score for items 1 to 7 is obtained. 

IV. CONTINUATION OF THERAPY 

Authorization of 12 months may be granted for treatment of tardive dyskinesia when the member’s tardive dyskinesia symptoms have improved as indicated by a decreased AIMS score (items 1 to 7) from baseline.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Ingrezza [package insert]. San Diego, CA: Neurocrine Biosciences, Inc.; April 2021.
2. Hauser, Robert, et al. KINECT-3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia. American Journal of Psychiatry. 2017 Mar 21: 1-9.
3. American Psychiatric Association. (2021). Practice Guideline for the Treatment of Patients With Schizophrenia, third edition. https://doi.org/10.1176/appi.books.9780890424841

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 14, 2022