Subject: Specialty Quantity Limit Ingrezza 1733-H P2023a

Drug

INGREZZA  (valbenazine)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.


II.  COVERED QUANTITIES

           

Medication	Standard Limit	FDA-recommended dosing
Ingrezza 40 mg capsule	30 capsules per 30 days	Tardive dyskinesia   Initial: 40 mg orally once daily for 1 week   Maintenance: 80 mg orally once daily   A dosage of 40 mg or 60 mg orally once daily may   be considered depending on response and   tolerability.   Chorea associated with Huntington’s disease   Initial: 40 mg orally once daily for 2 weeks   Increase the dose in 20 mg increments every 2   weeks to the recommended dosage of 80 mg once   daily. A dosage of 40 mg or 60 mg once daily may   be considered depending on response and   tolerability.
Ingrezza 60 mg capsule	30 capsules per 30 days
Ingrezza 80 mg capsule	30 capsules per 30 days
Ingrezza 4-week   Initiation Pack (7 x 40 mg   capsules, 21 x 80 mg   capsules)	1 pack (28 capsules)   per 28 days
Ingrezza 4-week   Initiation Pack (14 x 40   mg capsules, 14 x 60 mg   capsules)	1 pack (28 capsules)   per 28 days

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

 

1. Ingrezza [package insert]. San Diego, CA: Neurocrine Biosciences, Inc.; August 2023.

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.

November 09, 2023