Subject: Specialty Quantity Limit tetrabenazine-Xenazine 2264-H P2023
|
XENAZINE
(tetrabenazine)
|
|
tetrabenazine
|
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If the member’s plan
allows a quantity limit exception review for the requested
medication, coverage of an additional quantity may be provided
up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard
Limit
|
Exception
Limit*
|
FDA-recommended dosing
|
|
Xenazine
(tetrabenazine)
12.5 mg tablet
|
120 tablets
per 30 days
|
240 tablets
per 30 days
|
Chorea associated with
Huntington’s disease: Start with
12.5 mg daily. Titrate up to 50 mg
per day in weekly increments of
12.5 mg daily with a maximum
single dose of 25 mg.
Extensive and intermediate CYP2D6
metabolizers: Titrate up to
maximum recommended daily dose
of 100 mg in weekly increments of
12.5 mg daily with a maximum
single dose of 37.5 mg.
|
|
Xenazine
(tetrabenazine)
25 mg tablet
|
60 tablets
per 30 days
|
120 tablets
per 30 days
|
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity
Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
1. Xenazine [package insert]. Deerfield, IL: Lundbeck Inc.; November
2019.
2. Tetrabenazine [package insert]. Weston, FL: Apotex Corp.; October
2021.
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 13, 2023
