Specialty Quantity Limit Ingrezza 1733-H P2023b - Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan

Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan

Subject: Specialty Quantity Limit Ingrezza 1733-H P2023b

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 (valbenazine) 40 mg capsule	30 per 30 days	Tardive dyskinesia Initial: 40 mg once daily for 1 week Maintenance: 80 mg once daily A dosage of 40 mg or 60 mg once daily may be considered depending on response and tolerability. Chorea associated with Huntington’s disease Initial: 40 mg 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 Sprinkle (valbenazine) 40 mg capsule	30 per 30 days
Ingrezza (valbenazine) 60 mg capsule	30 per 30 days
Ingrezza Sprinkle (valbenazine) 60 mg capsule	30 per 30 days
Ingrezza (valbenazine) 80 mg capsule	30 per 30 days
Ingrezza Sprinkle (valbenazine) 80 mg capsule	30 per 30 days
Ingrezza (valbenazine) 4-week Initiation Pack (7 x 40 mg capsules, 21 x 80 mg capsules)	1 pack (28 capsules) per 28 days
Ingrezza (valbenazine) 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:

Ingrezza [package insert]. San Diego, CA: Neurocrine Biosciences, Inc.; April 2024

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.

June 23, 2024

Additional Information

Clinical Policy Bulletin Notes

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