Subject: Ingrezza SGM 1750-A P2026

Drug

INGREZZA  (valbenazine)

Policy:

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 Indications¹

Treatment of adults with:

·        Tardive dyskinesia

·        Chorea associated with Huntington’s disease

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

Prescriber Specialties

This medication must be prescribed by or in consultation with one of the following:

·        Chorea associated with Huntington’s disease: Neurologist or a specialist in the treatment of chorea associated with Huntington’s disease.

·        Tardive dyskinesia: Neurologist, psychiatrist, or a specialist in the treatment of tardive dyskinesia.

Documentation

Submission of the following information is necessary to initiate the prior authorization review for initial requests:

·        Tardive dyskinesia: Chart notes or medical record documentation of clinical manifestations of disease.

·        Chorea associated with Huntington’s disease: Chart notes or medical record documentation of characteristic motor examination features.

Coverage Criteria

Tardive Dyskinesia^1-3

Authorization of 12 months may be granted for treatment of tardive dyskinesia in adult members when both of the following criteria are met:

·        Member exhibits clinical manifestations of disease.

·        Patient has a history of treatment with a dopamine receptor antagonist.

·        Member’s tardive dyskinesia has been assessed through clinical examination or with a structured evaluative tool (e.g., Abnormal Involuntary Movement Scale [AIMS], Dyskinesia Identification System: Condensed User Scale [DISCUS]).

Chorea Associated with Huntington’s Disease^1,4

Authorization of 12 months may be granted for treatment of chorea associated with Huntington’s disease in adult members when both of the following criteria are met:

·        Member demonstrates characteristic motor examination features.

·        Member meets one of the following conditions:

§  Laboratory results indicate an expanded HTT CAG repeat sequence of at least 36

§  Member has a positive family history for Huntington’s disease

Continuation of Therapy

Authorization of 12 months may be granted for members with an indication listed in the coverage criteria who are experiencing benefit from therapy as evidenced by disease stability or disease improvement.

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Ingrezza [package insert]. San Diego, CA: Neurocrine Biosciences, Inc.; April 2026.

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.

October 03, 2026