Subject: Specialty Quantity Limit tetrabenazine-Xenazine 2264-H P2026

Drug

XENAZINE  (tetrabenazine)

Policy:

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.

Covered Quantities

Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Medication	Standard Limit	Exception Limit
Xenazine (tetrabenazine) 12.5 mg tablet	120 per 30 days	240 per 30 days
Xenazine (tetrabenazine) 25 mg tablet	60 per 30 days	120 per 30 days

FDA-recommended dosing

Starting dose 12.5 mg daily. Titrate up to 50 mg per day in weekly intervals of 12.5 mg daily with a maximum single dose of 25 mg.

Extensive and intermediate CYP2D6 metabolizers: Titrate up to 100 mg per day in weekly intervals of 12.5 mg daily with a maximum single dose of 37.5 mg.

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Xenazine [package insert]. Deerfield, IL: Lundbeck; November 2019.

2.     Tetrabenazine [package insert]. Weston, FL: Apotex Corp.; November 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 16, 2026