Xenazine
Drug - Xenazine (tetrabenazine) [Lundbeck]
December 2017
Therapeutic area - Movement disorders
Approval Criteria
- Patient is at least 18 years old AND
- Must be prescribed by a provider specializing in neurology AND
- Provider’s specialty must be provided at time of request
- Patient is diagnosed with chorea related to Huntington’s disease AND
- Patient is able to swallow AND
- Prescriber must attest that patient is not suicidal or does not have history of untreated or inadequately treated depression AND
- Patient must not have any ONE of the following:
- Concurrent therapy with deutetrabenazine, valbenazine, reserpine, or MAOIs
- Pregnancy
- Hepatic impairment
Quantity limits
136 tablets per 34 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411