Valbenazine (Ingrezza)


Indications for Prior Authorization:

  • Treatment of tardive dyskinesia (TD) in adults

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by or in collaboration with a specialist (e.g., psychologist), AND
  • 18 years or older, AND
  • Diagnosis of schizophrenia, schizoaffective disorder, or a mood disorder, AND
  • Diagnosis of antipsychotic-induced moderate to severe tardive dyskinesia (moderate or severe TD as indicated by a score of 3 or 4 on item 8 (severity of abnormal movement overall) of the Abnormal Involuntary Movement Scale (AIMS), AND
  • Documentation of the member's current AIMS score from item 1-7, AND
  • Patient must try and fail at least 2 other guideline recommended treatments first (e.g., clonazepam, amantadine, tetrabenazine), AND
  • The member is not at a significant risk for suicidal or violent behavior and does not have unstable psychiatric symptoms
  • Avoid in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT interval

Reauthorization criteria:

  • Documentation that the member's TD symtpoms have improved due to Ingrezza use as evidenced by AIMS score (items 1-7) showing reduction of score from baseline, AND
  • The member is not at a significant risk for suicidal or violent behaviro and does not have unstable psychiatric symptoms


  • Initial dose is 40 mg once daily, and increased after 1 week to the recommended dose of 80 mg daily (continuation of 40 mg once daily may be considered for some patients)
  • The recommended dose for patients with moderate or severe hepatic impairment is 40 mg once daily
  • Consider dose reduction based on tolerability in known CYP2D6 poor metabolizers
  • Patients taking a strong CYP3A4 inhbitor should be dosed as 40 mg once daily


  • Initial: 2 months
  • Renewal: 1 year

Last review date: June 12, 2017

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