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DrugXenazine (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


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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