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