Vesicular Monoamine Transporter Inhibitors

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PDL Reference Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
68546017628 AUSTEDO TD TITRATN PK (WK 1-2) deutetrabenazine TAB DS PK 6 mg (14)-9 mg (14) N Y PA Document
68546018270 AUSTEDO 12MG START TITR(WK1-4) deutetrabenazine TAB DS PK 6 mg (28)-9 mg (28)-12 mg (14) N Y PA Document
68546047156 AUSTEDO XR deutetrabenazine TAB ER 24H 12 mg N Y PA Document
68546047956 AUSTEDO XR deutetrabenazine TAB ER 24H 18 mg N Y PA Document
68546047256 AUSTEDO XR deutetrabenazine TAB ER 24H 24 mg N Y PA Document
68546047356 AUSTEDO XR deutetrabenazine TAB ER 24H 30 mg N Y PA Document
68546047456 AUSTEDO XR deutetrabenazine TAB ER 24H 36 mg N Y PA Document
68546047556 AUSTEDO XR deutetrabenazine TAB ER 24H 42 mg N Y PA Document
68546047656 AUSTEDO XR deutetrabenazine TAB ER 24H 48 mg N Y PA Document
68546047056 AUSTEDO XR deutetrabenazine TAB ER 24H 6 mg N Y PA Document
68546047729 AUSTEDO XR TITRATION KT(WK1-4) deutetrabenazine TAB24HDSPK 12 mg (7)-18 mg (7)-24 mg (7)-30 mg (7) N Y PA Document
68546017260 AUSTEDO deutetrabenazine TABLET 12 mg N Y PA Document
68546017060 AUSTEDO deutetrabenazine TABLET 6 mg N Y PA Document
68546017160 AUSTEDO deutetrabenazine TABLET 9 mg N Y PA Document
31722082111 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
43598039467 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
47335027723 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
60505388207 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
68094090510 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
68682042112 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
69452011721 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
70436010109 TETRABENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
67386042101 XENAZINE tetrabenazine TABLET 12.5 mg N Y PA Document
31722082211 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
43598039567 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
47335017923 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
60505388307 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
68094080510 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
68682042225 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
69452011821 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
70436010209 TETRABENAZINE tetrabenazine TABLET 25 mg N Y PA Document
67386042201 XENAZINE tetrabenazine TABLET 25 mg N Y PA Document
70370204806 INGREZZA INITIATION PK(TARDIV) valbenazine tosylate CAP DS PK 40 mg (7)-80 mg (21) N Y PA Document
70370404001 INGREZZA SPRINKLE valbenazine tosylate CAP SPRINK 40 mg N Y PA Document
70370406001 INGREZZA SPRINKLE valbenazine tosylate CAP SPRINK 60 mg N Y PA Document
70370408001 INGREZZA SPRINKLE valbenazine tosylate CAP SPRINK 80 mg N Y PA Document
70370204001 INGREZZA valbenazine tosylate CAPSULE 40 mg N Y PA Document
70370106001 INGREZZA valbenazine tosylate CAPSULE 60 mg N Y PA Document
70370108001 INGREZZA valbenazine tosylate CAPSULE 80 mg N Y PA Document
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