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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
deutetrabenazine AUSTEDO TD TITRATN PK (WK 1-2) TAB DS PK N PA Document  
deutetrabenazine AUSTEDO TABLET N PA Document  
tetrabenazine XENAZINE TABLET N PA Document  
tetrabenazine TETRABENAZINE TABLET N PA Document  
valbenazine tosylate INGREZZA INITIATION PACK CAP DS PK N PA Document  
valbenazine tosylate INGREZZA CAPSULE N PA Document  
deutetrabenazine AUSTEDO 12MG START TITR(WK1-4) TAB DS PK PA Document