Managing Tardive Dyskinesia When VMAT2 Inhibitors Are Not Covered
Work with a movement disorder specialist or psychiatrist who can provide the prior authorization documentation that Medicaid requires for Ingrezza (valbenazine) or Austedo (deutetrabenazine), as these VMAT2 inhibitors are the only FDA-approved first-line treatments for moderate to severe tardive dyskinesia. 1, 2
Understanding the Insurance Barrier
- Medicaid typically requires specialist evaluation and documentation before approving VMAT2 inhibitors for tardive dyskinesia 1
- The American Psychiatric Association recommends VMAT2 inhibitors (valbenazine or deutetrabenazine) as first-line pharmacotherapy for moderate to severe or disabling tardive dyskinesia 1
- Both medications have demonstrated efficacy in multiple class 1 studies and represent breakthrough therapies for this condition 3, 4, 5, 6
Immediate Steps While Pursuing Coverage
If you cannot immediately access a specialist, begin the referral process now while implementing these interim strategies:
Optimize the Antipsychotic Regimen
- Reduce the dose of the current antipsychotics if clinically feasible, as lower doses may decrease tardive dyskinesia severity while maintaining psychiatric stability 1, 7
- Switch to atypical antipsychotics with lower D2 affinity (such as quetiapine or clozapine) if the patient is on typical antipsychotics or high-potency atypicals 1, 7
- Atypical antipsychotics have significantly lower risk of causing or worsening extrapyramidal symptoms compared to typical antipsychotics 7
Address Polypharmacy Concerns
- Since your patient requires two antipsychotics, document the clinical necessity for this approach, as antipsychotic polypharmacy increases side effect burden 8
- Consider whether clozapine monotherapy could replace the two-antipsychotic regimen, as clozapine is underutilized and may provide better efficacy with lower tardive dyskinesia risk 8
- If polypharmacy must continue, select antipsychotics with differing side-effect profiles to minimize cumulative dopaminergic blockade 8
What NOT to Do
Do not use anticholinergic medications (such as benztropine or trihexyphenidyl) for tardive dyskinesia—these are indicated for acute dystonia and parkinsonism, not tardive dyskinesia, and may worsen the condition 1
Documentation for Prior Authorization
Prepare this information for the specialist consultation and Medicaid appeal:
- Baseline and serial Abnormal Involuntary Movement Scale (AIMS) scores documenting severity 1, 7, 3
- Duration of antipsychotic exposure and specific agents used 3
- Impact on quality of life, function, and social/occupational activities 3
- Documentation that tardive dyskinesia is moderate to severe or disabling 1
- Evidence that dose reduction or medication switching has been attempted or is not feasible due to psychiatric instability 1, 7
- Justification for continued antipsychotic use (i.e., why discontinuation is not an option) 1, 7
Long-Term Considerations
- Both valbenazine and deutetrabenazine provide sustained benefit regardless of whether patients continue dopamine receptor antagonists, with favorable long-term safety profiles 9
- Deutetrabenazine has shown clinically meaningful improvements maintained over 3 years, with similar efficacy whether patients have psychotic disorders or mood disorders 9
- Once approved, valbenazine offers once-daily dosing with rapid onset of effect within 2 weeks 5
Monitoring During the Interim Period
- Perform AIMS assessments every 3-6 months to track progression 1, 7
- Watch for worsening parkinsonism if antipsychotic doses are adjusted, as this can cause more functional disability than the tardive dyskinesia itself 2
- Monitor for falls, gait disturbances, and rigidity, which may indicate drug-induced parkinsonism requiring further dose adjustment 2
The specialist referral is non-negotiable for accessing these medications through Medicaid—this is your most important action step. 1