How to Navigate Insurance When Treating Tardive Dyskinesia

Sometimes, best psychiatric practice guidelines do not align with insurance coverage, leading to frustration and delayed treatment for patients.

In this video, Desiree Matthews, PMHNP-BC, CEO, Steering Committee, Psych Congress, talks through her experience navigating insurance barriers to tardive dyskinesia treatment. Matthews explains why the block exists, appeal processes, and strategies for accessing the medications that TD patients need.

For more expert insights for your practice, visit the Tardive Dyskinesia Excellence Forum here on Psych Congress Network.

Read the Transcript

Desiree Matthews, PMHNP-BC: Hello, my name is Desiree Matthews, and I'm a psychiatric nurse practitioner. I work in a community mental health center out of Charlotte, North Carolina.

Psych Congress Network: What challenges have you encountered when regarding insurance coverage for tardive dyskinesia medications? Could you offer some advice to fellow advanced practice providers on how to advocate for their patients to ensure they receive the insurance coverage they need for TD treatment?

Matthews: Once you decide on prescribing a VMAT2 inhibitor, the big question I get is how do you access these medications? Since these medications both deutetrabenazine and valbenazine are branded with no generic options available at this time. I the beginning, I would say back in 2017 and 2018 when these medications were first approved, the prior authorization process was a bit murky. I would have a lot of insurances come back and say, you need to try tetrabenazine even. You need to try benztropine or an anticholinergic, as we all know, are not approved for tardive dyskinesia. Even again, in that package prescribing insert for benztropine, it actually tells us very plainly that benztropine is not indicated for tardive dyskinesia. In fact, it can worsen it. So I would get a lot of pushback initially in those early years of VMAT2 inhibitors about using these non-FDA approved treatment options.

So, on my prior authorizations, oftentimes they did end up into the appeal process at that time. We were writing response letters stating just that we were requesting an FDA-approved medication to treat tardive dyskinesia, and that the options that they were giving us to try first were not evidence-based, they were not FDA-approved, and also ensuring that I placed information in the prior authorization or the appeal that I am not able to modify the antipsychotic regimen. My patient may need that anti-psychotic and also provided the insurance company paper and literature about the irreversible nature and the persistence that tardive dyskinesia generally presents with.

But now I would say fast forward to 2023 and now 2024—the prior authorization process, I would say is a bit easier. First, I would say make sure that you always have an AIMS done on baseline as well as periodically through the treatment process. In my state, North Carolina, Medicaid does require us to resubmit a prior authorization every 180 days to show that we have reduced the AIMS from baseline so the patients have less tardive dyskinesia movements, but also that they're sustaining those results over time. So whenever I have a patient on a VMAT2 inhibitor, I go ahead whenever that visit is just to make sure I grab an AIMS to make sure that the patient does not have a disruption in treatment because I didn't do the AIMS score for them.

The other thing I would say is to make sure to understand if you need to use a specialty pharmacy. Some of these medications are considered certainly specialty medications from the insurance point of view. So you may not be able to walk into Walmart or walk into Walgreens to be able to get these VMAT2 inhibitors. Sometimes insurance requires you to use a specialty pharmacy, which is often a mail order pharmacy.

However, both for deutetrabenazine and valbenazine, they have robust support programs for patients and their healthcare providers. So I would say if you have any problem accessing this, I would encourage you to go onto the website, reach out to somebody from the company because there is a lot of support on the backend to help make sure that you can access these FDA-approved medications.

Psych Congress Network: Which strategies or resources do you find helpful when navigating the authorization process with insurance?

Matthews: For additional considerations when you are trying to access VMAT2 inhibitors for your patients with tardive dyskinesia, it's important to ensure that, number one, when you are doing the prior authorization that you have the correct ICD 10 code. So be sure that you put tardive dyskinesia in that field for the prior authorization. In my experience from learning, some support staff may put their primary mental health diagnosis. So I really encourage people to actually place that tardive dyskinesia diagnosis in the chart for your prior authorization support staff to be able to pick that up. Because again, if you submit it under schizophrenia or bipolar disorder, it's likely to get immediately rejected and you'll have to go and do another prior authorization.

Another thing is, again, be careful to read the prior authorization fully and answer the questions to the best of your ability. In some cases, I found that insurance companies will ask, is the tardive dyskinesia moderate or severe? But it doesn't give a qualifier. Is it based on the AIMS? Is it based on psychosocial functioning? So that is a bit of an open-ended question, and I think that brings us to a really good point is that if the patient is having a functional impact, that this may further support your case. We have a scale called the TD Impact Scale. It's a global impression scoring method, and it asks patients about physical vocational impact, impact on mood that their tardive dyskinesia may have. So certainly putting something about their functional impact, maybe they're having trouble swallowing, maybe they're embarrassed and can't go to work. This may further help support your case if you really are getting pushback. So that may be more in an appeals process, but certainly we do have scales such as the TD impact scale to further support your case with that AIMS exam.

Thank you for joining me here today. I hope these tips were helpful for your practice, and I hope to see you again soon.

Desiree Matthews, PMHNP-BC, CEO, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating healthcare provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.

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