Botulinum Toxins

Drugs:
Botox (onabotulinumtoxin A)
Dysport (abobotulinumtoxin A)
Xeomin (incobotulinumtoxin A)
Myobloc (rimabotulinumtoxin B)
Daxxify (daxibotulinumtoxin A-lanm)

January 2026

Therapeutic area - Botulinum toxins

Initial approval criteria

  • The requested drug will not be prescribed for an excluded indication (e.g. cosmetic) AND
  • The requested drug is prescribed for ONE of the following:
    • A medically accepted indication as defined in Section 1927 of the Social Security Act; OR
    • Continuation of therapy:
      • Continuation of therapy is defined as the patient has received treatment with the requested drug for at least 90 days preceding the prior authorization request for a medically accepted indication as defined in Section 1927 of the Social Security Act
      • The use of free goods or pharmaceutical samples will not be considered as meeting this criterion
  • Must be age-appropriate according to a medically accepted indication as defined in Section 1927 of the Social Security Act AND
  • The patient does NOT have any FDA labeled contraindications to the requested drug; AND
  • Initial approval is for 12 months

Renewal criteria

  • Patient continues to meet the initial approval criteria AND
  • Documentation showing a positive response to the requested drug AND
  • Patient has NOT experienced any treatment-restricting adverse effects (e.g., severe hypersensitivity reactions).
  • Renewal approval is for 12 months

Quantity limits

  • The requested drug is being prescribed within recommended dosing guidelines

Billing for botulinum toxin

  • The requested drug must be billed as a professional claim

Definition

Free goods or pharmaceutical samples: medication samples, medications obtained from any patient assistance programs or any discount programs, medications obtained through free trial programs, manufacturer vouchers, coupons, or debit cards while the member is on Medical Assistance.

Questions?

Provider Call Center: (844) 575-7887