Health Net
Myobloc (rimabotulinumtoxinB)
Drugs for Nerves and Muscles : Drugs for Nerves and Muscles
  • Prior Authorization: Blepharospasm, Migraine:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Cervical Dystonia, Chronic Sialorrhea:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Limb Spasticity, Migraine Prevention, Neurogenic Detrusor Overactivity (NDO), Primary Axillary Hyperhidrosis, Spasticity: Adult, Spasticity: Lower Limb:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)

    Overactive Bladder:
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: Blepharospasm, Cervical Dystonia, Migraine Prevention:
    ST Multiple Brands

    Chronic Sialorrhea:
    ST Single Generic

    Migraine:
    Step Therapy Applies

    Overactive Bladder:
    ST Multiple Generics

  • Blepharospasm:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)

    Cervical Dystonia:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Chronic Sialorrhea:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Limb Spasticity, Neurogenic Detrusor Overactivity (NDO), Spasticity: Adult, Spasticity: Lower Limb:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No

    Migraine:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Migraine Frequency: N/A
    Is supporting documentation required for initial approval: Yes
    Is supporting documentation required for re-approval: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Diagnosis of Chronic Migraine Required: No
    Required Decrease in Duration of Chronic Migraine for Reauthorization: N/A
    Provider Responsibility Language Referenced in Policy: No
    Dose Conversion Language Included in Policy: No
    Reauthorization Criteria Includes 50% Reduction Language: No
    Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
    Retreatment Language Included in Policy: N/A
    Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist

    Migraine Prevention:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Specialist Type(s): Appropriate Specialist

    Overactive Bladder:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: No
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Primary Axillary Hyperhidrosis:
    Duration: 6 Month(s)
    Medical Test Required: No
    Reauthorization Required: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Documented Diagnosis: Yes

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