Health Net
Botox (onabotulinumtoxinA)
Drugs for Nerves and Muscles : Drugs for Nerves and Muscles
  • Prior Authorization: Blepharospasm:
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Cervical Dystonia:
    Documented Diagnosis: Yes
    Age Requirement: >= 16
    Duration: 1 plan year
    Reauthorization Required: Yes

    Chronic Sialorrhea:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Limb Spasticity, Pediatric Upper Limb Spasticity, Spasticity: Upper Limb:
    Documented Diagnosis: Yes
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Migraine, Primary Axillary Hyperhidrosis:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Migraine Prevention:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)

    Neurogenic Detrusor Overactivity (NDO):
    Documented Diagnosis: Yes
    Age Requirement: >= 5
    Duration: 1 plan year
    Reauthorization Required: Yes

    Overactive Bladder, Spasticity: Adult:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Spasticity: Lower Limb:
    Documented Diagnosis: Yes
    Age Requirement: >= 2
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Step Therapy: Cervical Dystonia, Limb Spasticity, Spasticity: Adult:
    ST Single Brand

    Chronic Sialorrhea, Migraine, Migraine Prevention:
    ST Multiple Generics

    Neurogenic Detrusor Overactivity (NDO), Overactive Bladder:
    ST Generic and Brand

    Pediatric Upper Limb Spasticity, Spasticity: Upper Limb:
    ST Multiple Brands

    Primary Axillary Hyperhidrosis:
    ST Single Generic

  • Blepharospasm:
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Ophthalmologist
    Reauthorization Required: Yes
    Duration of Reauthorization: >= 6 month(s)

    Cervical Dystonia:
    Age Requirement: >= 16
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Chronic Sialorrhea:
    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)

    Limb Spasticity:
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedic Specialist;Physiatrist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)

    Migraine:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Pain Management Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Migraine Frequency: Unspecified
    Is supporting documentation required for initial approval: No
    Is supporting documentation required for re-approval: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Diagnosis of Chronic Migraine Required: Yes
    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
    ICHD2ICHD3 Language Included in Policy: 2 of at least 15 days per month with headaches lasting four hours a day or longer;chronic migraines occurring at least 15 days in a single month, for at least 3 months
    Retreatment Language Included in Policy: N/A
    Policy Contains ICHD2 or ICHD3 Language: ICHD2 and ICHD3 criteria exist

    Migraine Prevention:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Specialist Type(s): 1 of Neurologist;Pain Management Specialist

    Neurogenic Detrusor Overactivity (NDO):
    Age Requirement: >= 5
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Urologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Overactive Bladder:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Urologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Diagnosis Types: 1 of Diagnosis of Overactive Bladder (OAB) ;Overactive bladder with urinary incontinence

    Pediatric Upper Limb Spasticity:
    Age Requirement: >= 2
    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: = 6 month(s)

    Primary Axillary Hyperhidrosis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Documented Diagnosis: Yes

    Spasticity: Adult:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Spasticity: Lower Limb:
    Age Requirement: >= 2
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Spasticity: Upper Limb:
    Age Requirement: >= 2
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)

<< Return | Back to top