- Blepharospasm, Cervical Dystonia, Chronic Sialorrhea, Limb Spasticity:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Migraine Prevention:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Neurogenic Detrusor Overactivity (NDO), Pediatric Upper Limb Spasticity:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Overactive Bladder:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: 1 of Idiopathic overactive bladder;Neurogenic overactive bladder
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE; Dosing Limit: See clinical criteria for details;
- PA Applies
- Step Therapy: Cervical Dystonia, Limb Spasticity:
ST Single Brand
Chronic Sialorrhea:
ST Single Generic
Migraine Prevention:
ST Multiple Generics
- Prior Authorization: Blepharospasm, Cervical Dystonia, Chronic Sialorrhea, Limb Spasticity, Neurogenic Detrusor Overactivity (NDO), Overactive Bladder, Pediatric Upper Limb Spasticity:
Documented Diagnosis: Yes
Duration: 1 year(s)
Migraine Prevention:
Documented Diagnosis: Yes
Duration: 6 Month(s)
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