- 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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