This policy addresses only onabotulinumtoxina, commercially available as Botox.

Size: px
Start display at page:

Download "This policy addresses only onabotulinumtoxina, commercially available as Botox."

Transcription

1 OnabotulinumtoxinA DESCRIPTION Botulinum toxin, produced by the bacterium Clostridium botulinum, is one of the most potent naturally occurring neurotoxins known. It induces chemodenervation by first binding to acceptors on motor nerve terminals. It then enters the terminals and blocks the release of acetylcholine and other neurotransmitters at the neuromuscular junction. This renders smooth and striated muscles incapable of contraction. Acetylcholine also mediates the sympathetic innervation of the sweat glands, explaining how botulinum toxin disrupts the cholinergic outflow to the skin and halts glandular secretion. The minute amount of toxin used clinically produces only partial, localized chemical denervation with transient results. Over time, axons generate temporary sprouts which release acetylcholine and the original nerve terminal is eventually re-established, ending the toxin s therapeutic activity. Seven antigenic-specific serotypes of botulinum toxin have been identified, types A, B, C-1, D, E, F and G, but only botulinum toxin types A and B are commercially available. These commercial preparations of the two serotypes (three of serotype A and one of serotype B) vary widely in potency and dosage. They have been given different names to reinforce these differences and to prevent medication errors. It is emphasized that the use and dosage of different formulations of botulinum toxin is not interchangeable. This policy addresses only onabotulinumtoxina, commercially available as Botox. POLICY OnabotulinumtoxinA for the treatment of the following is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.) o Achalasia - esophageal o Blepharospasm o Cerebral palsy with concurrent equinus gait o Cerebral palsy-related spasticity, localized or segmental o Cervical dystonia o Chronic anal fissure o Diplegia o Focal upper limb dystonia (e.g., organic writer's cramp) o Hemifacial spasms o Hemiplegia, spastic o Hereditary spastic paraplegia o Hyperhidrosis o Laryngeal dystonia (Spasmodic dysphonia) o Lower limb spasticity o Monoplegia o Oromandibular dystonia (orofacial dyskinesia) o Other paralytic syndromes o Overactive Bladder (OAB) o Paraplegia o Quadriplegia o Schilder s disease o Spasticity due to multiple sclerosis o Sialorrhea o Spastic hemiplegia

2 o Strabismus o Upper limb spasticity o Urinary incontinence OnabotulinumtoxinA for the Prophylaxis of Chronic Migraine Headache is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.) OnabotulinumtoxinA for the treatment or prevention of ANY OTHER disease or conditions is considered investigational. MEDICAL APPROPRIATENESS The proposal is to add text/statements in red and to delete text/statements with strikethrough: INITIAL APPROVAL (OnabotulinumtoxinA is considered medically appropriate if ALL of the following criteria are met: o Individual evaluated for any disorders which may contribute to respiratory or swallowing difficulty o Treatment of ANY ONE of the following in individual 18 years of age or older unless otherwise noted: Achalasia - esophageal if ANY ONE of the following: High risk of complication from pneumatic dilation or surgical myotomy Treatment failure with pneumatic dilation or surgical myotomy Prior perforation from pneumatic dilation Previous epiphrenic diverticulum or hiatal hernia Presence of esophageal varices Blepharospasm in individual age 12 or older Cervical dystonia in individual age 16 or older with history of recurrent involuntary contraction of one or more muscles in the neck with ANY ONE of the following: Sustained head tilt (torticollis) Abnormal posturing with limited range of motion in neck Chronic anal fissure if individual has failed conventional therapy Focal dystonias of ANY ONE of the following: Focal upper limb dystonia (e.g., organic writer s cramp) if individual has ANY ONE of the following: o Functional impairment o Pain as a result Laryngeal dystonia (Spasmodic dysphonia) Oromandibular dystonia (orofacial dyskinesia) if individual has pain as a result and/or functional impairment due to condition Hyperhidrosis, Severe Primary Focal if ALL of the following: Condition is ANY ONE of the following: o Axillary o Palmar Treatment is not adequately managed with topical agents Treatment has failed or is contraindicated for ANY ONE of the following: o Oral pharmacotherapy for axillary hyperhidrosis o Iontophoresis for palmar hyperhidrosis Condition causes ANY ONE of the following: Functional impairment/pain (e.g., inability perform critical activities of daily living due to condition) Medical complications such as skin infections Overactive bladder (OAB) if ALL of the following: Symptoms of ALL of the following: o Urge urinary incontinence o Urgency o Frequency

3 o Individual has failed a 1 month or longer trial of two medications from either the antimuscarinic (i.e. darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium) or beta-adrenergic (i.e. mirabegron) classes Sialorrhea associated with neurologic disorders of ANY ONE of the following: Parkinson s disease Severe developmental delays if 5 years of age or older with failure of oral therapy Cerebral palsy if 5 years of age or older with failure of oral therapy Amyotrophic lateral sclerosis Spastic conditions of ANY ONE of the following: Acquired spasticity secondary to spinal cord or brain injury Cerebral palsy with concurrent equinus gait Cerebral palsy-related spasticity, localized or segmental if 2 years of age or older Diplegia Hemifacial spasms Hemiplegia, spastic Hereditary spastic paraplegia Lower limb spasticity (e.g., used post-stroke for spasms) Monoplegia Paraplegia Quadriplegia Schilder s disease Spasticity due multiple sclerosis Spasticity related to stroke Upper limb spasticity (e.g., used post-stroke for spasms) Strabismus if individual is 12 years of age or older Urinary incontinence if ALL of the following: Individual has undergone urodynamic studies with diagnosis of idiopathic detrusor overactivity (IDO) Individual has failed a 1 month or longer trial of two medications from either the antimuscarinic (i.e. darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium) or beta-adrenergic (i.e. mirabegron) classes Prophylaxis of Chronic Migraine Headache if individual is/has ALL of the following: Utilizing prophylactic intervention modalities (e.g., pharmacotherapy, behavioral therapy, or physical therapy, etc.) Fifteen or more migraine-like headache days per month for at least 3 months Headaches have diagnostic migraine features on at least 8 days per month for at least 3 months (see list of diagnostic migraine features with and without aura below) Failed a 1 month or longer trial of any two oral medications for the prevention of migraines (see list of prophylactic medications below for examples): Suspected migraines are relieved by a triptan or ergot derivative medication Fifteen or more migraine days per month for at least 3 months Minimum of 5 attacks (with aura and/or without aura) with migraine features (Note: migraine without aura attacks must last 4 to 72 hours [untreated or unsuccessfully treated]) Attacks on at least 8 days per month for at least 3 months Meets the International Headache Society migraine feature diagnostic criteria for migraines with or without aura (see Migraine Features chart below) Utilizing prophylactic intervention modalities (e.g., pharmacotherapy, behavioral therapy, or physical therapy, etc.) Failed a 1 month or longer trial of any two of the following oral medications: Antidepressants (e.g., amitriptyline, fluoxetine, nortriptyline, etc.)

4 Beta blockers (e.g., propranolol, metoprolol, nadolol, timolol, atenolol, etc.) Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan, etc.) Anti-epileptics (e.g., valproate, topiramate, etc.) Calcium channels blockers (e.g., verapamil, etc.) Migraine-Prophylaxis Oral Medications (list not all-inclusive) Antidepressants (e.g., amitriptyline, fluoxetine, nortriptyline, etc.) Beta blockers (e.g., propranolol, metoprolol, nadolol, timolol, atenolol, etc.) Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ex. lisinopril, candesartan, etc.) Anti-epileptics (e.g., valproate, topiramate, etc) Calcium channels blockers (e.g., verapamil, etc) Migraine Features Migraine without aura At least five attacks have the following: Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) Headache has at least two of the following characteristics: o Unilateral location o Pulsating quality o Moderate or severe pain intensity o Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) During headache at least one of the following: o Nausea and/or vomiting o Photophobia and phonophobia Migraine with aura At least two attacks have the following: One or more of the following fully reversible aura symptoms: o Visual o Sensory o Speech and/or language o Motor o Brainstem o Retinal At least two of the following characteristics: o At least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession o Each individual aura symptom lasts 5 to 60 minutes o At least one aura symptom is unilateral o The aura is accompanied, or followed within 60 minutes, by headache RENEWAL CRITERIA OnabotulinumtoxinA is considered medically appropriate for renewal if ALL of the following criteria are met: o Individual continues to meet all of the initial approval criteria o Absence of unacceptable toxicity from the agent, e.g., symptoms of a toxin spread effect (e.g. asthenia, diplopia, ptosis, dysphagia, dysphonia, dysarthria, breathing difficulties, etc.) o Disease response is documented by ANY ONE of the following: Achalasia, esophageal, with improvement and/or relief in symptoms (e.g. dysphagia, pain, etc.) or improvement in esophageal emptying as evidenced by functional testing Blepharospasm with improvement of severity and/or frequency of eyelid spasms

5 Cervical dystonia with improvement in the severity and frequency of pain and improvement of abnormal head positioning Chronic anal fissure if complete healing of anal fissure or symptomatic improvement of persistent fissures Focal dystonias - of the upper limb (i.e., organic writer s cramp) - improvement in pain and/or function, Laryngeal dystonia (Spasmodic dysphonia) - improvement in voice function or quality or Oromandibular dystonia improvement in pain and function Hyperhidrosis Severe Primary Axillary or Severe Palmar - Significant reduction in spontaneous sweat production and individual has a significant improvement in activities of daily living Overactive Bladder with significant improvement in daily frequency of urinary incontinence or micturition episodes and/or volume voided per micturition individual has post-void residual (PVR) periodically assessed as medically appropriate Sialorrhea with significant decrease in saliva production Spastic conditions Focal Upper/Lower limbs, Cerebral Palsy, MS, Stroke, Plegias, etc. - Decrease in tone and/or resistance, of affected areas, based on a validated measuring tool (e.g. Ashworth Scale, Physician Global Assessment, Clinical Global Impression (CGI),etc.) Hemifacial Spasms with decrease in frequency and/or severity of spasm, or a decrease in tone and/or improvement in asymmetry to the affected side of the face Strabismus with improvement in alignment of prism diopters compared to pre-treatment baseline Urinary incontinence with significant improvements in weekly frequency of incontinence episodes and individual has post-void residual (PVR) periodically assessed as medically appropriate Prophylaxis of migraines if significant decrease in number and frequency of headaches, improvement in function and individual continues to utilize prophylactic intervention modalities (i.e. pharmacotherapy, behavioral therapy, physical therapy, etc.) INDICATION(S) Blepharospasm Cervical Dystonia Strabismus Achalasia Upper Limb Spasticity Lower Limb Spasticity Chronic Migraine Cerebral palsy in DOSAGE & ADMINISTRATION Units ( ml per site) injected into each of 3 sites per affected eye every three months. There appears to be little benefit obtainable from injecting more than 5 Units per site. The effect of treatment lasts an average of 12 weeks. Cumulative dose in 30 days should not exceed 200 units 198 Units to 300 Units divided among the affected muscles. No more than 50 Units per site. May re-treat in 12 weeks. Based on muscle(s) affected, Units in any one muscle initially. Subsequent doses may be increased up to two-fold compared to previously administered dose. No more than 25 U in any one muscle for recurrent cases. The effect of treatment usually lasts about 12 weeks. 100 Units (20-25 Units per quadrant) per administration, dose may be repeated in 6 months Dosing in initial and sequential treatment sessions should be tailored to the individual based on the size, number and location of muscles involved, severity of spasticity, the presence of local muscle weakness, the patient s response to previous treatment, or adverse event history with BOTOX. In clinical trials, doses ranging from 75 Units to 400 Units were divided among selected muscles at a given treatment session, no sooner than every 12 weeks. 300 to 400 Units divided among 5 muscle groups (gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus), no sooner than every 12 weeks 155 Units administered intramuscularly (IM) as 0.1 ml (5 Units) injections per each site. Injections should be divided across 7 specific head/neck muscle areas. Recommended re-treatment schedule is every 12 weeks. Dosing is highly variable and must be individualized. Clinical studies have utilized doses

6 pediatric patients Severe primary axillary hyperhidrosis Sialorrhea Neurogenic bladder/detrusor overactivity Overactive Bladder (OAB) Palmar Hyperhidrosis Chronic Anal Fissures Laryngeal Dystonia Hemifacial Spasms Oromandibular Dystonia All other indications - unless otherwise specified ranging from 2-20 Units/kg injected into the upper and/or lower extremities. The maximum recommended dose of 400 Units per 12 weeks should not be exceeded. 50 Units intradermally per axilla every 16 weeks Units in the parotid gland injected in two places and Units in the submandibular glands (total dose from Units per patient/administration). Repeat in 3 months if needed. 200 Units per treatment injected into the detrusor muscle using 30 injections (6.7 units each). Re-inject no sooner than 12 weeks from the prior bladder injection 100 Units per treatment injected into the detrusor muscle using 20 injections (5 units each). Re-inject no sooner than 12 weeks from the prior bladder injection units per hand, repeated every 6 months, as needed Recommended doses of up to 25 units, injected into the anal sphincter. Retreat every 3 months. Starting dose of units into thyroarytenoid muscle. Dose titrated based on response & side effects. Retreat every 3 months Recommended dose of 20 to 40 U, divided among affected muscles. Retreatment within 12 weeks 40 units injected into masseter and submentalis complex muscles every 12 weeks. Not to exceed a cumulative dose of 400 U (for one or more indications) every 12 weeks. Note: When initiating treatment, the lowest recommended dose should be used. In treating adult patients for one or more indications, the maximum cumulative dose should not exceed 400 Units in a 3 month (12 week) interval. Unless otherwise stated, re-treatment should occur no sooner than 12 weeks from the prior injection. LENGTH OF AUTHORIZATION Coverage will be provided for six months and may be renewed Click here to view DOSAGE LIMITS APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS BlueCross BlueShield of Tennessee s Medical Policy complies with Tennessee Code Annotated Section regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature. IMPORTANT REMINDER We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

7 ADDITIONAL INFORMATION For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) published by the National Comprehensive Cancer Network, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information). No controlled studies were found in the published literature that validate the use of onabotulinumtoxina for the treatment or prevention of other conditions or diseases. SOURCES American Academy of Neurology and Child Neurology Society (January, 2010). Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review). Retrieved May 9, 2016 from the National Guideline Clearinghouse (NGC: ). American Academy of Neurology. (2008, May). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review). Retrieved February 22, 2017 from American Academy of Neurology. (2008, May). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin in the treatment of spasticity (an evidencebased review). Retrieved February 22, 2017 from BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2017). Botulinum toxin ( ). Retrieved August 23, 2018 from BlueWeb. BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2018). Treatment of hyperhidrosis ( ). Retrieved August 23, 2018 from BlueWeb. Headache Classification Committee of the International Headache Society (IHS). ( ). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalagia. 2018, 38 (1), Retrieved March 22, 2018 from data/3245_ichd-3-cephalalgia-2018-issue-1.pdf. Lexi-Comp Online. (2018). AHFS DI. OnabotulinumtoxinA. Retrieved August 23, 2018 from Lexi-Comp Online with AHFS. Mazlan, M., Rajasegaran, S., Engkasan, J. P., Nawawi, O., Goh, K. J., Freddy, S.J. (2015). A double-blind randomized controlled trial investigating the most efficacious dose of botulinum toxin-a for sialorrhea treatment in Asian adults with neurological diseases. Toxins, 2015(7), MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2018, May). OnabotulinumtoxinA. Retrieved August 23, 2018 from MICROMEDEX Healthcare Series. Møller, E., Pedersen, S. A., Vinicoff, P. G., Bardow, A., Lykkeaa, J., Svendsen, P., Bakke, M. (2015). OnabotulinumtoxinA treatment of drooling in children with cerebral palsy: a prospective, longitudinal open-label study. Toxins, 2015 (7),

8 Simpson, D. M., Blitzer, A., Brashear, A., Comella, C., Dubinsky, R., Hallett, M., et al. (2008, January). Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 2008 (70), U. S. Food and Drug Administration. (2018, May). Center for Drug Evaluation and Research. Botox (onabotulinumtoxina) for injection. Retrieved August 23, 2018 from EFFECTIVE DATE ID_MRx

This policy addresses only the type B formulation rimabotulinumtoxinb marketed as Myobloc.

This policy addresses only the type B formulation rimabotulinumtoxinb marketed as Myobloc. RimabotulinumtoxinB NDC CODE(S) 10454-0710-XX Myobloc 2500 UNIT/0.5ML SOLN (SOLSTICE NEUROSCIENCES) 10454-0711-XX Myobloc 5000 UNIT/ML SOLN (SOLSTICE NEUROSCIENCES) 10454-0712-XX Myobloc 10000 UNIT/2ML

More information

Policy. Medical Policy Manual Approved Revised: Do Not Implement Until 4/2/19. IncobotulinumtoxinA

Policy. Medical Policy Manual Approved Revised: Do Not Implement Until 4/2/19. IncobotulinumtoxinA IncobotulinumtoxinA NDC CODE(S) 00259-1605-XX Xeomin 50 UNIT SOLR (MERZ PHARMACEUTICAL) 00259-1610-XX Xeomin 100 UNIT SOLR (MERZ PHARMACEUTICAL) 00259-1620-XX Xeomin 200 UNIT SOLR (MERZ PHARMACEUTICAL)

More information

This policy addresses only the type A formulation abobotulinumtoxina marketed as Dysport.

This policy addresses only the type A formulation abobotulinumtoxina marketed as Dysport. AbobotulinumtoxinA NDC CODE(S) 00299-5962-xx Dysport 300 UNIT VIAL (GALDERMA LABORA) 15054-0500-XX Dysport 500 UNIT SOLR (IPSEN BIOPHARMACEUTICALS) 15054-0530-XX Dysport 300 UNIT SOLR (IPSEN BIOPHARMACEUTICALS)

More information

This policy addresses only onabotulinumtoxina, commercially available as Botox.

This policy addresses only onabotulinumtoxina, commercially available as Botox. OnabotulinumtoxinA DESCRIPTION Botulinum toxin, produced by the bacterium Clostridium botulinum, is one of the most potent naturally occurring neurotoxins known. It induces chemodenervation by first binding

More information

Botox. Botox (onabotulinum toxin A) Description

Botox. Botox (onabotulinum toxin A) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.01 Subject: Botox Page: 1 of 8 Last Review Date: September 15, 2017 Botox Description Botox (onabotulinum

More information

Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb)

Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date:

More information

Neuromuscular Blocking Agents

Neuromuscular Blocking Agents Neuromuscular Blocking Agents DRUG POLICY This Prior Authorization request will be reviewed for medical necessity only. Benefits are subject to the terms and conditions of the patient s contract. Please

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? Pharmacy Prior Authorization AETA BETTER HEALTH MICHIGA Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

Botulinum Toxins. Length of Authorization: From 90 days to 12 months

Botulinum Toxins. Length of Authorization: From 90 days to 12 months Botulinum Toxins Goal(s): Approve botulinum toxins for funded OHP conditions supported by evidence of benefit (eg, dystonia or spasticity associated with certain neurological diseases). Require positive

More information

Xeomin (incobotulinumtoxina) (Intramuscular/Intradetrusor/Intradermal)

Xeomin (incobotulinumtoxina) (Intramuscular/Intradetrusor/Intradermal) Xeomin (incobotulinumtoxina) (Intramuscular/Intradetrusor/Intradermal) Last Review Date: 6/1/2018 Date of Origin: 06/21/2011 Document Number: IC-0241 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012,

More information

Xeomin (incobotulinumtoxina) Document Number: IC-0241

Xeomin (incobotulinumtoxina) Document Number: IC-0241 Xeomin (incobotulinumtoxina) Document Number: IC-0241 Last Review Date: 3/1/2018 Date of Origin: 06/21/2011 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012, 12/2012, 2/2013, 3/2013, 6/2013, 9/2013,

More information

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?

2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb)

Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective

More information

Prior Authorization Update: Botulinum Toxins

Prior Authorization Update: Botulinum Toxins Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Botulinum Toxins Reference Number: TCHP.PHAR.1812 Effective Date: 07.01.2018 Last Review Date: 04.13.2018 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the

More information

Circle Yes or No Y N. [If yes, no further questions.]

Circle Yes or No Y N. [If yes, no further questions.] 02/18/2016 Prior Authorization AETA BETTER HEALTH PE MEDICAID & AETA BETTER HEALTH KIDS Botulinum Toxins (PA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

BOTOX. Description. Section: Prescription Drugs Effective Date: January 1, 2013 Subsection: CNS Original Policy Date: December 7, 2011

BOTOX. Description. Section: Prescription Drugs Effective Date: January 1, 2013 Subsection: CNS Original Policy Date: December 7, 2011 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.12.01 Subject: Botox Page: 1 of 6 Last Review Status/Date: December 6, 2012 BOTOX Description Botox (onabotulinum

More information

[If yes, no further questions.]

[If yes, no further questions.] 05/30/2014 Prior Authorization AETA BETTER HEALTH OF ILLIOIS MEDICAID Botox (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

More information

Botulinum toxins: abobotulinumtoxina (Dysport ), incobotulinumtoxina (Xeomin ), onabotulinumtoxina (Botox ), & rimabotulinumtoxinb (Myobloc )

Botulinum toxins: abobotulinumtoxina (Dysport ), incobotulinumtoxina (Xeomin ), onabotulinumtoxina (Botox ), & rimabotulinumtoxinb (Myobloc ) Botulinum toxins: abobotulinumtoxina (Dysport ), incobotulinumtoxina (Xeomin ), onabotulinumtoxina (Botox ), & rimabotulinumtoxinb (Myobloc ) These services may or may not be covered by your HealthPartners

More information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES Generic Brand HICL GCN Exception/Other ONABOTULINUMTOXINA BOTOX 04867 BRAND BOTOX COSMETIC ABOBOTULINUMTOXINA DYSPORT 36477 RIMABOTULINUMTOXINB MYOBLOC 21869 INCOBOTULINUMTOXINA XEOMIN 36687 Please use

More information

Medication Prior Authorization Form

Medication Prior Authorization Form (OnabotulinumtoxinA) Dysport (abobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Xeomin (incobotulinumtoxina) Policy Number: 1042 Policy History Approve Date: 12/11/2015 Revise Dates: 07/07/2017 Next Review:

More information

Botox. Botox (onabotulinum toxin A) Description

Botox. Botox (onabotulinum toxin A) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.01 Subject: Botox Page: 1 of 10 Last Review Date: November 30, 2018 Botox Description Botox (onabotulinum

More information

Abbreviated Class Review: Botulinum toxins

Abbreviated Class Review: Botulinum toxins Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

Medication Prior Authorization Form

Medication Prior Authorization Form (OnabotulinumtoxinA) Dysport (abobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Xeomin (incobotulinumtoxina) Policy Number: 1042 Policy History Approve Date: 12/11/2015 Revise Dates: 7/7/2016 Next Review:

More information

Clare Gaduzo BSc RMN Registered Aesthetics Practitioner (qualified with Medics Direct)

Clare Gaduzo BSc RMN Registered Aesthetics Practitioner (qualified with Medics Direct) Clare Gaduzo BSc RMN Registered Aesthetics Practitioner (qualified with Medics Direct) 07935567067 cjg.aesthetics@yahoo.co.uk www.cjgaesthetics.co.uk http://www.facebook.com/cjgaesthetics @CJGAesthetics

More information

Aetna Better Health of Virginia

Aetna Better Health of Virginia Botox (onabotulinumtoxina) Myobloc (rimabotulinumtoxinb) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Indications: (use if necessary): Overactive Bladder BOTOX indicated for the treatment

More information

Drug Name (select from list of drugs shown / provide drug information) Patient Information. Prescribing Physician

Drug Name (select from list of drugs shown / provide drug information) Patient Information. Prescribing Physician Texas Standard Prior Authorization Form Addendum MOLINA TX MARKETPLACE Botulinum Toxins CL Molina Universal This fax machine is located in a secure location as required by HIPAA Regulations. Complete /

More information

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPMN.216

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPMN.216 Clinical Policy: (Botox) Reference Number: ERX.SPMN.216 Effective Date: 01/17 Last Review Date: Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory

More information

Dysport (abobotulinumtoxina) Document Number: IC-0239

Dysport (abobotulinumtoxina) Document Number: IC-0239 Dysport (abobotulinumtoxina) Document Number: IC-0239 Last Review Date: 3/1/2018 Date of Origin: 06/21/2011 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012, 12/2012, 2/2013, 3/2013, 6/2013, 9/2013,

More information

Neurotoxins (Botox, Dysport, Myobloc and Xeomin )

Neurotoxins (Botox, Dysport, Myobloc and Xeomin ) Last Review Date: November 10, 2017 Number: MG.MM.PH.01mC Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth

More information

Office Phone: * Cigna ID: * Date of Birth: Office Street Address: City: State: Zip:

Office Phone: * Cigna ID: * Date of Birth: Office Street Address: City: State: Zip: Phone: (800) 244-6224 Fax: (855) 840-1678 Botox (botulinum toxin type A) Notice: Please be sure to complete this form in its entirety. Missing information makes it difficult to approve requests and creates

More information

Table of Contents. 1.0 Description of the Procedure, Product, or Service Safety and Provider Compliance... 1

Table of Contents. 1.0 Description of the Procedure, Product, or Service Safety and Provider Compliance... 1 Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Safety and Provider Compliance... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific...

More information

BOTULINUM TOXIN POLICY TO INCLUDE:

BOTULINUM TOXIN POLICY TO INCLUDE: BOTULINUM TOXIN POLICY TO INCLUDE: Blepharospasm in adults, Hemi facial spasm in adults, spasmodic torticollis (cervical dystonia), focal spasticity treatment of dynamic equinus foot deformity, focal spasticity

More information

CLINICAL MEDICAL POLICY

CLINICAL MEDICAL POLICY Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Botox (onabotulinumtoxina) Injections MP-024-MD-DE Medical Management; Clinical Pharmacy Provider Notice Date: 07/15/2018;

More information

CLINICAL MEDICATION POLICY

CLINICAL MEDICATION POLICY CLINICAL MEDICATION POLICY Policy Name: Botox (onabotulinumtoxina) Policy Number: Approved By: Medical Management, Clinical Pharmacy Revision Date: 12/11/2017 Products: Highmark Health Options Application:

More information

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: CP.PHAR.232

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: CP.PHAR.232 Clinical Policy: (Botox) Reference Number: CP.PHAR.232 Effective Date: 07/16 Last Review Date: 05/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory

More information

Treatment Framework patient tracker

Treatment Framework patient tracker Treatment Framework patient tracker Utilize the BOTOX Treatment Framework when evaluating your Focal Spasticity patients to establish The right goals The right muscles/dose The right plan Use the following

More information

Erythropoiesis Stimulating Agents (ESAs): Epoetin Alfa * DIALYSIS *

Erythropoiesis Stimulating Agents (ESAs): Epoetin Alfa * DIALYSIS * Erythropoiesis Stimulating Agents (ESAs): Epoetin Alfa * DIALYSIS * DESCRIPTION Erythropoietin is a glycoprotein produced in the kidneys responsible for the stimulation of red blood cell production. Epoetin

More information

Elements of Provider Documentation Consistent with Medicare Guidelines

Elements of Provider Documentation Consistent with Medicare Guidelines S T R E A M L I N E Elements of Provider Documentation Consistent with Medicare Guidelines 1 Document medical necessity Include a statement that BOTOX (onabotulinumtoxina) treatment is reasonable and necessary

More information

Botulinum Toxin Medical Policy Prior Authorization Program Summary

Botulinum Toxin Medical Policy Prior Authorization Program Summary OBJECTIVE The intent of the botulinum toxin medical drug criteria is to ensure appropriate selection of patients for treatment according to product labeling and/or clinical studies and/or guidelines and

More information

Myobloc (rimabotulinumtoxinb) Document Number: IC-0240

Myobloc (rimabotulinumtoxinb) Document Number: IC-0240 Myobloc (rimabotulinumtoxinb) Document Number: IC-0240 Last Review Date: 3/1/2018 Date of Origin: 06/21/2011 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012, 12/2012, 2/2013, 3/2013, 6/2013, 9/2013,

More information

See Policy CPT/HCPCS CODE section below for any prior authorization requirements

See Policy CPT/HCPCS CODE section below for any prior authorization requirements Effective Date: 4/1/2017 Section: MED Policy No.: 209 Medical Officer 4/1/2018 Date Technology Assessment Committee Approved Date: 4/09;6/10, 01/11; 5/13; 2/15 Medical Policy Committee Approved Date: 11/09;

More information

Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.

Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Local Coverage Determination (LCD): Botulinum Toxins (L33274) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information CONTRACTOR NAME

More information

Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website.

Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Local Coverage Determination (LCD): Drugs and Biologicals: Botulinum Toxins (L34253) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: botulinum_toxin_injection 8/1985 10/2015 10/2016 10/2015 Description of Procedure or Service Description

More information

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPA.192 Effective Date:

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: ERX.SPA.192 Effective Date: Clinical Policy: (Botox) Reference Number: ERX.SPA.192 Effective Date: 01.11.17 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal

More information

10/17/2017 CHRONIC MIGRAINES BOTOX: TO INJECT OR NOT INJECT? IN CHRONIC MIGRAINE PROPHYLAXIS OBJECTIVES PATIENT CASE EPIDEMIOLOGY EPIDEMIOLOGY

10/17/2017 CHRONIC MIGRAINES BOTOX: TO INJECT OR NOT INJECT? IN CHRONIC MIGRAINE PROPHYLAXIS OBJECTIVES PATIENT CASE EPIDEMIOLOGY EPIDEMIOLOGY BOTOX: TO INJECT OR NOT INJECT? IN CHRONIC MIGRAINE PROPHYLAXIS OBJECTIVES JENNIFER SHIN, PHARMD PGY2 AMBULATORY CARE PHARMACY RESIDENT COMMUNITYCARE HEALTH CENTERS PHARMACOTHERAPY ROUNDS OCTOBER 20, 2017

More information

INDIANA HEALTH COVERAGE PROGRAMS

INDIANA HEALTH COVERAGE PROGRAMS INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Injections, Vaccines, and Other Physician-Administered Drugs Codes Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy

More information

Clinical Policy: Botulinum Toxins Reference Number: NE.PHAR.15

Clinical Policy: Botulinum Toxins Reference Number: NE.PHAR.15 Clinical Policy: Reference Number: NE.PHAR.15 Effective Date: 01/01/2017 Last Review Date: Revision Log See Important Reminder at the end of this policy for important regulatory and legal information.

More information

THE CLINICAL USE OF BOTULINUM TOXIN IN THE TREATMENT OF MOVEMENT DISORDERS, SPASTICITY, AND SOFT TISSUE PAIN

THE CLINICAL USE OF BOTULINUM TOXIN IN THE TREATMENT OF MOVEMENT DISORDERS, SPASTICITY, AND SOFT TISSUE PAIN THE CLINICAL USE OF BOTULINUM TOXIN IN THE TREATMENT OF MOVEMENT DISORDERS, SPASTICITY, AND SOFT TISSUE PAIN Spasmodic torticollis (cervical dystonia), blepharospasm, and writer s cramp are specific types

More information

Original Policy Date

Original Policy Date MP 5.01.03 Botulinum Toxin Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/Date Reviewed with literature search/12:2013 Return to Medical Policy Index

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: botulinum_toxin_injection 8/1985 10/2017 10/2018 10/2017 Description of Procedure or Service Description

More information

For each of your Focal Spasticity patients, establish... The right goals. The right muscles/dose

For each of your Focal Spasticity patients, establish... The right goals. The right muscles/dose FOCAL SPASTICITY Treatment Framework For each of your Focal Spasticity patients, establish... The right goals The right plan The right muscles/dose Indications Spasticity: Upper Limb Spasticity for injection

More information

The proposal is to add text/statements in red and to delete text/statements with strikethrough: POLICY

The proposal is to add text/statements in red and to delete text/statements with strikethrough: POLICY Omalizumab DESCRIPTION Omalizumab is a recombinant DNA-derived humanized IgG1κ monoclonal antibody which selectively binds to immunoglobulin E (IgE). High serum levels of IgE are found in individuals with

More information

Botulinum Toxin. When Policy Topic is covered The use of botulinum toxin may be considered medically necessary for the following:

Botulinum Toxin. When Policy Topic is covered The use of botulinum toxin may be considered medically necessary for the following: Botulinum Toxin Policy Number: 5.01.05 Last Review: 01/2018 Origination: 02/1998 Next Review: 02/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for botulinum toxin

More information

BOTULINUM TOXINS A AND B

BOTULINUM TOXINS A AND B DRUG POLICY BOTULINUM TOXINS A B Policy Number: 2014D0017N Effective Date: 9/1/2014 Table of Contents Page COVERAGE RATIONALE... 1 BENEFIT CONSIDERATIONS... 7 BACKGROUND... 8 CLINICAL EVIDENCE... 8 U.S.

More information

Pharmacy Medical Necessity Guidelines: Botulinum Toxins

Pharmacy Medical Necessity Guidelines: Botulinum Toxins Pharmacy Medical Necessity Guidelines: Effective: January 1, 2018 Effective: Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical

More information

Policy. covered. (spasmodic. Cervical dystonia. injury, or more of. migraine. agents. - Migraine - Migraine. per month. communication, dystonia

Policy. covered. (spasmodic. Cervical dystonia. injury, or more of. migraine. agents. - Migraine - Migraine. per month. communication, dystonia Botulinum Toxin Policy Number: 5.01.05 Origination: 02/1998 Last Review: 02/2014 Next Review: 02/2015 Policy BCBSKC will provide coverage for botulinum toxin A and B injections it is determined to be medically

More information

BOTOX (onabotulinumtoxina) for Therapeutic Use

BOTOX (onabotulinumtoxina) for Therapeutic Use BOTOX (onabotulinumtoxina) for Therapeutic Use BOTOX (onabotulinumtoxina) & BOTOX Cosmetic (onabotulinumtoxina) Important Information IMPORTANT SAFETY INFORMATION BOTOX and BOTOX Cosmetic may cause serious

More information

DOSAGE FORMS AND STRENGTHS For Injection: 100 Units or 200 Units vacuum-dried powder in a single-dose vial (3)

DOSAGE FORMS AND STRENGTHS For Injection: 100 Units or 200 Units vacuum-dried powder in a single-dose vial (3) HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use safely and effectively. See full prescribing information for. (onabotulinumtoxina) for injection,

More information

Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN)

Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN) Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN) Policy Number: Original Effective Date: MM.04.004 03/14/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 10/01/2013 Section: Prescription

More information

Developing a Patient Welcome Letter BOTOX (onabotulinumtoxina) for appropriate patients

Developing a Patient Welcome Letter BOTOX (onabotulinumtoxina) for appropriate patients S T R E A M L I N E Developing a Patient Welcome Letter (onabotulinumtoxina) for appropriate patients Indications Bladder Dysfunction: Overactive Bladder for injection is indicated for the treatment of

More information

NAME OF THE MEDICINE BOTOX purified neurotoxin complex injection (50U, 100 U or 200 U) (botulinum toxin, type A) DESCRIPTION Composition

NAME OF THE MEDICINE BOTOX purified neurotoxin complex injection (50U, 100 U or 200 U) (botulinum toxin, type A) DESCRIPTION Composition NAME OF THE MEDICINE BOTOX purified neurotoxin complex injection (50U, 100 U or 200 U) (botulinum toxin, type A) DESCRIPTION Composition Active ingredient: Each vial of BOTOX contains either 50 units (U),

More information

Scientific Update Laxman Bahroo, MD

Scientific Update Laxman Bahroo, MD Scientific Update Laxman Bahroo, MD Associate Professor Director; Botulinum Toxin Clinic Director; Neurology Residency Program Medstar Georgetown University Hospital Washington, D.C. Disclosures Advisory

More information

BOTOX Billing & Coding for NeuroRehab

BOTOX Billing & Coding for NeuroRehab S T R E A M L I N E Billing & Coding for NeuroRehab Cervical Dystonia, Blepharospasm, and Focal Spasticity Indications Spasticity: Upper Limb Spasticity for injection is indicated for the treatment of

More information

DRUG USE EVALUATION: UTILIZATION OF BOTULINUM TOXIN

DRUG USE EVALUATION: UTILIZATION OF BOTULINUM TOXIN There are currently four botulinum toxin (BoNT) products available in the United States: abobotulinumtoxina (ABO), incobotulinumtoxina (INC), onabotulinumtoxina (ONA), and rimabotulinumtoxinb (RIM). They

More information

Botulinum Toxin Drug Class Prior Authorization Protocol

Botulinum Toxin Drug Class Prior Authorization Protocol Line of Business: Medi-Cal Effective Date: May 18, 2016 Renewal Date: August 16, 2017 Botulinum Toxin Drug Class Prior Authorization Protocol This policy has been developed through review of medical literature,

More information

BOTULINUM TOXINS A AND B

BOTULINUM TOXINS A AND B BOTULINUM TOXINS A AND B UnitedHealthcare Community Plan Medical Benefit Drug Policy Policy Number: CS2018D0017S Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT

More information

Botox (onabotulinumtoxina) Document Number: IC-0238

Botox (onabotulinumtoxina) Document Number: IC-0238 Botox (onabotulinumtoxina) Document Number: IC-0238 Last Review Date: 3/1/2018 Date of Origin: 06/21/2011 Dates Reviewed: 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 02/2013, 03/2013, 06/2013,

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association CGRP Page 1 of 8 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: CGRP (calcitonin gene-related peptide) Prime Therapeutics will review Prior Authorization requests

More information

BOTULINUM TOXINS A AND B

BOTULINUM TOXINS A AND B BOTULINUM TOXINS A AND B UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0017S Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS...

More information

Clinical Policy: IncobotulinumtoxinA (Xeomin) Reference Number: ERX.SPA.194 Effective Date:

Clinical Policy: IncobotulinumtoxinA (Xeomin) Reference Number: ERX.SPA.194 Effective Date: Clinical Policy: (Xeomin) Reference Number: ERX.SPA.194 Effective Date: 01.11.17 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal

More information

NAME OF THE MEDICINE. BOTOX purified neurotoxin complex injection (100 U or 200 U) (botulinum toxin, type A) DESCRIPTION.

NAME OF THE MEDICINE. BOTOX purified neurotoxin complex injection (100 U or 200 U) (botulinum toxin, type A) DESCRIPTION. NAME OF THE MEDICINE BOTOX purified neurotoxin complex injection (100 U or 200 U) (botulinum toxin, type A) DESCRIPTION Composition Active ingredient: Each vial of BOTOX contains either 100 units (U) or

More information

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: CP.PHAR.232

Clinical Policy: OnabotulinumtoxinA (Botox) Reference Number: CP.PHAR.232 Clinical Policy: (Botox) Reference Number: CP.PHAR.232 Effective Date: 07/16 Last Review Date: 07/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory

More information

Clinical Policy Title: Botulinum toxin products

Clinical Policy Title: Botulinum toxin products Clinical Policy Title: Botulinum toxin products Clinical Policy Number: 00.02.02 Effective Date: September 1, 2013 Initial Review Date: May 13, 2013 Most Recent Review Date: May 19, 2017 Next Review Date:

More information

Drug Class Update: Botulinum Toxins

Drug Class Update: Botulinum Toxins Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

M0BCore Safety Profile

M0BCore Safety Profile M0BCore Safety Profile Active substance: Clostridium botulinum neurotoxin type A haemagglutinin complex Pharmaceutical form(s)/strength: powder for solution for injection, 300 unit and 500 unit P-RMS:

More information

BOTOX (onabotulinumtoxina) Treatment Record for Cervical Dystonia

BOTOX (onabotulinumtoxina) Treatment Record for Cervical Dystonia (onabotulinumtoxina) Record for Cervical Dystonia Patient name: Clinical rationale for treatment (medical necessity): Clinical rationale for EMG (if applicable): Comments: Diluent to Add (0.9% Sodium Chloride

More information

DYSrupt Your Patients Spasticity Symptoms

DYSrupt Your Patients Spasticity Symptoms The Dysport Profiles RALPH PATRICIA In the treatment of upper limb spasticity and lower limb spasticity in adults DYSrupt Your Patients Spasticity Symptoms Not actual patients In clinical trials with Dysport,

More information

Parkinson's Disease Center and Movement Disorders Clinic

Parkinson's Disease Center and Movement Disorders Clinic Parkinson's Disease Center and Movement Disorders Clinic 7200 Cambridge Street, 9th Floor, Suite 9A Houston, Texas 77030 713-798-2273 phone www.jankovic.org Botulinum Toxin Botulinum toxin (BTX) has been

More information

EMR template and postprocedure notes

EMR template and postprocedure notes EMR template and postprocedure notes Sample autopopulated text to create a BOTOX injection procedure report Information gathered from market research. These considerations are for reference only and should

More information

xx Xolair 150 MG SOLR (GENENTECH)

xx Xolair 150 MG SOLR (GENENTECH) Omalizumab NDC CODE(S) 50242-0040-xx Xolair 150 MG SOLR (GENENTECH) DESCRIPTION Omalizumab is a recombinant DNA-derived humanized IgG1κ monoclonal antibody which selectively binds to immunoglobulin E (IgE).

More information

BOTOX (onabotulinumtoxina) Treatment Record for Blepharospasm

BOTOX (onabotulinumtoxina) Treatment Record for Blepharospasm (onabotulinumtoxina) Record for Blepharospasm Patient name: Clinical rationale for injection: Response prior to treatment: Comments: Diluent to Add (0.9% Sodium Chloride Injection Only) 200-Unit Vial Resulting

More information

Policy. Medical Policy Manual Approved Revised: Do Not Implement until 6/30/2019. Nivolumab

Policy. Medical Policy Manual Approved Revised: Do Not Implement until 6/30/2019. Nivolumab Medical Manual Approved Revised: Do Not Implement until 6/30/2019 Nivolumab NDC CODE(S) 00003-3772-XX Opdivo 40 MG/4ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3774-XX Opdivo 100 MG/10ML SOLN (B-M SQUIBB

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium clostridium botulinum neurotoxin type A, 100 unit powder for solution for injection (Xeomin ) No. (464/08) Merz Pharma UK Ltd 09 May 2008 The Scottish Medicines Consortium

More information

BOTOX blepharospasm treatment record

BOTOX blepharospasm treatment record blepharospasm treatment record NEUROREHAB Patient name Clinical rationale for injection Response prior to treatment Comments Diluent to Add (0.9% Sodium Chloride Injection Only) 200-Unit Vial Resulting

More information

MYOBLOC and Cervical Dystonia A Patient s Guide

MYOBLOC and Cervical Dystonia A Patient s Guide MYOBLOC and Cervical Dystonia A Patient s Guide MYOBLOC (rimabotulinumtoxinb) Injection is indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position

More information

PEDIATRIC PHARMACOTHERAPY A Monthly Newsletter for Health Care Professionals from the Children s Medical Center at the University of Virginia

PEDIATRIC PHARMACOTHERAPY A Monthly Newsletter for Health Care Professionals from the Children s Medical Center at the University of Virginia PEDIATRIC PHARMACOTHERAPY A Monthly Newsletter for Health Care Professionals from the Children s Medical Center at the University of Virginia Volume 9 Number 3 March 2003 W Clinical Applications for Botulinum

More information

Policy. Medical Policy Manual Approved Revised: Do Not Implement Until 3/2/19. Nivolumab (Intravenous)

Policy. Medical Policy Manual Approved Revised: Do Not Implement Until 3/2/19. Nivolumab (Intravenous) Nivolumab (Intravenous) NDC CODE(S) 00003-3772-XX Opdivo 40 MG/4ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3774-XX Opdivo 100 MG/10ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3734-XX Opdivo 240

More information

Prof. of Neurology, Cairo University Vice President of the Egyptian Society of Neurology, Secretary General of Pan Arab union of Neurological

Prof. of Neurology, Cairo University Vice President of the Egyptian Society of Neurology, Secretary General of Pan Arab union of Neurological Prof. of Neurology, Cairo University Vice President of the Egyptian Society of Neurology, Secretary General of Pan Arab union of Neurological Societies The Egyptian Society of Neurology, Psychiatry and

More information

Botulinium Type B is covered when filed with one of the indications listed in the attachment below( Botox B, ICD9 edits).

Botulinium Type B is covered when filed with one of the indications listed in the attachment below( Botox B, ICD9 edits). Medical Coverage Policy Botulinum Toxin Injection EFFECTIVE DATE: 09/17/2007 POLICY LAST UPDATED: 07/15/2014 OVERVIEW Botulinum toxin is produced by the anaerobic clostridium botulinum. Botulinum toxin

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Ajovy) Reference Number: CP.PHAR.## Effective Date: 10.30.18 Last Review Date: 02.19 Line of Business: Commercial, TBD HIM*, Medicaid Revision Log See Important Reminder at the end of

More information

NAVIGATING THE BOTOX REIMBURSEMENT LANDSCAPE

NAVIGATING THE BOTOX REIMBURSEMENT LANDSCAPE S T R E A M L I N E NAVIGATING THE REIMBURSEMENT LANDSCAPE (onabotulinumtoxina) for appropriate patients Indications Chronic Migraine is indicated for the prophylaxis of headaches in adult patients with

More information

Developing a Patient Welcome Letter BOTOX (onabotulinumtoxina) for appropriate patients

Developing a Patient Welcome Letter BOTOX (onabotulinumtoxina) for appropriate patients S T R E A M L I N E Developing a Patient Welcome Letter (onabotulinumtoxina) for appropriate patients Indications Chronic Migraine for injection is indicated for the prophylaxis of headaches in adult patients

More information

IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING

IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING [Date] [Dr. Name] [Address] [City, State Zip] Dear Dr. [Last name]: I d like to introduce myself as a colleague in your area who specializes in the diagnosis and management of patients living with Chronic

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Dysport) Reference Number: CP.PHAR.230 Effective Date: 07.01.16 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder

More information

MEDICATION GUIDE BOTOX BOTOX Cosmetic (Boe-tox) (onabotulinumtoxina) for Injection

MEDICATION GUIDE BOTOX BOTOX Cosmetic (Boe-tox) (onabotulinumtoxina) for Injection 17.2 Ability to Operate Machinery or Vehicles Advise patients that if loss of strength, muscle weakness, blurred vision, or drooping eyelids occur, they should avoid driving a car or engaging in other

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association CGRP Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: CGRP (calcitonin gene-related peptide) Prime Therapeutics will review Prior Authorization requests

More information