2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
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1 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 and date. Fax signed forms to Aetna Better Health Michigan at When conditions are met, we will authorize the coverage of Botulinum Toxins (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Botox (onabotulinumtoxina) Myobloc (rimabotulinumtoxinb) Other, specify drug Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Quantity Frequency Strength Route of administration Expected length of therapy Member information Member name: Member ID: Member Group o.: Member DOB: Member phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. 1. Is the requested drug prescribed by a specialist based on the condition treated (e.g., neurologist, headache specialist, physical medicine, ophthalmologist, dermatologist)? Please indicate specialty: 2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 9.] 1
2 3. Is this request for Botox? [If no, skip to question 8.] 4. Is the member receiving a cumulative dose of more than 400 units every 90 days? [If yes, then no further questions.] 5. Is this request for Botox for chronic migraine prophylaxis? [If no, skip to question 8.] 6. Was the member s migraine headache frequency reduced by at least 7 days per month (when compared to pre-treatment average) by the end of the initial trial of botulinum toxin therapy? [If yes, skip to question 52.] 7. Was the member s migraine headache duration reduced by at least 100 total hours per month (when compared to the pre-treatment average) by the end of the initial trial of botulinum toxin therapy? [If yes, skip to question 52.] 8. Has the member had a response to treatment? [If yes, skip to question 52.] 9. Is this a request for Botox for treatment of cervical dystonia (also called spasmodic torticollis)? [If yes, skip to question 50.] 10.Is this a request for Dysport, Myobloc, or Xeomin for treatment of cervical dystonia (also called spasmodic torticollis)? [If yes, skip to question 51.] 11.Is this a request for Botox for treatment of blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders? [If yes, skip to question 49.] 12.Is this a request for Xeomin for treatment of blepharospasm? [If no, skip to question 14.] 13. Has the member previously been treated with onabotulinumtoxina (Botox)? 2
3 [If yes, skip to question 51.] 14.Is this a request for Botox, Xeomin or Dysport for the treatment of chronic limb spasticity? [If no, skip to question 21.] 15.Is the spasticity due to an injury to the brain or spinal cord, or along with a neurological disorder (for example, stroke, traumatic brain injury (TBI), multiple sclerosis (MS), spinal cord injury (SCI), cerebral palsy (CP))? 16. Has the member had a trial and failure of baclofen AD at least 1 additional formulary muscle relaxant such as dantrolene? List medications tried and reason for failure: 17.Has the member tried physical and/or occupational therapy? 18.Is this a request for Xeomin for the treatment of lower limb spasticity? [If yes, then no further questions.] 19.Is this a request for Dysport for the treatment of lower limb spasticity? [If no, skip to question 51.] 20.Is the member at least 2 years old? [If yes, skip to question 52.] 21.Is this a request for Botox for treatment of chronic sialorrhea (excessive drooling)? [If no, skip to question 23.] 22.Is the member at least 21 months old? [If yes, skip to question 25.] 23.Is this a request for Myobloc or Xeomin for treatment of chronic sialorrhea (excessive drooling)? [If no, skip to question 27.] 3
4 24.Is the member at least 18 years old? 25.Does the member meet any of the following: A) trial and failure of anticholinergic such as glycopyrrolate (pediatric use 3-16 years old), or B) trial and failure of benztropine (adult)? List medications tried and reason for failure: [If yes, skip to question 52.] 26.Is the request for Botox in a member who is 21 months old to less than 3 years old? [If yes, skip to question 52.] 27.Is this a request for Myobloc or Xeomin? [If yes, then no further questions.] 28.Is this a request for Botox for treatment of strabismus? [If yes, skip to question 49.] 29.Is this a request for Botox for treatment of hemifacial spasm? [If yes, skip to question 51.] 30.Is this a request for Botox for chronic migraine prophylaxis? [If no, skip to question 33.] 31.Is therapy being requested for prevention of chronic migraine in a member who experiences migraines at least 15 days per month with headaches lasting 4 hours a day or longer? 32.Has the member had an inadequate response to or intolerable side effects with at least 3 medications from TWO classes of migraine headache prophylaxis medications for at least 2 months (60 days): A) Beta-blocker: propranolol, metoprolol, timolol, atenolol, nadolol, B) Anticonvulsant: valproic acid, divalproex, topiramate, C) Antidepressants: amitriptyline, venlafaxine, D) List medications tried and reason for failure: [If yes, skip to question 51.] 4
5 33.Is this a request for Botox for the treatment of neurogenic bladder in a member with a diagnosis of urinary incontinence due to detrusor overactivity associated with a neurologic condition? [If no, skip to question 36.] 34.Has the member had a trial and failure of 2 formulary urinary anticholinergics (e.g., oxybutynin, trospium, tolterodine)? List medications tried and reason for failure: 35.Has the member had a trial and failure of behavioral therapy (e.g., bladder training, bladder control strategies, pelvic floor muscle training, or fluid management) for at least 8 to 12 weeks? [If yes, skip to question 51.] 36.Is this a request for Botox for the treatment of overactive bladder? [If no, skip to question 39.] 37.Has the member had a trial and failure of 2 formulary urinary anticholinergics (e.g., oxybutynin, trospium, tolterodine)? List medications tried and reason for failure: 38. Has the member had a trial and failure of behavioral therapy (e.g., bladder training, bladder control strategies, pelvic floor muscle training, or fluid management) for at least 8 to 12 weeks? [If yes, skip to question 51.] 39.Is this a request for Botox for the treatment of esophageal achalasia? [If no, skip to question 42.] 40. Does the member meet OE of the following: A) member remains symptomatic despite surgical myotomy or pneumatic dilation, or B) member is at high surgical risk or unwilling to undergo surgical myotomy or pneumatic dilation? Please indication which applies to the member: 5
6 [If yes, skip to question 51.] 41.Has the member presented with atypical achalasia symptoms and Botox is needed to help guide therapy and/or confirm diagnosis? [If yes, skip to question 51.] 42.Is this a request for Botox for treatment of chronic anal fissures? [If no, skip to question 44.] 43. Has the member had a trial and failure of nitroglycerin ointment 0.4 percent (Rectiv) AD either bulk fiber supplements, stool softeners, or sitz baths for at least 1 month? List treatments tried and reason for failure: [If yes, skip to question 51.] 44.Is this a request for Botox for treatment of severe primary axillary hyperhidrosis (excessive underarm sweating)? [If no, skip to question 47.] 45. Does the member s condition interfere with daily activities? 46.Has the member had a trial and failure of topical aluminum chloride 20 percent? [If yes, skip to question 51.] 47.Is this a request for Botox or Dysport for the management of focal spasticity or equinus gait (tiptoeing) in a member 2 to 18 years of age with cerebral palsy? 48. Will the member be enrolled in, or is the member currently being managed with, occupational therapy? [If yes, skip to question 52.] 49.Is the member at least 12 years old? [If yes, skip to question 52.] 6
7 50.Is the member at least 16 years old? [If yes, skip to question 52.] 51.Is the member at least 18 years old? 52. Are treatments scheduled at least 12 weeks apart? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date 7
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 informationCircle 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[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 informationAetna Better Health of Virginia
Botox (onabotulinumtoxina) Myobloc (rimabotulinumtoxinb) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Indications: (use if necessary): Overactive Bladder BOTOX indicated for the treatment
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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
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Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date:
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Generic Brand HICL GCN Exception/Other ONABOTULINUMTOXINA BOTOX 04867 BRAND BOTOX COSMETIC ABOBOTULINUMTOXINA DYSPORT 36477 RIMABOTULINUMTOXINB MYOBLOC 21869 INCOBOTULINUMTOXINA XEOMIN 36687 Please use
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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 informationBotulinum 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 informationDrug 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 informationSee 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
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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
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Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Xeomin (incobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective
More informationBotulinum 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 informationBOTOX. 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
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(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 information2. Is the patient responding to medication? Y N
Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS ADD-ADHD Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
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Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Anticoagulant Injectable (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationTable 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 informationOffice 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
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Pharmacy Prior Authorization AETA BETTER HEALTH ILLIOIS (MEDICAID) CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationCircle Yes or No Y N. [If no, skip to question 8.] 2. Has the patient been compliant with therapy as verified by the prescriber?
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Tecfidera (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information3. Does the patient meet ALL of the following requirements? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Procrit - Retacrit (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
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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 information2. Is this request for a preferred medication? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationBotox. 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 information3. Does the patient continue to receive nutritional or psychological counseling? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
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(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 information3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Is the patient responding to Remicade therapy? Y N
09/29/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Remicade (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Does the member continue to receive nutritional or psychological counseling?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationAbbreviated 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
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Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?
09/23/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information3. Has the member received the requested drug for less than 2 years? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information3. Has the member received the requested drug for less than 2 years? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationThis 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 information2. Did the patient receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. Did the member receive this medication during a recent hospitalization? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationLinks 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 information2. Does the patient have a diagnosis of Crohn s disease? Y N
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Stelara (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More information2. Does the patient have chronic urticaria? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Xolair (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationClinical 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 informationThis 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 informationCircle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationPharmacy 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 information2. Does the member have a diagnosis of central precocious puberty? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Leuprolide (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Somatostatin Analogs (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationClinical 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.
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Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationBotulinum 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 information1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?
09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More information2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. 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 KETUCK Multiple Sclerosis Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
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Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More information2. 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 EW JERSE (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationCircle Yes or No Y N. [If no, then no further questions.]
01/04/2016 Prior Authorization MERC MARICOPA ITEGRATED CARE - TXIX/XXI SMI (MEDICAID) Multiple Sclerosis Agents (AZ88) This fax machine is located in a secure location as required by HIPAA regulations.
More informationThis 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
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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 informationScientific 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
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Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationClinical 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
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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 information2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4.
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationPrior Authorization. Drug Name (select from list of drugs shown) Gilenya (fingolomid) Quantity Frequency Strength. Physician Name:
06/01/2016 Prior Authorization Aetna Better Health Michigan Gilenya This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed
More information3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?
Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA CCC PLUS and MEDALLIO/FAMIS 4.0 Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationSee 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 information2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationBotulinum 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
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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 informationDRUG 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 information1. 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 EW JERSE (MEDICAID) Eligard Trelstar - Vantas (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2. 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 (MEDICAID) Multiple Sclerosis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationBotulinium 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 information2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?
Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationPolicy. 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 informationPolicy. 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 informationBotulinum 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 informationPlease submit supporting medical documentation, notes and test results.
Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Valcyte (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.
More informationCircle Yes or No Y N. [If yes, skip to question 30.] 2. Is this request for a child? Y N. [If no, skip to question 20.]
05/20/2015 Prior Authorization MERC CARE PLA (MEDICAID) Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationOriginal 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 information2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationBOTULINUM 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 informationCorporate 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 informationCalcitonin Gene Related Peptide Receptor Inhibitors Prior Authorization Criteria:
Request for Prior Authorization for Calcitonin Gene Related Peptide Receptor Inhibitors Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Calcitonin Gene
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Orencia (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed
More informationBOTOX (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 information3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationCircle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.
10/01/2016 Prior Authorization Aetna Better Health of West Virginia COLO STIMULATIG FACTORS (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationCorporate 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 informationCircle Yes or No Y N. [If yes, skip to question 13 REAUTHORIZATION REQUESTS]
04/30/2014 Prior Authorization AETA BETTER HEALTH OF ILLIOIS MEDICAID Peginterferon (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationCLINICAL 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 informationBOTULINUM 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 informationClinical 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 informationClare 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
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