September 1, 2022
Starting December 1, 2022, botulinum toxins will require a prior authorization to ensure that members meet medical necessity criteria. They will no longer be covered on the pharmacy benefit and will now be applied to the medical benefit. The following brands are impacted by this change: Botox® (onabotulinumtoxinA), Dysport® (abobotulinumtoxinA), Myobloc® (rimabotulinumtoxinB), and Xeomin® (incobotulinumtoxinA).
Members who have claims for use of botulinum toxins will be notified of this change on November 1, 2022 and will be advised to contact their provider to request a prior authorization based on the policy criteria. Refer to the medical policy, Botulinum Toxins – 5.01.512, for more information. Additionally impacted policies include:
Members who receive a prior authorization approval on the medical benefit may experience an increase in out-of-pocket costs.