CurrentAvMedPolicy N/A

Botox - Chronic Migraine (Pharmacy)

Pharmacy prior authorization and step-edit requirements for coverage of botulinum toxin Type A (Botox) for chronic migraine headache prophylaxis, including initial and reauthorization clinical criteria, quantity limits, exclusions (cosmetic), documentation and administration setting options.

Policy Summary

PayerAvMed

PolicyBotox - Chronic Migraine (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit completed pharmacy prior authorization/step-edit request with prescriber signature and required documentation (chart notes, pharmacy paid claims) to fax 1-305-671-0200; incomplete/illegible requests may delay authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this update.

155 units/12 wksAdult per-cycle max dose

400 units/3 monthsAdult 3-month cumulative max

>=15Required headache days/month

>=4 hrsMinimum headache duration/day

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Scope: This policy is a pharmacy prior authorization/step-edit governing coverage of onabotulinumtoxinA (Botox) for prophylaxis of chronic migraine headache. It defines initial and reauthorization clinical criteria, dosing and quantity limits, documentation requirements, applicable administration settings, and exclusions. Applicable providers/sites include physician offices or specialty pharmacy when documented. Coverage stance: covered_with_criteria, meaning Botox is covered for chronic migraine when all specified clinical criteria and documentation are met.

Key thresholds and limits

Headache days per month>= 15

Headache duration>= 4 hours per day

Migraine days on CGRP + Botox evaluation>= 4 migraine headache days per month after therapy

Botox dosing limit (adults)155 units once every 12 weeks; do not exceed 400 units in any 3-month interval

Botox dosing limit (pediatrics)Total dose should not exceed the lower of 10 units/kg body weight or 340 units in a 3-month interval

Adult per-cycle max155 units/12 weeks

Adult 3-month cumulative max400 units/3 months

Unproven Uses & Exclusions

Exclusions: Requests for cosmetic indications are explicitly excluded and will be denied. Pediatric dosing limits differ from adults and are specified separately (pediatric max is the lower of 10 units/kg or 340 units per 3 months); cosmetic use is outside the scope of this migraine prophylaxis policy. The form requires an ICD-10 diagnosis code to be provided, but no specific ICD-10 code(s) are listed on the form.

Applicable Codes

ICD-10 (diagnosis)ICD-10

ICD Code to be provided on form (no specific codes listed in document)

Injectable/Oral CGRP examples referencedmixed

Aimovig	erenumab (example injectable CGRP inhibitor)
Ajovy	fremanezumab (example injectable CGRP inhibitor)
Emgality	galcanezumab (example injectable CGRP inhibitor)
Nurtec ODT	rimegepant (oral CGRP inhibitor indicated for migraine prevention)
Qulipta	atogepant (oral CGRP inhibitor)

Provider Actions

Prior Authorization

Prior authorization required

Submit completed pharmacy prior authorization/step-edit request with prescriber signature and required documentation (chart notes, pharmacy paid claims) to fax 1-305-671-0200; incomplete/illegible requests may delay authorization.

Fax: 1-305-671-0200
Include prescriber signature and required documentation (chart notes, pharmacy paid claims)

Documentation Required

Documentation of failed prophylactic trials

Provide verification that the member had 2-month trials of at least one medication from TWO different migraine prophylactic classes. Verification may be chart notes or pharmacy paid claims and should document the specific agents and durations.

Verify 2-month trial of at least one medication from each of two different prophylactic classes (examples: anticonvulsants, beta blockers, antidepressants, candesartan)
Verification via chart notes or pharmacy paid claims

Documentation Required

Medication overuse headache evaluation and plan

Document evaluation for Medication Overuse Headache (MOH). If MOH is diagnosed, include a treatment plan to taper off the offending medication.

MOH defined as headaches ≥ 15 days per month from regular overuse of acute or symptomatic headache medication for > 3 months
If MOH is diagnosed, submit a plan to taper the offending medication

Prior Authorization

Concurrent CGRP agent use

Requests for concurrent use of CGRP inhibitors with Botox require additional documentation and a prior authorization. Provide chart notes and/or pharmacy paid claims demonstrating the member continues to experience ≥ 4 migraine headache days per month after therapy and/or documentation of incremental benefit.

Concurrent CGRP + Botox requires prior authorization
Document continued migraine days ≥ 4 per month after therapy or evidence of incremental benefit

Billing Rule

Dose and frequency limits

Adhere to dose and frequency limits: adults may receive up to 155 units once every 12 weeks; do not exceed 400 units in any 3-month interval. Pediatric total dose limits differ as specified.

Adult dosing: up to 155 units every 12 weeks
Do not exceed 400 units in any 3-month interval
Pediatric limit: total dose should not exceed the lower of 10 units/kg or 340 units in a 3-month interval

Denial Risk

Cosmetic indications excluded

Requests for Botox for cosmetic indications are excluded and will be denied.

Documentation Required

Response documentation for reauthorization

For reauthorization, submit documentation showing a positive response to therapy: reduction in headache frequency and decreased use of acute migraine medications since initiation of Botox. Continue monitoring for medication overuse headache.

Document reduction in headache frequency since Botox initiation
Document decreased use of acute migraine medications (e.g., NSAIDs, triptans)
Continue monitoring for MOH

Background

Background: Prior authorization governs use of Botox (onabotulinumtoxinA) for prevention of chronic migraine. The form outlines clinical entry criteria (adult age, ≥ 15 headache days per month, headaches lasting ≥ 4 hours per day), required documentation of failed trials of guideline-supported prophylactic medication classes, and procedures for reauthorization. It references prior therapy pathways including injectable and oral CGRP inhibitors (examples provided) and requires verification of prior therapies via chart notes or pharmacy paid claims. Cosmetic uses are explicitly excluded.

Medication Overuse Headache (MOH) — definitionHeadaches occurring >= 15 days per month that develop as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months.

Clinical Evidence

Evidence and guideline references: The policy references guideline-supported prophylactic medication classes and cites the American Headache Society/American Academy of Neurology treatment guidelines (2012/2015/2021/2024) and ICSI 2013 as the evidence basis for required prior trials, but no discrete trial metrics or external evidence tables are provided in the form. The policy also references CGRP inhibitor therapy pathways — listing injectable examples (Aimovig, Emgality, Ajovy) and oral examples (Nurtec ODT, Qulipta) — as acceptable prior or concurrent therapy pathways subject to prior authorization and specified criteria.

Policy Summary

PayerAvMed

PolicyBotox - Chronic Migraine (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Botox - Chronic Migraine (Pharmacy)

Coverage Summary

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Unproven Uses & Exclusions

Applicable Codes

Provider Actions

Background

Clinical Evidence

Revision History