Centene Botox Coverage Update Prior Auth

Coverage Criteria and Clinical Requirements

Overactive Bladder and Urinary Incontinence — Initial

Initial Approval Criteria — Overactive Bladder and Urinary Incontinence (must meet ALL):

OAB Initial Criteria: Member has a diagnosis of overactive bladder (OAB) with urinary urgency, frequency, and nocturia with or without incontinence, OR urinary incontinence associated with a neurologic condition (e.g., cord injury, dysraphism, multiple sclerosis). Therapy is prescribed by or in consultation with a neurologist or urologist. Age ≥ 5 years. For adults: failure of at least one anticholinergic agent OR an oral beta-3 agonist, each used for ≥30 days, unless contraindicated. For pediatrics: failure of at least two anticholinergic agents, each used for ≥30 days, unless contraindicated. No botulinum toxin therapy for cosmetic or medical conditions within the last 12 weeks, and Botox is not prescribed concurrently with other botulinum toxin products. Treatment plan must detail number of Units per indication and per treatment session. Dose limits: adults — ≤100 Units per treatment session; urinary incontinence with neurologic condition: if weight <34 kg, ≤6 U/kg per session; if weight ≥34 kg, ≤200 Units per session.see text

Illinois HIM step therapy exception noted

Chronic Migraine — Initial

Initial Approval Criteria — Chronic Migraine (must meet ALL):

Chronic Migraine Initial Criteria: Diagnosis of chronic migraine (≥15 headache days per month for ≥3 months with headache lasting ≥4 hours). Prescribed by or in consultation with a neurologist or specialist. Age ≥18 years. Failure of at least two oral migraine preventive therapies from different therapeutic classes, each for 8 weeks, unless contraindicated. If request is for concurrent use with CGRP therapy, prescriber must provide supportive high-quality evidence per policy (or document continued significant migraine burden despite CGRP monotherapy). No botulinum toxin therapy within the last 12 weeks and Botox is not prescribed concurrently with other botulinum toxin products. Treatment plan must detail number of Units per indication and per treatment session. Dose limit for initial therapy: ≤155 Units per treatment session.

Upper/Lower Limb Spasticity — Initial

Initial Approval Criteria — Upper and Lower Limb Spasticity (must meet ALL):

Spasticity Initial Criteria: Diagnosis of upper or lower limb spasticity (e.g., due to paralysis, multiple sclerosis, cerebral palsy, stroke). Prescribed by or in consultation with a neurologist, orthopedist, or physiatrist. Age ≥2 years. No botulinum toxin therapy within the last 12 weeks and Botox is not prescribed concurrently with other botulinum toxin products. Treatment plan must detail number of Units per indication and per treatment session. Dose limits: adults (≥18 years) — ≤400 Units per treatment session. Pediatrics (2–17 years): upper limb — lower of 6 U/kg or 200 U per session; lower limb — lower of 8 U/kg or 300 U per session; if both upper and lower limbs treated same session — lower of 10 U/kg or 340 U per session.

Cervical Dystonia — Initial

Initial Approval Criteria — Cervical Dystonia (must meet ALL):

Cervical Dystonia Initial Criteria: Diagnosis of cervical dystonia. Prescribed by or in consultation with a neurologist, orthopedist, or physiatrist. Age ≥16 years. Member is experiencing involuntary contractions of neck and shoulder muscles resulting in abnormal postures or movements causing functional impairment or pain. No botulinum toxin therapy within the last 12 weeks and Botox is not prescribed concurrently with other botulinum toxin products. Treatment plan must detail number of Units per indication and per treatment session. Dose limits: age ≥18 years — ≤100 Units total in the sternocleidomastoid (SCM) muscle and ≤300 Units per treatment session; ages 16–17 years — ≤100 Units total in SCM and the lower of 10 U/kg or 300 U per session.

Cervical Dystonia (focal dystonia) - Initial/renewal