CurrentCommunity-CarePolicy N/A

Botulinum toxin products — medical coverage criteria

Defines coverage, prior authorization, quantity limits, and continuation criteria for botulinum toxin products (preferred: Botox, Dysport, Xeomin) across neurologic and related indications for Community-Care members in North Carolina.

Policy Summary

PayerCommunity-Care

PolicyBotulinum toxin products — medical coverage criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateAug 1, 2025

Key ActionObtain prior authorization and document indication-specific diagnostic and trial criteria (including pediatric weight when applicable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9+indications

12 weeksmin dosing interval

Appendix 1quantity limits

J0585–J0589HCPCS codes

Coverage and Medical Necessity Criteria

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Chronic sialorrhea - Initial: Member has a diagnosis of chronic sialorrhea AND if requested drug is onabotulinumtoxinA (Botox) then trial of incobotulinumtoxinA (Xeomin) was ineffective, contraindicated, or not tolerated AND dosing limited to every 16 weeks.

Cervical dystonia - Initial: Diagnosis of cervical dystonia AND if the requested drug is onabotulinumtoxinA (Botox), ONE of the following applies: (a) trials of incobotulinumtoxinA (Xeomin) and abobotulinumtoxinA (Dysport) were ineffective, contraindicated, or not tolerated OR (b) member is aged 16 to <18 years AND dosing limited to every 12 weeks.

Blepharospasm - Initial: Diagnosis of blepharospasm AND if the requested drug is onabotulinumtoxinA (Botox), ONE of the following applies: (a) trial of incobotulinumtoxinA (Xeomin) was ineffective, contraindicated, or not tolerated OR (b) member is aged 12 to <18 years AND dosing limited to every 12 weeks.

Upper limb spasticity - Initial: Diagnosis of upper limb spasticity AND if the requested drug is onabotulinumtoxinA (Botox), BOTH incobotulinumtoxinA (Xeomin) and abobotulinumtoxinA (Dysport) trials were ineffective, contraindicated, or not tolerated AND dosing limited to every 12 weeks.

Lower limb spasticity - Initial: Diagnosis of lower limb spasticity AND if the requested drug is onabotulinumtoxinA (Botox), trial of abobotulinumtoxinA (Dysport) was ineffective, contraindicated, or not tolerated AND dosing limited to every 12 weeks.

Strabismus - Initial: Diagnosis of strabismus AND disease interferes with normal visual development AND aged ≥ 12 years AND dosing limited to every 12 weeks.

Overactive bladder/Urinary incontinence - Initial: Diagnosis of overactive bladder OR urinary incontinence AND aged ≥ 18 years AND trial of two medications from anticholinergic or beta-3 adrenergic agonist classes were ineffective, contraindicated, or not tolerated AND dosing limited to every 12 weeks.

Axillary hyperhidrosis - Initial: Diagnosis of axillary hyperhidrosis AND aged ≥ 18 years AND dosing limited to every 12 weeks.

Neurogenic detrusor overactivity - Initial: Diagnosis of neurogenic detrusor overactivity AND aged ≥ 5 years AND trial of two anticholinergic medications was ineffective, contraindicated, or not tolerated AND dosing limited to every 12 weeks.

Chronic migraine prophylaxis - Initial: Diagnosis of chronic migraine AND aged ≥ 18 years AND prescriber meets one of the listed specialist/credential criteria AND fifteen or more headache days per month for at least the previous 3 months AND trial of topiramate was ineffective, contraindicated, or not tolerated AND one of: (a) botulinum toxin will not be used concomitantly with a CGRP inhibitor OR (b) botulinum toxin will be used concomitantly with a CGRP inhibitor and the member has failed at least three months of individual therapy with either a botulinum toxin for migraine prevention or the CGRP inhibitor requested for concomitant use AND dosing limited to every 12 weeks.

Continuation Therapy

Covered when ALL of the following are met for continuation of chronic migraine therapy

Chronic migraine - Continuation: Member has a diagnosis of chronic migraine AND experienced a meaningful improvement in frequency and/or severity of migraine AND one of the following: (a) botulinum toxin will not be used concomitantly with a CGRP inhibitor for migraine prevention OR (b) botulinum toxin will be used concomitantly with a CGRP inhibitor and the member has failed at least 3 months of individual therapy with either a botulinum toxin for migraine prevention or the CGRP inhibitor requested for concomitant use.

Products used for cosmetic purposes are excluded from plan benefits. Examples of excluded cosmetic indications include onabotulinumtoxinA (Botox Cosmetic) when used for aesthetic facial lines such as moderate to severe glabellar lines, lateral canthal lines, platysma bands, and forehead lines. PrabotulinumtoxinA (Jeuveau) for temporary improvement of moderate to severe glabellar lines is also excluded. IncobotulinumtoxinA (Xeomin) used for the appearance of upper facial lines (glabellar, horizontal forehead, or lateral canthal lines) and daxibotulinumtoxinA-lanm (Daxxify) for temporary improvement of moderate to severe glabellar lines are likewise not covered under the cosmetic use exclusion.

Billing Codes and Quantity Limits

Applicable HCPCS CodesHCPCS

J0585	Injection, onabotulinumtoxina, 1 unit
J0586	Injection, abobotulinumtoxina, 5 units
J0587	Injection, rimabotulinumtoxinb, 100 units
J0588	Injection, incobotulinumtoxin a, 1 unit
J0589	Injection, daxibotulinumtoxinA-lanm, 1 unit

Cervical dystonia (Botox) — dosing/interval

Maximum unitsUp to 300 units

Dosing intervalEvery 12 weeks