Botulinum toxin prior authorization and coverage criteria
Customize your policy alerts
Sign up for all Hawaii Medical Service Association (HMSA) policy alerts
Know when Hawaii Medical Service Association (HMSA) releases new policies or updates existing guidance.
Monitor payer policy activity
Defines CVS Caremark/HMSA prior authorization questionnaire and medical necessity criteria for coverage of botulinum toxin products (Botox, Dysport, Xeomin, Myobloc, Daxxify) across neurologic and related indications for HMSA members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Chronic migraine (Botox)
Covered when ALL of the following are met
Attach documentation (e.g., chart notes) confirming prior trials of at least two oral preventive medications
Continuation criteria (general)
Covered for continuation when ALL of the following are met
Question #504 on the re-authorization form asks if the patient is benefiting; an affirmative response is required for continuation; documentation must be available on request
Indication-specific coverage
Covered when the specific diagnosis and age/previous therapy criteria (if listed) are met
See form question flow for product-specific indication checks (e.g., Botox #100–#110, Dysport #200–#211, Xeomin #300–#316, Myobloc #400–#406, Daxxify #425–#427)
This prior authorization form screens for cosmetic use up front. If the therapy is prescribed for cosmetic purposes (for example, treatment of wrinkles) the form instructs to mark Yes and stop: No Further Questions. Cosmetic requests are therefore not evaluated further on this prior authorization form and should be handled through the appropriate cosmetic benefit or separate process.
The Botox diagnosis menu contains several diagnoses that immediately terminate further criteria flow when selected. Examples listed on the form that require no further questions include chronic anal fissures, dysphagia due to cricopharyngeal dysfunction, essential tremor, excessive salivation secondary to Parkinson's disease, hemifacial spasm, oromandibular dystonia, and spasmodic dysphonia. When one of these diagnoses is chosen the form indicates No Further Questions, and the request is not processed through the standard botulinum toxin medical necessity pathway on this template.
Products and Diagnostic Thresholds
| Botox | OnabotulinumtoxinA (product name Botox) — listed product |
| Dysport | AbobotulinumtoxinA (product name Dysport) — listed product |
| Xeomin | IncobotulinumtoxinA (product name Xeomin) — listed product |
| Myobloc | RimabotulinumtoxinB (product name Myobloc) — listed product |
| Daxxify | DaxibotulinumtoxinA (product name Daxxify) — listed product |
Authorization, Documentation, and Submission Requirements
Prior Authorization Required
Prior authorization is required through CVS Caremark/HMSA before botulinum toxin products (e.g., Botox) will be considered for coverage. The prescriber must complete and submit the HMSA/CVS Caremark prior authorization form with the diagnosis and site of administration. To request authorization, contact CVS Caremark at 1-866-237-5512 (or local contact 1-808-254-4414) or follow payer instructions on the prior authorization form.
- Submit HMSA/CVS Caremark Prior Authorization Request form with diagnosis and administration site
- CVS Caremark prior authorization phone: 1-866-237-5512; local queries: 1-808-254-4414
- Specialty Customer Care / CaremarkConnect for eligibility/copay/delivery questions
Required Trials Prior to Botox for Chronic Migraine
For chronic migraine, members must have trialed and had inadequate response or intolerance to at least two different classes of oral preventive medications prior to initiating Botox. Acceptable classes include antiepileptic drugs, antidepressants, and beta-blockers (each trial ≥ 8 weeks unless intolerance/contraindication documented). Attach documentation of medication trials.
- Require documented trials of ≥2 different oral preventive medication classes (e.g., antiepileptics, antidepressants, beta-blockers)
- Each trial should be at least 8 weeks unless intolerance or contraindication is documented
- Attach chart notes or other documentation confirming prior medication trials
Documentation for Migraine Trials
Attach chart notes or other supporting documentation confirming diagnosis and prior medication trials (including dates, doses, and reasons for discontinuation if applicable). Documentation must demonstrate chronic migraine criteria (frequency/duration) and trials of oral preventives.
- Attach documentation confirming at least 15 headache days per month for >3 months and ≥8 migraine days/month when applicable
- Include notes showing trials of at least two oral preventive therapies with duration and reason for failure/intolerance
Prior Authorization Form Required
Prescriber must complete the HMSA/CVS Caremark prior authorization form and include the diagnosis and site of administration. Ensure the form is fully completed to avoid processing delays.
- Complete HMSA/CVS Caremark Prior Authorization Request form
- Include diagnosis, administration site, member identifiers, and prescriber NPI/contact
Failure to Obtain Required Prior Authorization May Result in Non-Coverage
Failure to obtain the required prior authorization may result in denial of coverage and member liability for the medication and administration costs.
- Claims submitted without required prior authorization are at risk for denial
- Confirm approval prior to administration to avoid non-coverage
Context and Policy Use
This prior authorization template is used to determine medical necessity for multiple clinical indications in which botulinum toxin injections may be considered (for example, chronic migraine prophylaxis, spasticity, cervical dystonia, blepharospasm, hyperhidrosis, overactive bladder). The form standardizes intake across those indications by collecting diagnosis, prior authorization history, age/diagnosis‑specific eligibility, and documentation of prior therapeutic trials or benefit from therapy to support both initiation and continuation decisions.
Diagnostic and Therapy Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.