Botulinum Toxins (Botox, Dysport, Xeomin, Myobloc, Daxxify) — Prior Authorization Criteria
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Prior authorization form and criteria for coverage of botulinum toxin products administered through CVS Caremark for HMSA members; applies to providers requesting coverage for these medications.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial Botox for chronic migraine
Covered when ALL of the following are met:
Chunk 4
Chunk 4
Chunk 4
Chunk 4
Chunks 4,5,6,7,8
Continuation (general except migraine)
Covered for continuation when the following criterion is met:
Chunk 15
Indication-specific criteria
Conditional coverage for various indications by age and prior therapy where specified:
Chunks 3,10,12,13
Chunks 10,12,13,14
Chunks 10,12,13
Chunk 3
Chunk 10
Requests for botulinum toxin prescribed solely for cosmetic purposes (for example, treatment of wrinkles) are identified separately on the prior authorization form and must be indicated on question #1. Cosmetic-use requests are not processed through the therapeutic coverage pathways and should be documented as such on the form.
On the form the prescriber must also identify the specific botulinum product requested (question #4 for continuation requests or question #5 for new starts) by checking the appropriate product box (Botox, Dysport, Xeomin, Myobloc, or Daxxify).
For continuation (re-authorization) requests, the form requires documentation that the patient is benefiting from ongoing botulinum toxin therapy (question #504). Continuation requests may be questioned or denied if the submitted information does not demonstrate clinical benefit.
For indications with specific initial coverage criteria (for example, chronic migraine), continuation requests will also be evaluated against those original indication criteria (e.g., headache frequency/duration and prior preventive therapy trials). Providers should attach chart documentation supporting symptomatic benefit and continued need when submitting the faxed form.
Diagnosis and Criteria Definitions
| ICD-10 | ICD-10 code to be provided on form (blank on document) |
Prior Authorization, Documentation, and Denial Triggers
Prior authorization required via CVS Caremark
Prior authorization is required for botulinum toxin products listed (Botox, Dysport, Xeomin, Myobloc, Daxxify) through CVS Caremark per the HMSA benefit plan; providers must complete and fax the HMSA/CVS Caremark prior authorization form to CVS Caremark at 1-866-237-5512 (or contact CVS Caremark with questions).
- Fax completed form to CVS Caremark toll-free at 1-866-237-5512.
- Contact CVS Caremark for prior authorization questions at 1-808-254-4414.
Step therapy: two preventive therapy trials (≥60 days each)
For chronic migraine, the member must have completed an adequate trial (or have a contraindication) of two migraine preventive therapies from at least two of the specified drug classes, with each trial lasting at least 60 days; document which two therapies were tried.
- Required classes include antiepileptic drugs, antidepressants, beta-adrenergic blockers, and CGRP-targeting therapies.
- Each preventive medication trial must be at least 60 days in duration.
Attach documentation of prior preventive therapy trials
Attach supporting clinical documentation (for example, chart notes) confirming trials of at least two oral preventive medications for chronic migraine or documentation of contraindications, and ensure the form includes accurate diagnosis and patient demographics.
- Include documentation that confirms at least two prior preventive therapies were tried.
- Ensure diagnosis and patient identifiers are accurately entered on the prior authorization form.
Denial risk when clinical criteria or prior-therapy requirements are not met
Requests may be denied if required clinical criteria are not met — for chronic migraine this includes insufficient headache frequency/duration per IHS criteria or lack of documented trials of two preventive therapies from two classes.
- Denial risk if headaches are fewer than 15 days per month or do not meet the duration criterion (4 hours on ≥8 days/month).
- Denial risk if two required preventive therapy trials (from ≥2 classes, ≥60 days each) are not documented.
Background and Clinical Context
Botulinum toxin products (including Botox, Dysport, Xeomin, Myobloc, and Daxxify) are used across a range of neurologic and non-neurologic conditions. The form specifically captures common therapeutic indications such as chronic migraine prophylaxis, spasticity, cervical dystonia, blepharospasm, sialorrhea/chronic sialorrhea, and primary axillary hyperhidrosis, among others.
For chronic migraine the form applies International Headache Society diagnostic elements and documents required prior therapies; other sections of the form collect indication-specific details (for example, assessment of abnormal head placement for cervical dystonia or age thresholds for spasticity) to ensure the request aligns with the covered clinical pathways.
The re-authorization portion of the form likewise asks whether the patient is benefiting from therapy (question #504) to support continuation decisions across these indications.
Key Definitions
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