Botulinum Toxins (Botox, Dysport, Xeomin, Myobloc, Daxxify) — Prior Authorization
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Prior authorization form and clinical criteria for coverage of botulinum toxin products under HMSA/CVS Caremark prescription benefits; applies to prescribers requesting drug coverage for HMSA members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Botulinum Toxin Products
Botox — Chronic Migraine (Initial)
Covered when ALL of the following are met
IHS criteria referenced
chunk 4
chunk 4
chunk 4
classes include antiepileptics, antidepressants, beta-blockers per chunks 5-7
Continuation / Re-authorization (general)
Covered for continuation when ALL of the following are met
chunk 4 and chunk 8 (re-authorization form flow)
re-authorization question and continuation criteria in chunks 8-9 and 15
attestation statement in chunk 15 and documentation guidance in chunk 8-9
Botox — Urinary indications
Covered when ALL of the following are met
chunk 10
chunk 10
chunk 10
Other neurological and related indications
Covered when ALL of the following are met
chunks 9,11,12,13
chunks 3,11,12,13
chunks 3,11,12,13,14
chunk 15
The prior authorization form includes an explicit screening question for cosmetic use: “Is therapy prescribed for cosmetic purposes (e.g., treatment of wrinkles)?” If the provider indicates Yes, the form directs No Further Questions and the request is not routed into the clinical criteria workflow. This behavior treats cosmetic indications as a separate pathway and prevents further clinical review on the same authorization request.
Providers submitting requests should therefore answer the cosmetic-use question up front; marking the request as cosmetic will effectively terminate the clinical criteria pathway for that submission and avoid unnecessary follow-up questions tied to medical indications.
Requests that are solely for cosmetic indications do not proceed through the clinical criteria. The form’s logic requires the provider to indicate whether therapy is for cosmetic purposes; selecting Yes results in No Further Questions, and the request is not evaluated against medical coverage criteria for botulinum toxin products.
Clinicians requesting coverage for non-cosmetic, medical indications must therefore answer No to the cosmetic-use question to continue through the condition-specific authorization items on the form.
Coding and Diagnostic Details
| ICD-10 | Form requests the ICD-10 code for the diagnosis (blank to be filled by provider). |
| Botox | OnabotulinumtoxinA (product selection on form) |
| Dysport | AbobotulinumtoxinA (product selection on form) |
| Xeomin | IncobotulinumtoxinA (product selection on form) |
| Myobloc | RimabotulinumtoxinB (product selection on form) |
| Daxxify | DaxibotulinumtoxinA (product selection on form) |
Provider Submission and Documentation Requirements
Submission and contact
Prior authorization requests must be submitted to CVS Caremark. Fax the completed Botulinum Toxins prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512. For prior authorization questions contact CVS Caremark at 1-808-254-4414. For enrollment/benefit, copay, or delivery questions contact CaremarkConnect at 1-800-237-2767.
- Send fax to: CVS Caremark Specialty Programs — 1-866-237-5512
- Clinical questions: 1-808-254-4414
- CaremarkConnect (eligibility/copay/delivery): 1-800-237-2767
Product-specific prior authorization
Prior authorization is required for specific botulinum toxin products and the form screens for the intended clinical indication. Indicate the product being requested (Botox, Dysport, Xeomin, Myobloc, Daxxify) and answer the condition-specific diagnostic questions on the form to support medical necessity.
- Products listed on the form: Botox, Dysport, Xeomin, Myobloc, Daxxify
- Form routes: product-specific sections with diagnosis checklists and follow-up questions
- Provide the most accurate diagnosis for the prescribed medication
Cosmetic use triggers non-coverage screening
Requests for cosmetic indications (for example, treatment of wrinkles) are screened out on the form. If therapy is prescribed for cosmetic purposes the form directs "Yes, No Further Questions" and the request will not proceed through clinical prior authorization.
- Question 1 on the form: "Is therapy prescribed for cosmetic purposes (e.g., treatment of wrinkles)?"
- If Yes → No further questions (cosmetic indications are not covered)
Required documentation and attestation
Attach supporting documentation (e.g., chart notes) confirming prior medication trials, dates, responses, and that the member is benefiting from therapy for continuation requests. The prescriber must attest that the information is accurate and that documentation is available for review.
- For migraine and other indications, include chart notes confirming prior trials and outcomes
- Continuation requests require documentation of benefit (form question #504)
- Prescriber attestation and signature are required on the form
Urinary/overactive bladder step therapy
For urinary incontinence or overactive bladder indications, behavioral therapy and trials of appropriate oral agents are required prior to approval. The form documents both initial and continuation criteria for bladder-related indications.
- Behavioral therapy must be tried prior to botulinum toxin for neurogenic urinary incontinence and overactive bladder (form questions #151 and #157)
- For neurogenic urinary incontinence: inadequate response or intolerance to an anticholinergic or beta-3 agonist is required (form question #152)
- For overactive bladder with urinary incontinence: inadequate response or intolerance to two agents from either anticholinergic class or beta-3 agonist is required (form question #158)
Background
Botulinum toxin products (the form lists Botox among other agents) are used across a range of neurologic and related indications including chronic migraine prophylaxis, spasticity, cervical dystonia, blepharospasm, sialorrhea, hyperhidrosis, and urinary indications such as overactive bladder or urinary incontinence. The authorization form separates initial and continuation pathways and routes questions by product and diagnosis to capture indication-specific requirements.
Because the form distinguishes multiple diagnoses and routes providers to indication-specific question sets, authorization for botulinum toxin must follow the product-specific flow on the fax form (for example, selecting Botox routes to the Botox question set) so that age thresholds, prior-therapy requirements, and re-authorization criteria for each indication can be assessed.
Definitions and Diagnostic Criteria
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