OnabotulinumtoxinA (Botox) clinical coverage criteria
Defines medical necessity criteria, age/dose limits, prescriber requirements, step-therapy/therapeutic alternative expectations, prior authorization documentation, continuation criteria, excluded indications, and approval durations for Botox across multiple FDA-approved and selected off-label indications for Commercial, HIM/ICHRA, and Medicaid lines of business.
No material clinical or coverage changes — policy has no listed updates in this brief.
Coverage Summary
Policy CP.PHAR.232 (Effective 07.01.16; Last review 05.26.2026) provides medical necessity criteria for onabotulinumtoxinA (Botox). The policy stance is covered with criteria, defining authorized FDA-approved indications and selected off‑label uses when prescriber, age, step-therapy, dosing, and documentation requirements are met.
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