Limited Coverage Drugs – abobotulinumtoxinA

Generic Name             

abobotulinumtoxinA
Strength 300 units/vial, 500 units/vial

Form

lyophilized powder for solution for injection

Special Authority Criteria

Approval Period

For the treatment of cervical dystonia (spasmodic torticollis) in adults.

Initial: 1 year
Renewali: 1 year 

For the treatment of focal spasticity.

Initial: 1 year
Renewali: 1 year

Special Notes

  1. For renewal requests, physicians must provide documentation of the patient’s functional and/or symptomatic improvement, as well as the dosage and injection schedule.

Practitioner Exemptions

Specialist practitioners (neurology, ophthalmology, physical medicine and rehabilitation) may be eligible to enter into a Collaborative Prescribing Agreement. CPAs are provided by invitation only: Special Authority will identify those practitioners who treat a high volume of patients that meet PharmaCare criteria for coverage. 

Special Authority Request Form