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: 3 years

For the treatment of focal spasticity.

Initial: 1 year
Renewali: 3 years

Practitioner exemptions

  • Physical medicine and rehabilitation specialists may be eligible to enter into a Collaborative Prescribing Agreement (CPA). CPAs are provided by invitation only. Special Authority will identify eligible practitioners who treat a high volume of patients that meet PharmaCare criteria for coverage

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

Special Authority request form(s)