Limited Coverage Drugs – Botulinum Neurotoxin Type A, with complexing proteins, also known as OnabotulinumtoxinA (Botox®)

Generic Name

 botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA
Strength 100 units

Form

 vial

Special Authority Criteria

Approval Period
For the treatment of:
  1. Spasmodic Torticollis

    OR
     
  2. Blepharospasm

    OR
     
  3. Strabismus

    OR
     
  4. Equinus foot deformity due to spasticity in pediatric Cerebral Palsy patients two years of age or older

    OR
     
  5. Focal spasticity, including the treatment of upper limb spasticity associated with stroke in adults.

1 year

 
         OR

For the treatment of:

     6.   Urinary incontinence due to neurogenic detrusor overactivity associated
           with multiple sclerosis (MS) or subcervical spinal cord injury (SCI) and
           in patients who have experienced treatment failure and/or intolerable side
           effects to a specified anticholinergic.

Notes:

  • Treatment failure is defined as using optimal doses of at least one anticholinergic for a minimum of 3 months without a reduction of symptoms.
  • One course: 200 U administered into the detrusor muscle of the bladder.
  • PharmaCare coverage is only provided for treatment at intervals of 36 weeks or greater.
  • For renewal requests physicians must provide documentation indicating > 50% reduction in the frequency of urinary incontinence episodes from the baseline.
 Initial: 1 course
Renewal: 1 year

Practitioner Exemptions

  • A Collaborative Prescribing Agreement is available to a limited number of practitioners in the following specialties: neurology, ophthalmology, and physical medicine & rehabilitation. These practitioners are not required to submit a Special Authority request form for coverage.

Special Notes

  • Botulinum neurotoxin type A, with complexing proteins, is also known under the generic name onabotulinumtoxinA. The brand name for this drug is Botox®.
  • PharmaCare covers this medication only for the indications stated above. Coverage cannot be provided for other indications such as migraines or hyperhidrosis. 
  • For coverage renewal of this drug, practitioners must submit:
    • documentation of a patient’s functional and/or symptomatic improvement, AND
    • the dosage and injection schedule.

Special Authority Request Form(s)