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

Generic Name

Form

Special Authority Criteria

Approval Period

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.

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.