Limited Coverage Drugs – Botulinum Neurotoxin Type A, with complexing proteins, also known as OnabotulinumtoxinA (Botox®)
|botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA|
Special Authority Criteria
|For the treatment of:
For the treatment of:
6. Urinary incontinence due to neurogenic detrusor overactivity associated
|Initial: 1 course
Renewal: 1 year
- 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.
- 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.