Limited coverage drugs – abobotulinumtoxinA

Last updated on August 7, 2024

 

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Generic name

abobotulinumtoxinA

Strength & form

300 units/vial, 500 units/vial lyophilized powder for solution for injection

Special Authority criteria

Approval period

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

Initial: 1 year
Renewal1: 3 years

For the treatment of focal spasticity

Initial: 1 year
Renewal1: 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

  • 1For 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)