Limited coverage criteria – abobotulinumtoxinA (Dysport Therapeutic™)

Last updated on September 18, 2025

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Generic name	abobotulinumtoxinA
Brand name	Dysport Therapeutic™
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)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria – abobotulinumtoxinA (Dysport Therapeutic™)

Generic name

Brand name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)