Pharmacy Prior Authorization Criteria

Myobloc (rimabotulinumtoxin B)

For diagnosis of Cervical Dystonia (CD)
Indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia.
For diagnosis of Chronic Sialorrhea
Indicated for the treatment of chronic sialorrhea in adults.

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Cervical Dystonia (also known as spasmodic torticollis)

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Chronic Sialorrhea

Prior Authorization (Reauthorization)

Length of Approval: 3 Month(s)
For diagnosis of All indications listed above

AND

2024-08-20, 2023-10-26, 2023-06-15, 2022-07-21, 2021-06-15, 2021-04-07, 2020-06-30, 2019-10-02

Myobloc Prescribing Information. Solstice Neurosciences, LLC. Louisville, KY. March 2021.
Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May;86(19):1818-26.

2024-08-20: 2024 annual review. Background updates, consolidated reauth criteria. No change to approval length at this time.
2023-10-26: Program update to standard reauthorization language. No changes to clinical intent.
2023-06-15: Annual review - no changes.
2022-07-21: Annual review - no changes.
2021-06-15: Annual review - updated references.
2021-04-07: Removed "single dose" language in approval duration due to feedback from PA team.
2020-06-30: Remove unit amounts from approval duration due to feedback from PA team. Removed drug name from reauth criteria for consistency.
2019-10-02: New indication