Pharmacy Prior Authorization Criteria

Daxxify (botulinum toxin type a injection)

Indications for Prior Authorization

Daxxify (botulinum toxin type a injection)

• For diagnosis of Cervical Dystonia
  indicated for the treatment of cervical dystonia in adult patients.

• For diagnosis of Cosmetic Uses [Non-approvable Use]
  Indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients. **Please Note: The request for Daxxify (botulinum toxin type a injection) injections to treat the appearance of glabellar lines is not authorized given that this use is for cosmetic purposes only.

Criteria

Daxxify

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Cervical Dystonia

• Diagnosis of cervical dystonia
AND
• Trial and failure, contraindication, or intolerance to one of the following:
• Xeomin
• Dysport
• Myobloc

Daxxify

Prior Authorization (Reauthorization)

Length of Approval: 3 Month(s)
For diagnosis of Cervical Dystonia

• Documentation of positive clinical response to therapy
AND
• At least 3 months have or will have elapsed since the last treatment

Daxxify

Prior Authorization

For diagnosis of Cosmetic Use

• Requests for coverage of any Daxxify product for treating the appearance of facial lines are not authorized and will not be approved. These uses are considered cosmetic only.

P & T Revisions

2024-08-20, 2023-10-11

References

1. Daxxify Prescribing Information. Revance Therapeutics, Inc. Newark, CA. August 2023.

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Revision History

• 2024-08-20: 2024 annual review. No changes.
• 2023-10-11: New Program for Daxxify

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