Payer PolicyActive
RimabotulinumtoxinB (Myobloc)
EVICORE-MEDICAL_DRUG-190C3006
EviCore by Evernorth
Effective: March 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for the FDA‑approved indication: treatment of adults (≥18) with cervical dystonia to reduce abnormal head position and neck pain; off‑label uses are excluded. Approval (up to 12 months) requires documented prior failure or intolerance to onabotulinumtoxinA (Botox), no hypersensitivity to botulinum toxin or excipients, no infection at the injection site, documentation of diagnosis and medical necessity, and planned dosing of 2500–5000 units divided among affected muscles every 12–16 weeks or longer.
Coverage Criteria Preview
Key requirements from the full policy
"Approval duration: 12 months."
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