Dysport® (abobotulinumtoxinA)

Covered for cervical dystonia and upper/lower limb spasticity (≥2 years) and compendial off‑label uses blepharospasm, hemifacial spasm, anal fissure, and chronic sialorrhea; other indications are excluded. Coverage requires meeting age limits, indication‑specific dosing/unit and session maximums (including weight‑based pediatric caps), minimum retreatment intervals (generally 12–16 weeks by indication), 12‑month approvals, and the policy lists no explicit documentation requirements.

"Cervical dystonia (FDA-approved)"

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