Botox® (onabotulinumtoxinA)

Botox (onabotulinumtoxinA) is covered for multiple FDA‑approved and compendial off‑label indications (e.g., overactive bladder, detrusor overactivity, chronic migraine, pediatric and adult spasticity, cervical dystonia, hyperhidrosis, blepharospasm, etc.) with exclusions such as active urinary tract infection and urinary retention (except patients routinely performing clean intermittent self‑catheterization), and includes dosing/frequency limits and pediatric weight‑based caps. Coverage requires indication‑specific criteria—age thresholds, prior therapy trials (e.g., at least one pharmacologic trial for OAB, two for chronic low back pain), specialist consultation for certain indications (e.g., neurologist for migraine), documented baseline and response measures (e.g., ≥15 headache days/month for initial migraine authorization and 50% improvement for reauthorization), and documentation of prior Botox doses/treatment intervals.

"Overactive bladder"