Payer PolicyActive
Myobloc (rimabotulinumtoxinB)
EVICORE-MEDICAL_DRUG-71DC51BF
EviCore by Evernorth
Effective: August 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Myobloc (rimabotulinumtoxinB) is covered only for FDA‑approved adult indications—cervical dystonia (2,500–5,000 units total divided among affected muscles) and chronic sialorrhea (1,500–3,500 units divided among parotid and submandibular glands); non‑FDA uses are excluded. Key requirements: patient must be ≥18 years, approval is for 12 months, dosing must follow the specified ranges, injections no more frequently than every 12 weeks, and documentation of diagnosis and age is required.
Coverage Criteria Preview
Key requirements from the full policy
"Approval duration: 12 months."
Sign up to see full coverage criteria, indications, and limitations.