Payer PolicyActive
Daxxify (daxibotulinumtoxinA-lanm)
EVICORE-MEDICAL_DRUG-851EF4D0
EviCore by Evernorth
Effective: January 1, 2024
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Daxxify (daxibotulinumtoxinA-lanm) is covered only for the FDA-approved indication of cervical dystonia in adults (≥18 years); other indications are not covered. Approval (12 months) requires documentation of age and diagnosis, dosing of 125–250 units intramuscularly divided among affected muscles, and administration no more frequently than every 3 months.
Coverage Criteria Preview
Key requirements from the full policy
"Daxxify is indicated for the treatment of cervical dystonia in adult patients."
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