AbobotulinumtoxinA (Dysport)

This policy covers Dysport for cervical dystonia, adult upper and lower limb spasticity, pediatric lower limb spasticity, and compendial blepharospasm and hemifacial spasm, and excludes uses not listed. Approvals are for 12 months with indication‑specific route, dose and frequency limits (cervical and adult upper limb ≤1,000 units IM not more often than every 12 weeks; adult lower limb ≤1,500 units IM q≥12 weeks; pediatric lower limb 15 U/kg unilateral or 30 U/kg bilateral up to 1,000 U IM q≥12 weeks with weight documentation; blepharospasm ≤120 U/eye SC q≥12 weeks; hemifacial spasm ≤220 U SC q≥3 months).

"Cervical dystonia (FDA-approved)"

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