Payer PolicyActive
Myobloc® (rimabotulinumtoxinB)
EVICORE-MEDICAL_DRUG-BC86A25C
EviCore by Evernorth
Effective: August 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Myobloc (rimabotulinumtoxinB) is covered for adults (≥18 years) only for FDA‑approved indications—cervical dystonia and chronic sialorrhea—and for the compendial off‑label use of upper‑limb spasticity; other uses are excluded. Approvals are valid 12 months and require dosing within specified ranges (cervical dystonia 2,500–5,000 U; chronic sialorrhea 1,500–3,500 U; upper‑limb spasticity up to 20,000 U) with administration no more often than every 12 weeks.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of cervical dystonia in adults."
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