Payer PolicyActive
RimabotulinumtoxinB (Myobloc®)
EVICORE-MEDICAL_DRUG-C752B241
EviCore by Evernorth
Effective: August 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Myobloc (rimabotulinumtoxinB) is covered only for FDA‑approved indications—adult (≥18) cervical dystonia and chronic sialorrhea—with off‑label use excluded. Approvals are for 12 months with dosing limits (cervical dystonia ≤5,000 units divided among affected muscles; sialorrhea ≤3,500 units divided among parotid/submandibular glands) given no more frequently than every 12 weeks, with implied documentation of diagnosis, age, doses/injection sites, and prior dosing intervals to support medical necessity.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of adults with cervical dystonia."
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