Payer PolicyActive
Daxxify® (daxibotulinumtoxinA-lanm)
EVICORE-MEDICAL_DRUG-E9C57DEC
EviCore by Evernorth
Effective: August 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Daxxify is covered only for the FDA-approved indication of cervical dystonia (spasmodic torticollis) in adults and is not covered for patients under 18 or for other indications. Coverage requires documentation of age ≥18 and medical necessity, dosing of 125–250 units intramuscularly divided among affected muscles given no more frequently than every 3 months, and approvals are valid for 12 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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