Payer PolicyActive
RimabotulinumtoxinB (Myobloc)
EVICORE-MEDICAL_DRUG-FEE37E8B
EviCore by Evernorth
Effective: October 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Myobloc (rimabotulinumtoxinB) is covered only for FDA‑approved uses — adults (≥18) with cervical dystonia or chronic sialorrhea — and is not covered for other indications. Coverage requires age ≥18, for cervical dystonia documented failure or tolerance to onabotulinumtoxinA (Botox), approval up to 12 months with dosing limits (max 5,000 units for cervical dystonia; 3,500 units for sialorrhea), dosing no more frequently than every 12 weeks, and documentation of diagnosis, prior Botox failure (if applicable), dose, and administration timing.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of adults with cervical dystonia."
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