WHA

Daxxify (botulinum toxin type a injection)

Indications for Prior Authorization

Daxxify (botulinum toxin type a injection)
  • For diagnosis of Cervical Dystonia
    indicated for the treatment of cervical dystonia in adult patients.

  • For diagnosis of Cosmetic Uses [Non-approvable Use]
    Indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients. **Please Note: The request for Daxxify (botulinum toxin type a injection) injections to treat the appearance of glabellar lines is not authorized given that this use is for cosmetic purposes only.

Criteria

Daxxify

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Cervical Dystonia (Spasmodic Torticollis)

  • Diagnosis of cervical dystonia
    • AND
  • Trial and failure, contraindication, or intolerance to one of the following:
    • Xeomin
    • Dysport
    • Myobloc
Daxxify

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Cervical Dystonia (Spasmodic Torticollis)

  • Documentation of positive clinical response to therapy
    • AND
  • At least 3 months have or will have elapsed since the last treatment
Daxxify

Prior Authorization


For diagnosis of Cosmetic Use

  • Requests for coverage of any Daxxify product for treating the appearance of facial lines are not authorized and will not be approved. These uses are considered cosmetic only.

  • Guideline ID
    GL-486396

  • Formulary
    Premium

  • Effective date
    Jan 1, 2026

  • P&T approval date
    Oct 18, 2023

P & T Revisions

1970-01-01, 2025-12-18, 2025-09-24, 2024-08-20, 2023-10-11

  1. Daxxify Prescribing Information. Revance Therapeutics, Inc. Newark, CA. November 2023.
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-09-24: 2025 Annual Review. Updated verbiage of Cervical Dystonia to include “Spasmodic Torticollis” to align with Medical Policy. Extended reauthorization duration from 3 months to 12 months. Updated background.
  • 2024-08-20: 2024 annual review. No changes.
  • 2023-10-11: New Program for Daxxify