Myobloc (rimabotulinumtoxin B)
Indications for Prior Authorization
Myobloc (rimabotulinumtoxin B)
-
For diagnosis of Cervical Dystonia (CD)
Indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain associated with cervical dystonia. -
For diagnosis of Chronic Sialorrhea
Indicated for the treatment of chronic sialorrhea in adults.
Criteria
Myobloc
Prior Authorization (Initial Authorization)
Length of Approval: 3 Month(s)
For diagnosis of Cervical Dystonia (also known as spasmodic torticollis)
- Diagnosis of cervical dystonia (also known as spasmodic torticollis) [2]
Myobloc
Prior Authorization (Initial Authorization)
Length of Approval: 3 Month(s)
For diagnosis of Chronic Sialorrhea
- Diagnosis of chronic sialorrhea
Myobloc
Prior Authorization (Reauthorization)
Length of Approval: 3 Month(s)
For diagnosis of All indications listed above
- Patient demonstrates positive clinical response to therapy. AND
- At least 3 months have elapsed since the last treatment [B]
P & T Revisions
2024-08-20, 2023-10-26, 2023-06-15, 2022-07-21, 2021-06-15, 2021-04-07, 2020-06-30, 2019-10-02
References
- Myobloc Prescribing Information. Solstice Neurosciences, LLC. Louisville, KY. March 2021.
- Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May;86(19):1818-26.
End Notes
- The duration of effect in patients responding to Myobloc treatment has been observed in studies to be between 12 and 16 weeks at doses of 5,000 Units or 10,000 Units. [1]
- The typical duration of effect of each treatment is up to 3 months with the repeat of treatments should be determined by clinical response but should generally be no frequent than every 12 weeks.
Revision History
- 2024-08-20: 2024 annual review. Background updates, consolidated reauth criteria. No change to approval length at this time.
- 2023-10-26: Program update to standard reauthorization language. No changes to clinical intent.
- 2023-06-15: Annual review - no changes.
- 2022-07-21: Annual review - no changes.
- 2021-06-15: Annual review - updated references.
- 2021-04-07: Removed "single dose" language in approval duration due to feedback from PA team.
- 2020-06-30: Remove unit amounts from approval duration due to feedback from PA team. Removed drug name from reauth criteria for consistency.
- 2019-10-02: New indication
HEALTHY LIVING