Botulinum Toxins

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00299596230 DYSPORT abobotulinumtoxinA VIAL 300 unit Y N Pharmacy PA
15054053006 DYSPORT abobotulinumtoxinA VIAL 300 unit Y N Pharmacy PA
15054050001 DYSPORT abobotulinumtoxinA VIAL 500 unit Y N Pharmacy PA
72960011201 DAXXIFY daxibotulinumtoxinA-lanm VIAL 100 unit Y N Pharmacy PA
00259161001 XEOMIN incobotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
00259411001 XEOMIN incobotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
46783016001 XEOMIN incobotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
00259162001 XEOMIN incobotulinumtoxinA VIAL 200 unit Y N Pharmacy PA
00259162010 XEOMIN incobotulinumtoxinA VIAL 200 unit Y N Pharmacy PA
00259160501 XEOMIN incobotulinumtoxinA VIAL 50 unit Y N Pharmacy PA
00259415001 XEOMIN incobotulinumtoxinA VIAL 50 unit Y N Pharmacy PA
46783016101 XEOMIN incobotulinumtoxinA VIAL 50 unit Y N Pharmacy PA
46783016501 XEOMIN incobotulinumtoxinA VIAL 50 unit Y N Pharmacy PA
00023114501 BOTOX onabotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
00023114502 BOTOX onabotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
00023923201 BOTOX COSMETIC onabotulinumtoxinA VIAL 100 unit Y N Pharmacy PA
00023392102 BOTOX onabotulinumtoxinA VIAL 200 unit Y N Pharmacy PA
00023392103 BOTOX onabotulinumtoxinA VIAL 200 unit Y N Pharmacy PA
00023391950 BOTOX COSMETIC onabotulinumtoxinA VIAL 50 unit Y N Pharmacy PA
10454071210 MYOBLOC rimabotulinumtoxinB VIAL 10,000 unit/2 mL Y N Pharmacy PA
10454071010 MYOBLOC rimabotulinumtoxinB VIAL 2,500 unit/0.5 mL Y N Pharmacy PA
10454071110 MYOBLOC rimabotulinumtoxinB VIAL 5,000 unit/mL Y N Pharmacy PA
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