Subject: Daxxify SGM 6132-A P2024_R

Drug

DAXXIFY  (daxibotulinumtoxinA-lanm)

Policy:

Indications

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-APPROVED INDICATIIONS

• The treatment of cervical dystonia in adult patients.

All other indications are considered experimental/investigational and not medically necessary

Prescriber Specialties

The medication must be prescribed by, or in consultation with a provider specialized in treating the member’s condition.

Exclusions

Coverage will not be provided for cosmetic use.

Coverage Criteria

Cervical dystonia

Authorization of 12 months may be granted for the treatment of adults with cervical dystonia (e.g., torticollis) when both of the following are met:

• Member is 18 years of age or older
• There is abnormal placement of the head with limited range of motion in the neck

Continuation of Therapy

All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteria and be experiencing benefit from therapy.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Daxxify [package insert]. Newark, CA: Revance Therapeutics, Inc; November 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 13, 2024