Special Authority Criteria – Botulinum Neurotoxin Type A, free from complexing proteins

Generic Name / Strength / Form

botulinum neurotoxin type A, free from complexing proteins

Criteria Approval Period

For the treatment of:

  1. Blepharospasm.

    OR

  2. Cervical dystonia of a predominantly rotational form (spasmodic torticollis).

    OR

  3. Post-stroke spasticity of the upper limb.

 

 One year

Practitioner Exemptions

  • Limited number of neurologists and ophthalmologists.

Special Notes

  • Botulinum toxin for cosmetic purposes and indications not approved for sale by Health Canada are not eligible for PharmaCare coverage.

  • For renewals, physicians must submit
    • documentation of a patient's functional and symptomatic improvement,

      AND

    • dosage and injection schedule

Special Authority Request Form

General Special Authority Request. (PDF  132K)