Limited Coverage Drugs - Botulinum Neurotoxin Type A, free from complexing proteins, also known as incobotulinumtoxinA (Xeomin®)

Generic Name

botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA
Strength 50 units, 100 units 

Form

vial

Special Authority 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.

1 year

 

Practitioner Exemptions

  • A Collaborative Prescribing Agreement is available to a limited number of practitioners in the following specialties: neurology, ophthalmology, and physical medicine & rehabilitation. These practitioners are not required to submit a Special Authority request form for coverage.

Special Notes

  • Botulinum neurotoxin type A, free from complexing proteins, is also known under the generic name incobotulinumtoxinA. The brand name for this drug is Xeomin®.
  • To renew prescriptions for this drug, practitioners must submit:
    • documentation of a patient's functional and symptomatic improvement

      AND
       
    • the dosage and injection schedule.

Special Authority Request Form(s)