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: Blepharospasm OR Cervical dystonia of a predominantly rotational form (spasmodic torticollis) OR Post-stroke spasticity of the upper limb	Initial:1 year Renewal: 3 years

Practitioner exemptions

• Physical medicine and rehabilitation specialists may be eligible to enter into a Collaborative Prescribing Agreement (CPA). CPAs are provided by invitation only. Special Authority will identify eligible practitioners who treat a high volume of patients that meet PharmaCare criteria 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)

• Log in to eForms
• 5328 - General Special Authority Request (PDF, 656KB)