Limited coverage criteria – botulinum neurotoxin type A, also known as incobotulinumtoxinA (Xeomin®)

 

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Generic name	botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA
Strength & form	50 units, 100 units 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
• HLTH 5865 – BotulinumtoxinA (PDF, 1.3MB)