Xeomin® (incobotulinumtoxinA)

Coverage is limited to Xeomin for its FDA‑approved indications—cervical dystonia and blepharospasm in adults, and chronic sialorrhea and upper‑limb spasticity in patients ≥2 years—and non‑FDA uses are excluded. Approval requires meeting age limits, specific dosing and frequency limits (e.g., cervical dystonia 120 U/session; blepharospasm 50 U initial, ≤100 U/session; adult upper‑limb spasticity ≤400 U; pediatric spasticity 8 U/kg single limb [max 200 U] or 16 U/kg both limbs [max 400 U]; adult sialorrhea 100 U with weight‑based pediatric 3:2 parotid:submandibular dosing), intervals generally ≥12 weeks (≥16 weeks for sialorrhea), 12‑month authorization, and documentation of diagnosis, age, dosing and schedule.

"Cervical dystonia in adults (FDA‑approved indication)."

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