IncobotulinumtoxinA (Xeomin®)

Covered only for FDA‑approved indications: cervical dystonia and blepharospasm in adults (≥18 years) and chronic sialorrhea and upper‑limb spasticity in patients ≥2 years (pediatric dosing guidance included); all other (off‑label) indications are excluded. Approvals are for up to 12 months and limited to specified maximum doses and minimum intervals: blepharospasm 100 U (50 U/eye) ≥12 weeks; cervical dystonia 120 U ≥12 weeks; adult upper‑limb spasticity 400 U ≥12 weeks; pediatric upper‑limb spasticity 8 U/kg unilateral (max 200 U) or 16 U/kg bilateral (max 400 U) ≥12 weeks; adult chronic sialorrhea 100 U (50 U/side) ≥16 weeks; pediatric chronic sialorrhea 75 U (37.5 U/side) ≥16 weeks.

"Use limited to the specified maximum doses and specified minimum intervals between administrations as listed above."

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