Xeomin® (incobotulinumtoxinA)

Xeomin (incobotulinumtoxinA) is covered only for FDA‑approved uses—cervical dystonia and blepharospasm in adults (≥18) and chronic sialorrhea and upper‑limb spasticity in patients ≥2—with 12‑month authorization and no coverage for non‑FDA indications. Coverage requires adherence to specific age, dosing and frequency limits (generally minimum intervals of 12 weeks for most indications and 16 weeks for sialorrhea; specified adult maximums and weight‑based pediatric dosing), and the policy lists no additional documentation checklist.

"Cervical dystonia in adults."

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