Limited coverage drugs – botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA (Xeomin®)

Last updated on August 27, 2024

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:

  1. Blepharospasm
    OR
  2. Cervical dystonia of a predominantly rotational form (spasmodic torticollis)
    OR
  3. 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)