Xeomin
Generic: incobotulinumtoxinA
50 UNIT — Solution
Acetylcholine Release Inhibitor
Also known as:
incobotulinumtoxinA
Xeomin Intramuscular Solution Reconstituted
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Signature Expanded Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Silver + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Gold + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Clear Silver with $0 Insulin Options | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Expanded Bronze | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Silver | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Gold | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Elite Bronze with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Focused Silver with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Complete Gold with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Expanded Bronze with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Silver with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Signature Gold with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Complete Gold + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Everyday Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Elite Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Complete Gold | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Everyday Bronze | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Elite Bronze | Tier 4 - Non-Preferred | ✓ | — | — | PA |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |