XEOMIN Access Forms

Downloadable Forms

Insurance Verification Request Form
This form should be completed if you would like us to verify patient insurance eligibility and coverage for XEOMIN® (incobotulinumtoxinA) (including medical and/or pharmacy benefit and specialty pharmacy options).

Sample Letter of Medical Necessity
This document is an example of a letter than can be sent on behalf of your patient to the payor to justify the medical necessity of XEOMIN.

Sample Appeal Letter
This letter is an example of a letter that can be sent to appeal a denied claim for XEOMIN.

Patient Assistance Program Enrollment Form
This application should be completed by patients to determine if they are eligible for our Patient Assistance Program for uninsured or underinsured patients.

Patient Savings Program Application
This application should be completed by patients to determine if they are eligible for our Patient Savings Program.

XEOMIN® Patient Savings Program Patient Brochure
This electronic brochure provides your patients additional information about the XEOMIN Patient Savings Program.