Sofdra — Blue Cross Blue Shield of Alabama

primary axillary hyperhidrosis

Initial criteria

Patient has a diagnosis of primary axillary hyperhidrosis defined by BOTH of the following:
• Focal, visible, excessive sweating of at least 6 months duration without apparent cause
AND TWO of the following characteristics: bilateral and relatively symmetric; impairs daily activities; frequency of at least one episode per week; age of onset less than 25 years; positive family history; cessation of focal sweating during sleep
AND ONE of the following:
• Patient has tried and had an inadequate response to 20% aluminum based topical antiperspirant (e.g., Drysol, OTC)
OR • Patient has an intolerance or hypersensitivity to 20% aluminum based topical antiperspirant
OR • Patient has an FDA labeled contraindication to 20% aluminum based topical antiperspirant
AND if the patient has an FDA labeled indication, then ONE of the following:
• Patient’s age is within FDA labeling for the requested indication for the requested agent
OR • There is support for using the requested agent for the patient’s age for the requested indication
AND Patient does NOT have any FDA labeled contraindications to the requested agent

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND Patient has had clinical benefit with the requested agent
AND Patient does NOT have any FDA labeled contraindications to the requested agent

initial 3 months, renewal 12 months