Sofdra — Blue Cross Blue Shield of Illinois

primary axillary hyperhidrosis

Initial criteria

The patient has a diagnosis of primary axillary hyperhidrosis defined by BOTH of the following: (A) Focal, visible, excessive sweating of at least 6 months duration without apparent cause AND (B) TWO of the following: bilateral and relatively symmetric, impairs daily activities, frequency of at least one episode per week, age of onset < 25 years, positive family history, cessation of focal sweating during sleep
ONE of the following: (A) tried and had an inadequate response to 20% aluminum based topical antiperspirant OR (B) intolerance or hypersensitivity to 20% aluminum based topical antiperspirant OR (C) FDA labeled contraindication to 20% aluminum based topical antiperspirant
If the patient has an FDA labeled indication, ONE of the following: (A) age is within FDA labeling for indication and agent OR (B) there is support for use for the patient’s age for the indication
The 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
Patient has had clinical benefit with the requested agent
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months