Qbrexza (glycopyrronium tosylate pad 2.4%) — Blue Cross Blue Shield of New Mexico
other FDA labeled or compendia supported indications (non-oncology or oncology)
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to the requested agent
- ONE of the following: (1) Patient has another FDA labeled indication and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective
Approval duration
12 months