Qbrexza (glycopyrronium tosylate pad 2.4%) — Blue Cross Blue Shield of New Mexico

Initial criteria

• 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 characteristics: 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 (e.g., Drysol, OTC) 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) Patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) Support for use for the patient’s age for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 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

Approval duration

3–12 months (BCBSIL: 12 months; others: initial 3 months, renewal 12 months)