Qbrexza — Blue Cross Blue Shield of Texas

primary axillary hyperhidrosis

Initial criteria

1. 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 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
2. ONE of the following:
A. The patient has tried and had an inadequate response to 20% aluminum based topical antiperspirant (e.g., Drysol, OTC) OR
B. The patient has an intolerance or hypersensitivity to 20% aluminum based topical antiperspirant OR
C. The patient has an FDA labeled contraindication to 20% aluminum based topical antiperspirant AND
3. If the patient has an FDA labeled indication, then ONE of the following:
A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
B. There is support for using the requested agent for the patient’s age for the requested indication AND
4. The patient does NOT have any FDA labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
2. The patient has had clinical benefit with the requested agent
3. The patient does NOT have any FDA labeled contraindications to the requested agent

BCBSIL: 12 months; others: initial 3 months, renewal 12 months