Sofdra — Medical Mutual
Hyperhidrosis, Primary Axillary
Initial criteria
- Patient age ≥ 9 years
- Symptomatic hyperhidrosis occurs more than once weekly AND symptoms cease at night
- Qbrexza will ONLY be applied to the axillae (underarms) [documentation required]
- Patient has tried and failed a clinical strength topical antiperspirant for one month (such as: 20% aluminum chloride hexahydrate, 15% aluminum chloride hexahydrate) unless contraindication exists [documentation required]
- Hyperhidrosis Disease Severity Scale (HDSS) of 3 or 4 [documentation required]
Reauthorization criteria
- Patient age ≥ 9 years
- Qbrexza will ONLY be applied to the axillae (underarms) [documentation required]
- Patient’s HDSS score has improved by at least two points since starting treatment with glycopyrronium [documentation required]
Approval duration
60 days initial, 1 year continuation