Glycopyrronium cloth 2.4% (Qbrexza™)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Indicated for the treatment of primary axillary hyperhidrosis in adults and pediatric patients 9 years of age and older.

Prior Authorization Criteria:

  • Patient is 9 years of age or older, AND
  • Diagnosis of primary axillary hyperhidrosis, AND
  • Tried and failed OTC antiperspirants (e.g. Hypercare 15%, Xerac AC) and Drysol as confirmed by chart note documentation and claims history, AND
  • Qbrexa™ will not be used with Botox®, AND
  • Patient does not have a contraindication to treatment:
    • Medical conditions that can be exacerbated by the anticholinergic effect of Qbrexza™ (e.g. glaucoma, paralytic ileus, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, myastenia gravis, Sjogren's syndrome)

Dosing:

  • Wipe 1 cloth across entire underarm once daily (a single wipe should be used to apply Qbrexza™ to both underarms)

Approval:

  • One year

Last review date: May 28, 2019