QBREXZA (glycopyrronium cloth 2.4%)
SELF ADMINISTRATION-TOPICAL
Indication for Prior Authorization:
- Indicated for topical treatment of primary axillary hyperhidrosis in adult and pediatric patients 9 years of age and older
Coverage 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 in combination 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)
Coverage Duration:
- Initial: 1 year
- Reauthorization: 1 year
Authorization is Not Covered for the Following:
The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.
Additional Information:
- Qbrexza is for topical use in the underarm area only and not for use in other body areas
- Qbrexza is contraindicated in patients with 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, myasthenia gravis, Sjogren’s syndrome)
- Additional warnings for: worsening of urinary retention, control of body temperature, and operating machinery or an automobile
- The elimination of glycopyrronium is severely impaired in patients with renal failure
Review History:
- 1/4/21- Annual review, format updated
- 5/28/19- Annual review, no changes
- 10/16/18- Original review
References:
- Qbrexza [package insert]. Menlo Park (CA): Dermira, Inc; 2018.
Last review date: January 4, 2021