CurrentHealth NetPolicy CP PMN.177

Clinical Policy: Glycopyrronium (Qbrexza)

Defines medical necessity and prior authorization requirements for Qbrexza (glycopyrronium tosylate cloths) for treatment of primary axillary hyperhidrosis for Commercial and Medicaid lines of business under Health Net/Centene-affiliated plans.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Glycopyrronium (Qbrexza)

Policy CodePolicy CP PMN.177

Change TypeNo material changes

Effective DateAug 14, 2018

Next Review Date

Key ActionPrior authorization is required and the provider must document that the member meets initial criteria including diagnosis of primary axillary hyperhidrosis and trial/failure of topical aluminum chloride unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥9minimum patient age for coverage

2.4%product concentration

1/daymaximum dosing frequency

12 motypical approval duration

Coverage Criteria

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial Approval Criteria: 1) Diagnosis of primary axillary hyperhidrosis; 2) Prescribed by or in consultation with a dermatologist; 3) Failure of a 3-month trial of topical aluminum chloride unless contraindicated or clinically significant adverse effects experienced; 4) Age >= 9 years; 5) Dose does not exceed a single cloth per day.all criteria required

Initial approval duration: Medicaid 12 months

Continued Therapy — Covered when ANY of the following apply (and dose limits maintained)

Covered when ANY of the following apply (and dose limits maintained)

Continued Therapy Criteria: a) Member currently receiving medication via Centene benefit or has previously met initial approval criteria and is responding positively to therapy; b) Member is currently receiving medication and is enrolled in a state/product with continuity of care regulations.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Glycopyrronium (Qbrexza)

Policy CodePolicy CP PMN.177

Change TypeNo material changes

Effective DateAug 14, 2018

Next Review Date

SourceLink

On This Page

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Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Provider must demonstrate the member meets initial approval criteria, including a diagnosis of primary axillary hyperhidrosis and that treatment is prescribed by or in consultation with a dermatologist.

Policy Number: CP PMN.177
Effective Date: 2018-08-14

Step Therapy

Step Therapy — Topical Aluminum Chloride

Step therapy requirement: coverage requires failure of a 3-month trial of topical aluminum chloride (e.g., Drysol, other aluminum chloride hexahydrate preparations) unless the member has a contraindication or experiences clinically significant adverse effects.

Required trial: 3 months of topical aluminum chloride
Exception: documented contraindication or intolerance

Documentation Required

Documentation Requirement

Documentation must be submitted to support that the member has met all required criteria. Acceptable documentation includes office chart notes, laboratory results, or other clinical information demonstrating diagnosis, prior therapies tried (including duration and response), age, prescriber specialty, and any adverse reactions or contraindications.

Include documentation of primary axillary hyperhidrosis diagnosis
Include documentation of a 3-month trial of topical aluminum chloride or reason for exemption
Include prescriber specialty (dermatologist or consult note) and member age

Denial Risk

Denial Risk for Non‑FDA Indications

Non‑FDA (off‑label) indications may be denied unless the provider submits sufficient documentation in accordance with applicable off‑label use policies.

See off‑label use policies: CP.CPA.09 (Commercial) and CP.PMN.53 (Medicaid) for documentation standards

Definitions

Qbrexza (glycopyrronium tosylate)

Generic nameGlycopyrronium tosylate (Qbrexza)

MechanismTopical competitive inhibitor of acetylcholine receptors on sweat glands

Formulation & concentrationPre‑moistened cloths (2.4% cloth)

AdministrationApply once daily (QD) using a single pre‑moistened cloth to both axillae

Maximum dosing frequencyOne cloth per day (one cloth used for both axillae)

Primary axillary hyperhidrosis

Required diagnosis for coveragePrimary axillary hyperhidrosis

Prescriber requirementPrescribed by or in consultation with a dermatologist

Prior therapy requirementFailure of a 3‑month trial of topical aluminum chloride unless contraindicated or intolerant

Dose limitDose must not exceed a single cloth per day

OpenPayer

Clinical Policy: Glycopyrronium (Qbrexza)

Coverage Criteria

Coding & Product Details

Provider Actions / Prior Authorization

Definitions

Background