Anthem Blue Cross (HMO, PPO, EPO) |
Qbrexza (glycopyrronium tosylate) |
Drugs for the Skin : Drugs for the Skin |
- Step Therapy Applies
- Quantity Limit: 1 cloth per 1 day(s).
- Prior Authorization: Primary Axillary Hyperhidrosis:
Documented Diagnosis: Yes
Age Requirement: >= 9
Duration: 1 year(s)
- Primary Axillary Hyperhidrosis:
Age Requirement: >= 9
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Policy Contains Verbiage for Botulinum Interchangeability: No
Documented Diagnosis: Yes
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