Confidence in Affordability: the QBREXZA Savings Card

Patients can manage their out-of-pocket costs with the QBREXZA Savings Card

$35 Patients with commercial insurance may pay as little as $35 per fill.*†‡

$70 Patients without insurance or with plans that do not cover QBREXZA may pay as little as $70 per fill.*†‡

Visit QBREXZA.com/activate with your patient to download a savings card

Our Savings Program card can be used at any participating retail pharmacy and is available in print, via the web, and downloadable to a mobile phone.

Program expiration date December 31, 2019

*Depending on eligibility and status of coverage. See terms and conditions below.

†One prescription fill=a 30-day supply (30 pouches).

‡The QBREXZA™ (glycopyrronium) cloth Savings Card is valid for patients with commercial insurance or patients who have no insurance. Patients enrolled in Medicare, Medicaid, Medigap, TRICARE, the Department of Veterans Affairs healthcare program, or any other federal or state government-funded healthcare program (“Government Programs”) are not eligible. Patients who become enrolled in such Government Programs during their enrollment period will no longer be eligible for the program. Eligible patients must be residents of the United States and the patient, or the patient’s parent or guardian, must be 18 years or older to receive QBREXZA Savings Card assistance.

For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript® for QBREXZA program at 1-877-DERMIRA Monday-Friday, 8 am-8 pm EST.

Dermira, Inc., reserves the right to rescind, revoke, or amend this offer at any time.

Terms and conditions

The QBREXZA Savings Card is valid ONLY for patients with commercial (private or nongovernmental) insurance or patients with no insurance. Patients enrolled in Medicare, Medicaid, Medigap, TRICARE, the Department of Veterans Affairs healthcare program, or any other federal or state government-funded healthcare program (“Government Programs”) are not eligible. Patients who become enrolled in such Government Programs during their enrollment period will no longer be eligible for the program. Eligible patients must be residents of the United States, and the patient, or the patient’s parent or guardian, must be 18 years or older to receive Savings Card Program assistance.

Eligible patients with commercial prescription drug insurance coverage for QBREXZA may pay as little as $35. Eligible patients with commercial prescription drug insurance coverage that does not cover QBREXZA or eligible patients without prescription drug insurance may pay as little as $70. Individual patient savings are limited to $2,500 in maximum total savings for the term of the program.

This Savings Card Program is not health insurance or a benefit plan. Distribution or use of the Savings Card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Savings Card benefits or reimbursement received to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Savings Card Program, as may be required.

The Savings Card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs that reimburse the patient in part or for the entire cost of his/her Dermira medication. Patient, guardian, pharmacist, prescriber, and any other person using the Savings Card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.

The Savings Card will be accepted by participating pharmacies in the United States. To qualify for the benefits of this Savings Card Program, the patient may be required to pay out-of-pocket expenses for each prescription. This Savings Card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this Savings Card must be consistent with all relevant health insurance requirements and payer agreements. Participating pharmacies are obligated to inform third-party payers about the use of the Savings Card as provided for under the applicable insurance or as otherwise required by contract or law. The Savings Card may not be sold, purchased, traded, or offered for sale, purchase, or trade.

The Savings Card is limited to one per person during this offer period and is not transferable. Void where prohibited by law, taxed, or restricted. Absent a change in Massachusetts law, effective July 1, 2019, this Savings Card will no longer be valid for residents of Massachusetts.

This Savings Card Program expires on 12/31/2019. Dermira reserves the right to rescind, revoke, amend, or terminate the program without notice at any time.

If you have questions or are in need of additional support, call 1-877-DERMIRA (877-337-6472).

INDICATION

QBREXZA is an anticholinergic indicated for topical treatment of primary axillary hyperhidrosis in adult and pediatric patients 9 years of age and older.

IMPORTANT SAFETY INFORMATION

Contraindications: 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).

WARNINGS AND PRECAUTIONS

Worsening of Urinary Retention: QBREXZA should be used with caution in patients with a history or presence of documented urinary retention. Prescribers and patients should be alert for signs and symptoms of urinary retention (e.g., difficulty passing urine, distended bladder), especially in patients with prostatic hypertrophy or bladder-neck obstruction. Instruct patients to discontinue use immediately and consult a physician should any of these signs or symptoms develop. Patients with a history of urinary retention were not included in the clinical studies.

Control of Body Temperature: In the presence of high ambient temperature, heat illness (hyperpyrexia and heat stroke due to decreased sweating) can occur with the use of anticholinergic drugs such as QBREXZA. Advise patients using QBREXZA to watch for generalized lack of sweating when in hot or very warm environmental temperatures and to avoid use if not sweating under these conditions.

Operating Machinery or an Automobile: Transient blurred vision may occur with use of QBREXZA. If blurred vision occurs, the patient should discontinue use until symptoms resolve. Patients should be warned not to engage in activities that require clear vision such as operating a motor vehicle or other machinery, or performing hazardous work until the symptoms have resolved.

ADVERSE REACTIONS

The most common adverse reactions seen in ≥2% of subjects treated with QBREXZA were dry mouth (24.2%), mydriasis (6.8%), oropharyngeal pain (5.7%), headache (5.0%), urinary hesitation (3.5%), vision blurred (3.5%), nasal dryness (2.6%), dry throat (2.6%), dry eye (2.4%), dry skin (2.2%) and constipation (2.0%). Local skin reactions, including erythema (17.0%), burning/stinging (14.1%) and pruritus (8.1%) were also common.

DRUG INTERACTIONS

Anticholinergics: Coadministration of QBREXZA with anticholinergic medications may result in additive interaction leading to an increase in anticholinergic adverse effects. Avoid coadministration of QBREXZA with other anticholinergic-containing drugs.

INSTRUCTIONS FOR ADMINISTERING QBREXZA

Instruct patients to use one cloth to apply QBREXZA to both axillae by wiping the cloth across one underarm, ONE TIME. Using the same cloth, apply the medication to the other underarm, ONE TIME. Inform patients that QBREXZA can cause temporary dilation of the pupils and blurred vision if it comes in contact with the eyes.

Instruct patients to wash their hands with soap and water immediately after discarding the used cloth.

USE IN SPECIFIC POPULATIONS

Pregnancy: There are no available data on QBREXZA use in pregnant women to inform a drug-associated risk for adverse developmental outcomes.

Lactation: There are no data on the presence of glycopyrrolate or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for QBREXZA and any potential adverse effects on the breastfed infant from QBREXZA or from the underlying maternal condition.

Renal Impairment: The elimination of glycopyrronium is severely impaired in patients with renal failure.

Please see Full Prescribing Information.