INTRODUCTION
Axillary hyperhidrosis is a chronic dermatological condition characterized by excessive underarm sweating, often interfering with daily activities.1 It is relatively common, with a prevalence of nearly 5.75%.1 Despite substantial impacts on quality of life, the exact pathogenesis remains unclear. Treatment strategies primarily focus on reducing excessive sweating, commonly including topical agents, oral pharmacotherapy, and botulinum toxin in the axillary region.2 Botulinum toxin selectively targets neurotransmitters in sebaceous glands to prevent the transmission of signals that induce sweat production.2,3 Although these neurotoxins have been proven to decrease sweating, insurance coverage varies, and the out-of-pocket expenses are typically high.1,2 To date, no studies have evaluated private insurance coverage of botulinum toxin in the treatment of primary axillary hyperhidrosis in the United States. Thus, our objective is to analyze the most up-to-date insurance coverage for botulinum toxin treatment for primary axillary hyperhidrosis among the largest private insurers in each US state.
The largest private insurers were identified using the National Association of Insurance Commissioners' yearly Accident and Health Market Share Report of 2024. Insurers were selected based on total earned premiums and market share percentage. Subsequently, insurers’ online medical coverage policies were searched for prior authorization requirements, and injection timing was documented. Results are listed in Table 1.
Of the 50 states, a total of 40 identified private insurers with publicly available coverage guidelines for botulinum toxin use in treating primary axillary hyperhidrosis. States without publicly available coverage information included the following: Illinois Health Service Corporation, Mississippi Blue Cross Blue Shield, Montana Health Service Corporation, New Mexico Health Service Corporation, Oklahoma Health Service Corporation, Oregon Cambia, Texas Health Service Corporation, Utah InterMountain Healthcare, Vermont Blue Cross Blue Shield, and Washington Kaiser. All private insurers with publicly available guidelines explicitly list primary axillary hyperhidrosis as a criterion for medically necessary botulinum toxin. The majority of policies listed coverage for all formulations of botulinum toxin type A, including Botox (onabotulinumtoxinA), Daxxify (daxibotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA). Additionally, all required prior authorization with evidence of failed topical or oral medications (eg, topical aluminum chloride, anticholinergics, etc.). The mean number of covered sessions per year was 3.9 sessions.
Our results indicate that all private insurers cover botulinum toxin for primary axillary hyperhidrosis after failed treatment with standard topical or oral agents, reinforcing evidence of its safety and efficacy.1 Despite this, the cost of illness for the disease remains high, with botulinum toxin accounting for the highest percentage of out-of-pocket costs.2 Financial barriers may include high copayments and deductibles, as well as the need for repeat treatments to achieve desired outcomes. Moreover, certain toxins may be more costly than others (eg, Botox, Daxxify, Dysport, etc.). Increasing patient education on insurance coverage policies and alternative financial assistance programs may aid in reducing the financial burden of disease and improving long-term outcomes.
Our study has several limitations--namely, only the largest private insurers per state were analyzed, limiting the generalizability of our results. Future research should investigate coverage variability among smaller insurers, as well as Medicaid and Medicare policies.
The largest private insurers were identified using the National Association of Insurance Commissioners' yearly Accident and Health Market Share Report of 2024. Insurers were selected based on total earned premiums and market share percentage. Subsequently, insurers’ online medical coverage policies were searched for prior authorization requirements, and injection timing was documented. Results are listed in Table 1.
Of the 50 states, a total of 40 identified private insurers with publicly available coverage guidelines for botulinum toxin use in treating primary axillary hyperhidrosis. States without publicly available coverage information included the following: Illinois Health Service Corporation, Mississippi Blue Cross Blue Shield, Montana Health Service Corporation, New Mexico Health Service Corporation, Oklahoma Health Service Corporation, Oregon Cambia, Texas Health Service Corporation, Utah InterMountain Healthcare, Vermont Blue Cross Blue Shield, and Washington Kaiser. All private insurers with publicly available guidelines explicitly list primary axillary hyperhidrosis as a criterion for medically necessary botulinum toxin. The majority of policies listed coverage for all formulations of botulinum toxin type A, including Botox (onabotulinumtoxinA), Daxxify (daxibotulinumtoxinA), Dysport (abobotulinumtoxinA), and Xeomin (incobotulinumtoxinA). Additionally, all required prior authorization with evidence of failed topical or oral medications (eg, topical aluminum chloride, anticholinergics, etc.). The mean number of covered sessions per year was 3.9 sessions.
Our results indicate that all private insurers cover botulinum toxin for primary axillary hyperhidrosis after failed treatment with standard topical or oral agents, reinforcing evidence of its safety and efficacy.1 Despite this, the cost of illness for the disease remains high, with botulinum toxin accounting for the highest percentage of out-of-pocket costs.2 Financial barriers may include high copayments and deductibles, as well as the need for repeat treatments to achieve desired outcomes. Moreover, certain toxins may be more costly than others (eg, Botox, Daxxify, Dysport, etc.). Increasing patient education on insurance coverage policies and alternative financial assistance programs may aid in reducing the financial burden of disease and improving long-term outcomes.
Our study has several limitations--namely, only the largest private insurers per state were analyzed, limiting the generalizability of our results. Future research should investigate coverage variability among smaller insurers, as well as Medicaid and Medicare policies.
