imiquimod 5% — Blue Cross Blue Shield of Alabama

Preferred products

• generic imiquimod 5% cream
• fluorouracil solution

Initial criteria

• The patient has a diagnosis of external genital and/or perianal warts (EGW)/condyloma acuminata AND the requested agent is imiquimod 5% OR Zyclara (imiquimod) 3.75% cream AND ONE of the following:
• For actinic keratoses or superficial basal cell carcinoma, ONE of the following applies:
• • The patient has tried and had an inadequate response to generic imiquimod 5% cream or fluorouracil solution OR
• • The patient has an intolerance or hypersensitivity to therapy with generic imiquimod 5% cream or fluorouracil solution OR
• • The patient has an FDA labeled contraindication to generic imiquimod 5% cream AND fluorouracil solution OR
• For external genital warts, ONE of the following applies:
• • The patient has tried and had an inadequate response to generic imiquimod 5% cream OR
• • The patient has an intolerance or hypersensitivity to therapy with generic imiquimod 5% cream OR
• • The patient has an FDA labeled contraindication to generic imiquimod 5% cream

Approval duration

up to 12 months