Aldara (imiquimod 5% cream) — Blue Cross Blue Shield of Montana

Preferred products

• generic imiquimod 5% cream

Initial criteria

• Generic imiquimod 5% cream was discontinued due to lack of efficacy, diminished effect, or an adverse event (chart notes required) OR
• The patient has an intolerance or hypersensitivity to generic imiquimod 5% cream (chart notes required) OR
• The patient has an FDA labeled contraindication to generic imiquimod 5% cream (chart notes required) OR
• Generic imiquimod 5% cream is expected to be ineffective or cause adherence barriers, worsen a comorbid condition, hinder functional ability, or cause harm (chart notes required) OR
• Generic imiquimod 5% cream is not in the best interest of the patient based on medical necessity (chart notes required) OR
• The patient has tried another prescription drug in the same pharmacologic class as generic imiquimod 5% cream that was discontinued due to lack of efficacy or an adverse event (chart notes required) AND
• One of the following: (A) The requested quantity/duration does not exceed the program quantity limit for the requested indication OR (B) There is supportive documentation for the requested quantity/duration for the requested indication
• For members residing in Ohio and in Fully Insured or HIM Shop (SG) plans: Patient must not have any FDA labeled contraindications AND one of the following applies: (1) Patient has another FDA labeled indication for the requested agent/route; OR (2) Patient has an indication supported in compendia; OR (3) Prescriber submitted two supporting peer-reviewed journal articles per specified standards

Approval duration

3–12 months (BCBSMT/BCBSNM); 6–12 months (BCBSIL); up to 12 months otherwise; standalone QL criteria: 12 months