Zyclara (imiquimod 3.75% cream) — Blue Cross Blue Shield of New Mexico

Preferred products

• Generic imiquimod 5% cream

Initial criteria

• Generic imiquimod 5% cream was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• The patient has 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 based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient's adherence of care; OR worsen a comorbid condition; OR decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental 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 or with the same mechanism of action as generic imiquimod 5% cream and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] AND
• ONE of the following: The requested quantity (dose) and/or duration does NOT exceed the program quantity limit for the requested indication OR There is support of therapy with the requested quantity (dose) and/or duration of therapy for the requested indication

Approval duration

3–12 months