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Zyclara 2.5% cream — Blue Cross Blue Shield of Texas

superficial basal cell carcinoma

Preferred products

  • generic imiquimod 5% cream
  • fluorouracil solution

Initial criteria

  • If the patient has an FDA labeled indication, then ONE of the following:
  • • Patient age is within FDA labeling for the requested indication OR there is support for using the requested agent for the patient's age for the requested indication
  • AND ONE of the following diagnosis/product combinations:
  • A. BOTH of the following: 1) Diagnosis of actinic (solar) keratoses of the face and/or scalp AND 2) Requested agent is diclofenac 3% gel, Carac 0.5% cream, Efudex 5% cream, Fluoroplex, Tolak, imiquimod 5%, Zyclara (imiquimod) 3.75% cream, Zyclara 2.5% cream, or Klisyri
  • B. BOTH of the following: 1) Diagnosis of actinic (solar) keratoses of the trunk and/or extremities AND 2) Requested agent is diclofenac 3% gel, Efudex (fluorouracil) 5% cream, or Fluoroplex
  • C. BOTH of the following: 1) Diagnosis of superficial basal cell carcinoma AND 2) Requested agent is imiquimod 5% or Efudex (fluorouracil) 5% cream
  • D. BOTH of the following: 1) Diagnosis of external genital and/or perianal warts (EGW)/condyloma acuminata AND 2) Requested agent is imiquimod 5% or Zyclara (imiquimod) 3.75% cream
  • AND ONE of the following additional conditions:
  • A. For stage four advanced metastatic cancer: prescriber has stated or documented diagnosis of stage IV advanced metastatic cancer AND agent is used to treat cancer or an associated condition AND use is consistent with best practices and FDA approval
  • B. For actinic keratoses or superficial basal cell carcinoma: one of the following—patient currently stable on requested agent; OR tried and had inadequate response to generic imiquimod 5% cream or fluorouracil solution; OR discontinued those therapies due to lack of efficacy, diminished effect, or adverse event; OR intolerance or hypersensitivity; OR FDA labeled contraindication to both generic imiquimod 5% cream and fluorouracil solution; OR expected ineffectiveness or harm; OR not in best interest based on medical necessity; OR previous failure of another agent in same pharmacologic class or mechanism of action.
  • C. For external genital and/or perianal warts (EGW): one of the following—patient currently stable on requested agent; OR tried and had inadequate response to generic imiquimod 5% cream.