Tolak — CareFirst (Caremark)
External genital warts (EGW)
Preferred products
- imiquimod 5 percent cream
- fluorouracil cream
- fluorouracil solution
Initial criteria
- For Actinic Keratosis (AK): Authorization may be granted when ONE of the following is met:
- • The request is for Carac, Tolak, OR Zyclara.
- • The request is for Klisyri AND the patient experienced an inadequate treatment response, intolerance, OR has a contraindication to ANY of the following: imiquimod 5 percent cream, fluorouracil cream or solution.
- For External Genital Warts (EGW): Authorization may be granted when the request is for Zyclara.
Reauthorization criteria
- For Actinic Keratosis (AK): The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., percentage of actinic keratosis lesions cleared, patient/prescriber satisfaction, etc.).
- For External Genital Warts (EGW): The request is for Zyclara AND the patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., percentage of warts cleared).
Approval duration
Initial therapy: 4 months; Continuation: 12 months