Continuation of Therapy — Imiquimod Agents
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This policy governs prior-authorization and continuation-of-therapy rules for imiquimod topical products (including 3.75% and 5% strengths) under the Mass General Brigham Health Plan pharmacy benefit; it affects Commercial/Exchange members and applies to requests for ongoing treatment and reauthorization.
Updated language for members who are new to the Plan and removed Zyclara 2.5% from the policy as the agent is moving to nonformulary status.
Imiquimod 5% cream is covered without prior authorization.
Coverage and Authorization Criteria
Imiquimod coverage and continuation criteria
Coverage and continuation criteria for imiquimod topical products.
Documentation must demonstrate current treatment at enrollment; samples or PAP-provided product are not acceptable evidence.
Initial Authorization Criteria
Initial authorization
Initial authorization considerations.
ONE of
- Imiquimod 5% cream: covered without prior authorization (no PA required).
- For other strengths (e.g., imiquimod 3.75%): authorization may be granted when the member has had an inadequate response or intolerance to imiquimod 5% cream, or there is clinical rationale why imiquimod 5% cream is not appropriate for the member.
Continuation and Reauthorization
Continuation and reauthorization
Reauthorization and continuation criteria.
Provider Requirements and Contact
Prior authorization applies; contact numbers for pharmacy PA
Prior authorization applies to the pharmacy benefit for imiquimod 3.75% (program type = Prior Authorization). For pharmacy benefit prior authorization requests, contact the pharmacy benefit prior authorization phone at 800-711-4555 or fax 844-403-1029. (Medical benefit contact numbers are listed separately: phone 833-895-2611, fax 888-656-6671.)
- Program Type: Prior Authorization (pharmacy benefit)
- Pharmacy benefit prior authorization phone: 800-711-4555
- Pharmacy benefit prior authorization fax: 844-403-1029
- Medical benefit contact: Phone 833-895-2611, Fax 888-656-6671
Documentation for new members and failure criteria
If the member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting that the member is currently receiving treatment with the requested drug; documentation must exclude product obtained as samples or via manufacturer patient assistance programs. Alternatively, authorization may be granted when the member has had an inadequate response or intolerance to imiquimod 5% cream or there is clinical rationale why imiquimod 5% cream is not appropriate.
- New-member window: coverage effective date ≤ 90 days requires medical records showing current treatment (exclude samples and manufacturer patient assistance).
- Failure of or intolerance to imiquimod 5% cream, or documented clinical rationale why 5% is inappropriate, may be used to justify authorization.
Reauthorization requires positive response; approvals for 12 months
Reauthorization requests will be approved when the member has had a positive response to therapy. Initial and reauthorization approvals are granted for a 12-month duration.
- Criterion for reauthorization: documentation of a positive response to therapy.
- Approval duration: initial and reauthorization approvals granted for 12 months.
Billing, Codes, and Administrative Flags
| No codes listed |
Product Definitions
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