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Imiquimod 5% cream Prior Authorization Criteria - Medicare Part D
Medicare Utilization Management Policy
Version Date: 01/01/2025

Prior Authorization Criteria for Approval

PA applies to new starts only

Imiquimod 5% cream will be approved when the following is met:

  1. The patient has ONE of the following diagnoses: 
    1. Actinic keratosis
      OR
    2. Superficial basal cell carcinoma
      OR
    3. External genital and/or perianal warts/condyloma acuminata
      OR
    4. Squamous cell carcinoma
      OR
    5. Basal cell carcinoma
      OR
    6. Another indication that is supported in CMS approved compendia for the requested medication

Length of Approval:

Actinic keratosis: 4 months

Superficial basal cell carcinoma: 2 months

External genital and/or perianal warts/condyloma acuminata: 4 months

Squamous cell carcinoma: 2 months

Basal cell carcinoma: 2 months

All other indications: 12 months
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