Imiquimod (Aldara) - Medical Necessity Request Form
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2Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Imiquimod (Aldara) – Medical Necessity Request
Diagnosis Information (please indicate diagnosis and answer related questions):
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Actinic Keratosis (Solar Keratosis)
Molluscum contagiosum
Vaginal Intraepithelial Neoplasia (VAIN)
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Lentigo Maligna (Hutchinson melanotic freckle)
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Superficial Basal Cell Carcinoma
a.
Is the cancer low risk? Yes or No
- If yes, are surgery and radiation contraindicated or medically less appropriate? Yes or No
b.
Is it primary? Yes or No
c.
Is the carcinoma confirmed by biopsy? Yes or No
d.
What is the maximum tumor diameter (Please include units (i.e. cm, mm) _______________
e.
Where is the tumor located?____________________________________________
f.
Are surgical methods appropriate? Yes or No
g.
Will there be patient follow up? Yes or No
h.
Is the patient immunocompetent? Yes or No
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Condyloma Acuminata (i.e. Genital or perianal HPV warts)
a.
Are the warts located externally? Yes or No
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Warts
a. Where are the warts located? ____________________________________
b. Are the warts located externally? Yes or No
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Herpes Simplex Virus (HSV)
a.
Has member failed therapy with Acyclovir, Valacyclovir or Famciclovir? Yes or No
b.
Is member HIV positive? Yes or No
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Melanoma
a. Is the melanoma recurrent, in situ (in the original position or place) or neither?
Recurrent
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Does member have local, satellitosis and/or in-transit recurrence? Yes or No
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Has diagnosis been confirmed by FNA (Fine needle aspiration) or biopsy? Yes or No
In situ
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Is the melanoma large, lentigo maligna type? Yes or No.
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Did the member have positive margins after optimal surgery? Yes or No
Neither
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Does member have stage III, in-transit melanoma? Yes or No
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Has diagnosis been confirmed by FNA (Fine needle aspiration) or biopsy? Yes or No
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Bowen’s Disease (squamous cell carcinoma in situ)
a.
Is the disease considered low risk? Yes or No
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Primary Cutaneous T-Cell Lymphoma (Mycosis Fungoides)
a.
Is the disease regional or localized? Yes or No
b.
Is disease stage 1A? Yes or No
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Other: ________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
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Rev. 03/16
HNJH Fax #: 888-567-0681
Page
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