Imiquimod (Aldara) - Medical Necessity Request Form (Page 2 of 2) in pdf

Imiquimod (Aldara) - Medical Necessity Request Form Page 2

Member 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

**Complete page 2 only for Subsequent/Renewal requests**

1. Has member shown response to therapy or had clinical improvement? Yes or No

2. Diagnosis Information (please indicate diagnosis and answer related questions):



Actinic Keratosis (Solar Keratosis)



Superficial Basal Cell Carcinoma



Condyloma Acuminata (i.e. Genital of perianal HPV warts)

Are the warts located externally? Yes or No



Warts

Where are the warts located? ______________________________________



Vaginal Intraepithelial Neoplasia (VAIN)



Herpes Simplex Virus (HSV)



Melanoma



Molluscum contagiosum



Lentigo Maligna (Hutchinson melanotic freckle)



Bowen’s Disease (squamos cell carcinoma in situ)



Primary Cutaneous T-Cell Lymphoma (Mycosis Fungoides)

Is the disease regional or localized? Yes or No

Is disease stage 1A? Yes or No

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

2 of 2

Rev. 03/16

HNJH Fax #: 888-567-0681

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Imiquimod (Aldara) - Medical Necessity Request Form Page 2