Human Papillomavirus (HPV) Recombinant Vaccine Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

• Prevention of the following diseases caused by Human Papillomavirus (HPV) types 6, 11, 16, and 18:
  
  • cervical cancer, vulvar and vaginal cancer
    
  • genital warts (condyloma acuminata)
    
  • cervical adenocarcinoma in situ (AIS)
    
  • cervical intraepithelial neoplasia (CIN) grade 2 and grade 3
    
  • vulvar intraepithelial neoplasia (VIN) grade 2 and grade 3
    
  • vaginal intraepithelial neoplasia (VaIN) grade 2 and grade 3
    
  • cervical intraepithelial neoplasia (CIN) grade 1

Exclusion Criteria

None

Required Medical Information

None

Age Restrictions

For girls and women between the ages of 9 and 26 years

Prescriber Restrictions

None

Coverage Duration

According to the following schedule: first dose – at elected date; second dose – 2 months after the first dose; third dose – 6 months after the first dose

Other Criteria

None