Hepatitis B Vaccine (Recombinant) Injection Prior Authorization Criteria

Hepatitis B Vaccine Prior Authorization Request Form

Covered Uses

• All FDA approved indications not otherwise excluded from Part D (FDA labeled indication:
  
  • For immunization against infection caused by all known subtypes of hepatitis b virus. Note – Part D will be billed for patients who are at a low level of risk

Exclusion Criteria

• Patients at intermediate or high level or risk
  
• If intermediate level of risk, Part B will be billed:
  
  • Staff in institutions for the mentally handicapped
    
  • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work
    
• If high level of risk, Part B will be billed:
  
  • Individuals with End Stage Renal Disease
    
  • Individuals with hemophilia who received Factor VIII or IX concentrates
    
  • Clients of institutions for individuals for the mentally handicapped
    
  • Persons who live in the same household as a hepatitis B virus (HBV) carrier
    
  • Homosexual men
    
  • Illicit injectable drug abusers

Required Medical Information

Indicate current level of risk

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Six (6) months covers all three (3) doses

Other Criteria

Part D vs. Part B evaluation also applies