Zoster Vaccine Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

(a) Prevention of herpes zoster (shingles)

Exclusion Criteria

(a) None

Required Medical Information

(a) None

Age Restrictions

(a) 60 years of age and older

Prescriber Restrictions

(a) None

Coverage Duration

(a) One dose per lifetime. Duration of authorization not applicable

Other Criteria

(a) None