No Prior Authorization (PA) Required for Gardasil Vaccine, CR 37236

January 10, 2014

A revised Gardasil Vaccine Criteria Sheet has been updated on the MIHMS Health PAS Online Portal as PA is no longer required for the Gardasil Vaccine, effective November 1, 2013 if all the following criteria are met:

  • Member is nine (9) through 26 years old*

  • Member is male or female

  • Vaccine is provided as part of an examination and/or treatment (MaineCare Benefits Manual Chapter II, Section 90.04-23)

  • Vaccine is administered in a covered place of service*

Note:

  • The criteria marked by an asterisk (*) are based on the Maine Centers for Disease Control and Prevention guidelines.

  • For members ages nine (9) through 18 years old, Gardasil is covered under the Vaccine for Children (VFC) Program administered by the Maine Centers for Disease Control and Prevention and should be billed with an SL modifier.

  • This is not a covered service for members age 27 years and older, even if the series began before the member’s 27th birthday.

To access the Gardasil Vaccine Criteria Sheet, log into your Trading Partner account on the Health PAS Online Portal and click on the “Prior Authorization” link on the left menu, then click on the “Manual Forms and Criteria Sheets” link on the left menu, and lastly, click on the “Prevention/Health/Promotion/OTS” link near the middle of the screen.