Limited Coverage Drugs - ulipristal acetate

Generic Name

ulipristal acetate

Strength

5 mg

Form tablet
Special Authority Criteria Approval Period

For the treatment of moderate to severe signs and symptoms of uterine fibroids in patients who are eligible for surgery, with:

  • Heavy menstrual bleeding, OR
    Bulk symptoms, OR
    Pain, AND
  • When  prescribed by a physician experienced in the management of gynecological conditions such as uterine fibroids.

90 days per lifetime

Practitioner Exemptions

  • None

Special Notes

Additional Information

Special Authority Request Form