Prior Authorization : Services Requiring Prior Authorization

Misoprostol

PA requests for misoprostol must be submitted using Section VI (Clinical Information for Drugs with Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA and the PA/RF.

PA requests for misoprostol may be submitted on the Portal, by fax, or by mail. PA requests for misoprostol may not be submitted using the STAT-PA system.

Clinical Criteria for Misoprostol

Clinical criteria that must be documented for approval of a PA request for misoprostol are all of the following:

• The member is currently taking at least one NSAID.
• The member is not pregnant.
• Misoprostol is being prescribed to reduce the risk of an NSAID-induced gastrointestinal ulcer.

Misoprostol may be approved for up to a maximum of 365 days.

Note: Coverage of misoprostol may be covered in gynecological procedures. However, coverage of misoprostol in conjunction with gynecological conditions is only allowed through the medical benefit. Providers should refer to Online Handbook topics Procedure Codes (#2661) and Coverage Policy for Miscarriage Management (#22677) for more information.