Coverage of Hydroxyprogesterone Caproate Injection

 

Effective immediately, the South Carolina Department of Health and Human Services (SCDHHS) will cover both Makena® and compounded hydroxyprogesterone caproate without prior authorization. SCDHHS will provide reimbursement directly to pharmacy providers for these products ordered by a prescriber.  SCDHHS will also directly reimburse physicians for these products when purchased and administered through the “buy and bill” process.  For information on reimbursement, coding and rates, see www.scdhhs.gov.  Coverage is allowed only for women with a singleton pregnancy with a history of singleton spontaneous preterm birth. Coverage is available from 16 through 36 weeks gestation if treatment begins between 16 and 20 weeks gestation. Other risk factors for preterm delivery do not qualify for coverage by SCDHHS. While prior authorization is not required, prescribers must maintain documentation in each patient’s medical record for review by SCDHHS.

This bulletin applies to services provided to beneficiaries who are enrolled in fee-for-service Medicaid or a Medical Home Network (MHN). Claims for participants enrolled in either a Medical Homes Network or the fee-for-service program should be billed directly to Medicaid. If you have any questions regarding this policy, please contact the Provider Service Center at (888) 289-0709.

Medicaid Managed Care Organizations (MCOs) will use the form attached to this bulletin for Prior Authorization Requests for both Makena® and compounded hydroxyprogesterone caproate with the Physician indicating the requested product next to their signature.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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