For Dates of Service Before January 1, 2012

Makena Injections

Makena injections are covered for BadgerCare Plus Standard Plan, BadgerCare Plus Benchmark Plan, and Medicaid members, and are reimbursed fee-for-service for all members, including members enrolled in a state contracted HMO.

Makena is a provider-administered drug and must be injected by a medical professional. Members may not self-administer Makena injections.

Attestation to Administer Makena Injections

Makena injections may be covered if all of the following occur:

• Prescribers complete the Attestation to Administer Makena Injections before beginning treatment. If a member has begun treatment with Makena before November 15, 2011, the prescriber should complete the Attestation to Administer Makena Injections before the first Makena injection after November 15, 2011. Prescribers will only be reimbursed for Makena injections administered on and after November 15, 2011.
• Prescribers complete a PA/RF and indicate process type 117.
• Prescribers submit the Attestation to Administer Makena Injections with the PA/RF to ForwardHealth by fax at (608) 221-8616 or by mail to the following address:

ForwardHealth
Prior Authorization
Ste 88
6406 Bridge Rd.
Madison WI, 53784-0088

• Prescribers receive an approved decision notice from ForwardHealth.

The Attestation to Administer Makena Injections is valid for up to a 21 week course of therapy.

Clinical Criteria

The following are clinical criteria for coverage of Makena injections. All the following criteria must be met:

• The member has experienced difficulty with prior use of 17P compound injection or the member has a medical reason that prevents the use of 17P compound injection.
• The member must be pregnant with a singleton pregnancy.
• The member must have had a previous pre-term delivery (i.e., spontaneous birth before 37 weeks gestation).
• The Makena injection treatment must be initiated between week 16 to week 20 of gestation and continue through 37 weeks gestation or delivery, whichever is first.
• The member must have a diagnosis of V23.41 (Pregnancy with history of preterm labor).

Claim Submission

Procedure code Q2042 (Hydroxyprogesterone Caproate Injection, 1mg), modifier U1, and the NDC for Makena injection must be indicated on professional claims for Makena injections. The addition of the U1 modifier identifies the brand Makena injection and will ensure the provider receives a brand reimbursement rate.

One dose of Makena equals 250 mg. Therefore, providers should enter "250" as the quantity. Providers are required to indicate the appropriate unit(s) on each claim submission. Claims for Makena injection may only be submitted if the drug has been administered.

Makena injection is a diagnosis-restricted drug. Diagnosis code V23.41 is the only allowable diagnosis. Claims submitted with other diagnosis other than the allowable diagnosis indicated will be denied.

Reimbursement

The maximum allowable reimbursement rate for Makena injection is $687.50 per 250 mg injection.

Providers may be reimbursed for the administration of Makena injection by indicating procedure code 96372 on the claim.

The rate for administering Makena injection is $3.31.