Information for Dates of Service Before October 1, 2015

Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections

Both the 17P compound injection and the Makena injection are covered services and are reimbursed fee-for-service for members enrolled in BadgerCare Plus and Wisconsin Medicaid, including members enrolled in state-contracted HMOs.

The 17P compound injection and the Makena injection are provider-administered drugs and must be administered by a medical professional. Members may not self-administer either a 17P compound injection or a Makena injection.

Clinical Criteria

The following is clinical criteria for coverage of 17P compound injections and Makena injections:

• The member is pregnant with a singleton pregnancy with normal cervical length and has a history of prior spontaneous pre-term birth. A spontaneous preterm birth is defined as a spontaneous (i.e., not indicated) birth occurring after 20 weeks gestation and before 37 weeks gestation.
• Optimally, the 17P compound injections or Makena injections are initiated between week 16 to week 24 gestation and may continue through week 37 gestation or delivery, whichever is first.

Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections

Claim Submission Procedures

Pharmacy providers may not submit claims for 17P compound injections or Makena injections.

To be reimbursed for the 17P compound injection, the following must be indicated on the claim according to the completion instructions for the 1500 Health Insurance Claim Form:

• A quantity of 250 mg for a single date of service.
• Procedure code J1725 (Injection, hydroxyprogesterone caproate, 1 mg).
• The NDC and description from the bulk powder used to compound the 17P injection.

To be reimbursed for the Makena injection, the following must be indicated on the claim according to the completion instructions for the 1500 Health Insurance Claim Form:

• A quantity of 250 mg for a single date of service.
• Procedure code J1725 (Injection, hydroxyprogesterone caproate, 1 mg).
• Modifier U1.
  
 

Note:

The addition of the U1 modifier identifies the brand Makena injection and will ensure the provider receives a brand reimbursement rate.

• The NDC from product administered.

The 17P compound injection and the Makena injection are gender and age-restricted, and are only reimbursed for females between the ages of 12-60 years old. The 17P compound injection and the Makena injection are also diagnosis-restricted. The ICD-9-CM code V23.41 (Pregnancy with history of pre-term labor) must be present on claims for 17P compound injection or Makena injection. Claims without this diagnosis code will be denied.

Reimbursement

17P Compound Injections

The maximum allowable rate for the 17P compound injection is $25.00 per 250 mg injection, which does not include reimbursement for the administration of the drug.

Providers may be reimbursed for the administration of the 17P compound injection by indicating procedure code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) on the claim.

Makena Injections

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.