For Dates of Service From November 15, 2011 to December 31, 2011

Alpha Hydroxprogesterone (17P) Caproate Compound Injection

The 17P compound injection is a covered service and is reimbursed fee-for-service for members enrolled in the BadgerCare Plus Standard Plan, the BadgerCare Plus Benchmark Plan, and Medicaid, including members enrolled in state-contracted HMOs. The 17P compound must be injected by a medical professional. Members may not self-administer the 17P injection.

Clinical Criteria

The following is clinical criteria for coverage of the 17P compound injection:

• The member must be pregnant with a singleton pregnancy.
• The member must have had a previous pre-term delivery (i.e., a spontaneous birth before 37 weeks gestation).
• The 17P injection 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.)

Attestation to Administer Alpha Hydroxyprogesterone (17P) Caproate Injections

The Attestation to Administer Alpha Hydroxyprogesterone (17P) Caproate Injections must be completed prior to giving the first injection. The completed Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injection must be kept in the member's medical record.

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.
• Procedure code Q2042(Hydroxyprogesterone Caproate Injection, 1 mg).
• The NDC and description from the bulk powder used to compound the 17P injection.

The 17P compound injection is a diagnosis-restricted drug. Diagnosis code V23.41 (Pregnancy with history of pre-term labor) is the only diagnosis code that is allowable on claims for the 17P compound injection. Claims with other diagnosis codes indicated will be denied.

Reimbursement

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.

The rate for administering the 17P compound injection is $3.31.