The 17P caproate compound injection is covered for members enrolled in the BadgerCare Plus Standard Plan, the BadgerCare Plus Benchmark Plan, and Medicaid. The compound is available through and only reimbursable for sterile compounding pharmacies.
The 17P compound must be injected by a medical professional. Members may not self-administer the 17P injection.
The following is clinical criteria for coverage of the 17P injection:
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 (17P) Caproate Injections must be kept in the member's medical record.
To be reimbursed for the 17P injection, the following must be indicated on the claim according to the completion instructions for the 1500 Health Insurance Claim Form:
The 17P 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 injection. Claims with other diagnosis codes indicated will be denied.
The claim for the 17P injection may be submitted to ForwardHealth by mail. The provider's usual and customary charge should be indicated on the claim.
The maximum allowable rate for the 17P injection is $22.66 per injection, which does not include reimbursement for the administration of the drug.
Providers may be reimbursed for the administration of the 17P 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 injection is $3.31.