Preventing Pre-Term Pregnancies

To: All Providers

Subject: Effective September 1, 2015 all Progesterone therapy will require a pre-authorization from Texas Children’s Health Plan. Claims billed using the branded Makena will no longer require a U1 modifier. Pre-authorized use of Makena (hydroxyprogesterone caproate injection) will need to be submitted as J1725 with the appropriate NDC information as required on all claims. Claims billed using the compounded 17-P therapy will now require the U1 modifier. Pre-authorized use of 17-P will need to be submitted as J1725 with the U1 modifier and appropriate NDC information as required on all claims. Pre-authorization requirements for progesterone therapy will include either a history of a singleton spontaneous preterm birth or a patient status of “at risk for a preterm birth with a singleton pregnancy.” Treatment is to begin between 16 weeks, 0 days and 20 weeks, 6 days of gestation. Weekly intramuscular administration to continue until 36 weeks, 6 days of gestation or delivery, whichever occurs first. If you have questions on Texas Children’s Health Plan’s pre-authorization guidelines, please contact Provider Relations at 832-828-1008 or 800-731-8527. Texas Children’s Health Plan’s utilization management staff are available at 832-828-1004, option 5 or by faxing your authorization request to 832-825-8760.