Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Hydroxyprogesterone caproate (Makena) may be considered medically necessary in a pregnancy that meets ALL of the followingcriteria:
- Current pregnancy; and
- Pregnancy is between 16 weeks, 0 days and 20 weeks, 6 days; and
- History of spontaneous preterm birth (less than 37 weeks, 0/7 days) but no preterm labor in the current pregnancy.
Hydroxyprogesterone caproate (Makena) is considered experimental/investigational and therefore not covered for allother indications not listed above. Scientific evidence does not support its use for other indications.