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 following criteria:
- 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) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.