Pharmacy Benefit
Medicaid Managed Care
Medicaid MCOs may require clinical prior authorization for Makena. Prescribing providers should contact the MCO using the Prescriber MCO Assistance Chart for its specific requirements and process.
Traditional Medicaid
Makena (hydroxyprogesterone caproate injection) requires clinical prior authorization for people enrolled in traditional Medicaid. Prescribing providers must complete either form 1345 or 1346 and submit to the Texas Prior Authorization Call Center.
| Form Name | Form Number |
|---|---|
| Makena Authorization Request | 1345 |
The following Standard Prior Authorization Addendum must accompany the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial.
| Form Name | Form Number |
|---|---|
| Makena Standard PA Addendum | 1346 |
Medical Benefit
Makena and the compounded version of 17P will continue to be available as a Medicaid medical benefit. For additional information about the medical benefit visit TMHP or call the TMHP Contact Center at 1-800-925-9126.