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.