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Hydroxyprogesterone Caproate (Makena) Procedure Code J1726 No Longer a Benefit Effective June 1, 2023

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On April 6, 2023, the U.S. Food and Drug Administration (FDA) announced the final decision to withdraw the approval of hydroxyprogesterone caproate (Makena).

Effective June 1, 2023, for dates of service on or after April 6, 2023, hydroxyprogesterone caproate (Makena) procedure code J1726 will no longer be a benefit of Texas Medicaid.

The Texas Medicaid Provider Procedures Manual, Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook, subsection 4.1.12, “Hydroxyprogesterone Caproate,” and the Outpatient Drug Services Handbook, subsection 6.43, “Hydroxyprogesterone Caproate,” will be updated to remove references to hydroxyprogesterone caproate.

Affected claims submitted for dates of service from April 6, 2023, through June 1, 2023, may be reprocessed. Affected claims may result in recoupment, which will be reflected on future Remittance and Status (R&S) Reports. No action on the part of the provider is required.

For more information, call the TMHP Contact Center at 800-925-9126.