Form 1345, Makena Authorization Request (Fee for Service Medicaid)

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Effective Date
06/2019
Document
1345.pdf (116.94 KB)

 

Instructions

Updated: 3/18

 

Purpose

To reduce the risk of preterm birth with singleton pregnancy and a history of spontaneous singleton preterm birth. Makena is a once weekly treatment administered by a healthcare provider.

When to Prepare

  • Only use this form for people enrolled in Medicaid fee-for-service.
  • Prescribing providers should contact the appropriate managed care organization for prior authorization requirements for people enrolled in managed care.
  • The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.

 

Detailed Instructions

Makena requests may be submitted for approval just prior to 16 weeks, 0 days gestation to allow time for the prior authorization approval process and shipping from the pharmacy.

Transmittal

  • Fax: 866-617-8864
    • Attention: Texas Prior Authorization Call Center

Questions