Health Care Professionals :: Progesterone

Which Insurance Plans Pay for 17P?

There are several health plans that pay for 17P. These include Blue Cross Blue Shield of North Carolina, Aetna, United Healthcare, Tricare and the State Employee Health Plan. Medicaid in North Carolina also pays for 17P. Patients with private insurance need to purchase 17P from a compounding pharmacy. The policies for reimbursement differ based on their plan. In some cases, they can then submit a reimbursement claim to their insurance company. In other cases, the providers submit the claims. Privately insured patients should talk with a claims agent from their insurer to confirm. Some pharmacies will only accept bills from compounding pharmacies in their network. Medical Center Pharmacy is one group in North Carolina that has contracts with Blue Cross Blue Shield of North Carolina, UnitedHealthcare and Aetna. Triangle Compounding Pharmacy is also a certified supplier.

What if my patient is uninsured?

The North Carolina General Assembly cares about the health of mothers and babies. They have made funds available to purchase 17P for low income mothers without health insurance or whose insurance plan does not pay for this medication. 17P for uninsured women may only be ordered through the mombaby website. Once an order is placed, the drug is sent to the provider and the special account is billed on behalf of the patient. Neither the provider nor the patient is charged for the medication or syringes.

How do I order 17P?

17P is a compounded medication and must be manufactured by a compounding pharmacy. A number of North Carolina pharmacies compound this drug. A list of names and contact information is posted on this website - see "compounding pharmacies" section.

Orders for patients with Medicaid as well as those who are uninsured may also be placed via this website see "order 17P Medicaid" or "order 17P Uninsured." To submit your order you will need a password. To obtain a password contact the project coordinator at 919-843-7865 or email sarahv@med.unc.edu. The medication should be received within three business days. Providers may order it in either a 5ml or 10ml vial. Single dose vials are also available. Syringes are included.

Who is providing 17P for the Project?

Triangle Compounding Pharmacy is North Carolina’s first Nationally Accredited Compounding Pharmacy. Located in Cary, North Carolina, Triangle Compounding has been providing individualized medications since 1999. Their website address is http://www.trianglecompounding.com. Their address is 550 New Waverly Place, Suite 100, Cary, NC 27511. Their toll free number is 866-858-0809. Their fax is 919-858-5145. You can email them at info@trianglecompounding.com. Again, a list of local compounding pharmacies is included on this website as another option for Medicaid and privately insured providers. Orders for the free drug program must be placed through this website.

Where can I access information about 17P?

The 17P Project has produced a 14-minute DVD about 17P, patient booklets in English and Spanish, and a brochure and practice bulletin for health care professionals. These materials are posted on this website see "17P for Providers" and "17P for Mothers". The video may be viewed online. Copies of all products may be requested by emailing sarahv@med.unc.edu. These products are all free of charge.

Can I order a stock vial for my clinic?

Under the uninsured program, each office may order a vial of 17P for office use. This vial is to be used to administer an initial dose to a patient while her prescription vial is being ordered, or for other urgent uses. It should not be used for regular patient care. To order the vial, place an order under the Uninsured Patient program and use "Office Use" as the patient name. Type in "stock vial" in the other categories and the number 111-111-1111 for the patient telephone number. Stock orders will be monitored by the pharmacy and the 17P Project. There will not be a fee for this vial.

How do I bill Medicaid?

The ICD-9-CM diagnosis code to be used for billing is V23.41. Providers must verify that the recipient’s history includes a previous spontaneous singleton preterm delivery that occurred before 37 weeks. Providers bill for the 17P medication using the HCPCS procedure code J3490. The claim form must include the National Drug code number from the bulk powder used. The maximum reimbursement rate for one unit is $20. Providers must bill their usual and customary charges. These charges include using code 96372 for the injection. Please note that the injection code prior to January 1, 2009 was 90772. Please use the new code now.

The provider orders 17P from a compounding pharmacy. He/she receives the medication and pays the pharmacy for the drug. The provider then bills Medicaid for each injection given.

Medicaid billing tips

The Division of Medical Assistance in North Carolina has been a strong partner in promoting the reduction of recurring preterm birth though the use of 17P. DMA reimburses providers for the use of 17 alpha hydroxyprogesterone caproate for mothers who meet the protocol for its use.

You may order 17P via the www.mombaby.org website or directly from a compounding pharmacy with which you already have a relationship. If you work with a local compounding pharmacy, be sure they purchase their product from a vendor who has a rebate agreement with Medicaid. Currently, Gallipot and Medisca, Inc are the two companies with such an agreement for this product.

Your facility will be billed by the compounding pharmacy for each vial of 17P you order. Triangle Compounding currently charges $15 for a single dose syringe, $60 for a 5-dose vial or $90 for a 10-dose vial.

Medicaid covers weekly 17P intramuscular injections for use in pregnant women with a history of a preterm delivery before 37 weeks gestation but no preterm labor in the current pregnancy. The recommended dose of 17P is a 250-mg weekly intramuscular injection administered from gestational weeks 16 through 36.

Medicaid will reimburse you for each dose administered at $20 per dose. The drug may not be billed until it has been administered.

To obtain Medicaid reimbursement for 17P, a health care provider must administer each dose of 17P.

According to Clinical Policy 1M-6 Maternal Care Skilled Nurse Home Visit, maternal care skilled nurse home visits are reimbursed up to two visits per month. Claims for additional visits will be considered for reimbursement only when conditions of coverage are met and documentation supports medical necessity. Providers can bill for the MCSNHV or for the administration code (96372) but not for both. Providers should refer to the DMA website and Medicaid bulletins for the latest information on Medicaid billing. The website is http://www.ncdhhs.gov/dma/

Private providers may file electronically to bill Medicaid for 17P. Local Health Departments must currently file on paper for 17P reimbursement.

You no longer need to attach a copy of the invoice with your bill. Instead, copy the NDC code number indicated on the invoice for the bulk powder used onto the electronic or paper claim form. The NDC number must be in the 11-digit format. The NDC units must be reported. For a 250 mg dose, the NDC units would be billed as “GM0.25” and the HCPCS units would be billed as J3490 – 1 unit. Remember, only claims with rebatable NDCs will be reimbursed.

Medicaid allows billing for doses given to multiple patients from the same vial. By sharing one vial among several Medicaid patients, you can help prevent wastage of drug and loss of funds for your clinic. You may need to review your clinic’s multi-dose vial policy.

Pay attention to your coding.
- Use ICD9-9-CM diagnosis code V23.41 (history of preterm labor).
- Use HCPCS procedure code J3490. Other CPT or HCPCS codes should not be used for 17P.

Providers should bill their usual and customary charges, including CPT code 96372, for 17P administration. Note: The appropriate code for administration of 17P for dates of service prior to January 1, 2009 was CPT code 90772.
Use HCPCS procedure code T1001 when billing for a Maternal Care Skilled Nurse Home Visit.

Be sure that the provider on your claim form is associated with your clinic. Some sites put the name of the referring provider on the claim form, instead of the name of the provider who is responsible for the patient’s care in their clinic. This error is common among health departments and clinics that are providing weekly 17P injections to patients who were prescribed 17P at a high-risk maternity clinic.

To remain up-to-date on Medicaid billing changes and policy consult the Division of Medical Assistance website at http://www.ncdhhs.gov/dma/ and review DMA’s monthly bulletins. Also, sign up for the 17P Project listserv by emailing cmih@med.unc.edu to receive updates from the 17P project.

Note: References in the responses are made to specific DMA Clinical Coverage Polices which can be found on the DMA website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm.