Variation in Medicaid Managed Care Coverage Policies for Progesterone to Prevent Preterm Birth [18K]

INTRODUCTION: Preterm birth (PTB) is the leading cause of U.S. infant morbidity and mortality; Medicaid enrollees disproportionately experience preterm deliveries. Data suggest that progesterone – an evidence-based therapy for preventing PTB – is not provided to all eligible Medicaid beneficiaries. This study aimed to identify variation in progesterone coverage guidelines among state Medicaid Managed Care Organizations (MCOs). METHODS: Using a cross-sectional design, participation in a national web-based survey was offered to executives at 20 Medicaid MCOs between November 11, 2015 and January 15, 2016. The survey inquired about coverage guidelines for progesterone and associated interventions to prevent PTB. MCOs identified key barriers in providing progesterone. Descriptive analyses were performed. RESULTS: Analyses included data from 18 plans providing coverage in 31 of the 39 states with Medicaid MCOs (response rate 90%). Responding MCOs were diverse: 55.6% were multistate, 33.3% were nonprofit, and 31.2% covered more than 1,000,000 lives. Most respondents (87.5%) covered branded progesterone, and 81.3% covered the compounded progesterone (C17P). Prior authorization was not universal for branded progesterone (86.7%) or C17P (75.0%). MCO gestational age restrictions for initiating progesterone varied from 22 to 37 weeks of gestation, even within the same state. Barriers to providing progesterone included: cost, lack of provider knowledge of indications and coverage, and variation in billing procedures. CONCLUSION: Significant variation in Medicaid MCO policies regarding progesterone exists both between and within states. This non-standardized approach may be a significant barrier to accessing this evidence-based intervention to prevent PTB.