Progesterone to Prevent Prematurity - IN.govPreterm birth is the leading cause for infant morbidity...

RECOMMENDATIONS TO INCREASE THE USE OF PROGESTERONE TO PREVENT PREMATURITY Indiana Perinatal Quality Improvement Collaborative(IPQIC)

Endorsed by the IPQIC Governing Council

June 2015

ProgesteronetoPreventPrematurity Page2

RecommendationstoIncreasetheUseofProgesteronetoPreventPrematurity

Aim

TheaimoftheProgesteronetoPreventPrematurity(P3)subcommitteeistoensure100%ofeligiblewomenreceiveprogesteronetopreventarecurrentprematurebirth.

SubcommitteeParticipantsThefollowingindividualswereinvolvedinthedevelopmentoftherecommendations:

Name Agency Role

RobertBaker,MD‐CoChair

ManagedHealthServices VicePresidentforMedicalAffairs

BrennanFitzpatrick,MD TheWomen'sHospital Director,HighRiskObstetricServices

LoriGrimm,RN TheWomen’sHospitalDeaconessHealthSystem

Manager,QualityandPatientSafety

KendraHam IndianaStateDeptofHealth MCHEpidemiologist

DawnKackley TerreHauteRegionalHospitalClinicalCoordinator,Women&Children’sServices

JosephLandwehr,MD‐CoChair IUHealthBallMemorial

Perinatologist

MinjooMorlan,MSW INMarchofDimesAssociateDirector,ProgramServices

DanielSunkel,MD Women'sClinic Obstetrician‐Gynecologist

ErinWalsh

FamilyandSocialServicesAdministration

OfficeofMedicaidPolicyandPlanning

KristiWilliams,PharmD

UnionHospital DirectorofMaternalandChildServices

Overview

PretermbirthistheleadingcauseforinfantmorbidityandmortalityinIndianaandintheUnitedStates.Prematuredeliveryaffects11.4%ofthebirthsintheUS.Pretermbirthsaccountfor50%ofthepregnancycostasestimatedbyMedicaiddata,largelycomingfromthecostsassociatedwithneonataladmissions.(MHPA)InIndiana,accordingtodatafrom2011‐2013,8.7‐9.0%ofallpretermbirthswereasecondpretermbirth.Ifprogesteronecouldprevent30‐40%ofalltherecurrentpretermbirths,220pretermbirthsin2011,209


pretermbirthsin2012and215pretermbirthsin2013couldhavebeeneliminated(644pretermbirthsover3years).AmongIndianamotherswhohadahistoryofapreviouspretermbirth,29‐33%gavebirthtoasecondpretermbirth(ISDH,MCH).(ISDH,MCH)MarchofDimeshasestimatedeachpretermbirthontheaveragecost$54,000perNICUadmission.Thiswouldleadtoapotentialsavingsof$11.9millionin2011and$11.2millionin2012.Thisdoesnottakeintoaccountthelongtermcostsandtheemotionaltollthatisplacedonthefamiliesandsocietyofinfantdeathsandofsurvivingprematureinfantswithongoingphysicalanddevelopmentalproblems.

Sinceonly8‐10%ofthepretermbirthsinIndianawererecurrentpretermbirths,thisdoesnotaddresstheother7600pretermdeliveriesin2011ortheother7300pretermdeliveriesin2012.Inordertomakeasignificantimpactonpreventingapretermdelivery,therefore,ascreeningstrategyforidentifyingasymptomaticwomenatriskforpretermdeliverymustbedevised.IamsetalandHassanetalhavedescribeduniversalcervicallengthscreeningprotocolsandtreatmentoptions.Thesestudiesandprotocolsestimatea30%reductioninpretermbirthintheseotherwiseasymptomaticwomenwhichcouldeliminate450‐500prematurebirthsinIndianayearly.Thistranslatesintohugesavingsbothmonetarilyandinthepreventedmorbidityandmortalityofthesenewborns.

AsthesubcommitteewasevaluatingthemosteffectivestrategytotacklethedauntingtasktoreducethenumberofprematurebirthsinIndiana,itbecameveryevidentthatthestrategyshouldtakeplaceinphases.Theresourcesarenotreadilyavailabletoapproachallissuessimultaneously;therefore,wedividedthelongtermstrategyintotwomajorphases:

Phase1–Identifywomenwithapriorpretermbirthandplacethemon17alpha‐hydroxyprogesteronecaproate(17‐P)injectionsperwellpublishedprotocols.Tofacilitatethisstrategy,thebarriersthatarefacingthepatientsandthemedicalpractitionersneedtobeidentifiedandminimized.Thegoalofthecommitteeistodevelopastrategythatwillfacilitatetheeaseofaccessto17Pforallparties.Phase1willbetheareafortherecommendationspresentedinthisdocument.

Phase2–Developascreeningprotocolthatidentifiesthewomenwhoarehighestriskforapretermdelivery,bothlowandhighriskgroups.Thecurrentscreeningprotocolsrecommenduniversalcervicallengthscreening,whichposesachallengefrombothanaccessstandpointandcost/benefitanalysis.Womenwhomeettheshortcervicallengthcriteriawouldthenbeplacedonvaginalprogesteroneiftheyhavenothadapreviouspretermbirth.TheserecommendationswillbeaddressedatalaterdateasPhase2.

NewProfessionalSocietyPracticeGuidelines

BelowisasummaryofrecentpracticeguidelinesfromtheAmericanCongressofObstetriciansandGynecologists(ACOG).(AmericanCollegeofObstetricsandGynecology)


Progesteronestronglyrecommended:

17‐Pforsingletonpregnancieswithapriorspontaneouspretermsingletonbirth,regardlessofcervicallength.Pretermbirthisdefinedaslessthan366/7weeks.

Progesteronenotrecommended:

Singletonwithoutapriorspontaneouspretermsingletonbirthwithanunknownornormalcervicallength

Multiplegestationsregardlessofcervicallength Symptomaticpregnancies(pretermlabororpretermprematureruptureof

membranes),regardlessofcervicallength

BarrierstotheUseof17P

Thesubcommitteediscussedbarrierstotheuseof17Pandobservedtheyfitinthefollowingcategories:

Payment:

Multiplepriorauthorizationmechanismsdependentonthemember’sMedicaidorcommercialinsurance;

Homebasedinjectionprovidersnotfamiliartothemedicalpractitioner,e.g.,useofAlereHomeHealthServices;

Practitionernotdirectlyreimbursedfortheserviceandhasadditionalpaperwork;and

Officevisitsforinjectionrequirethemedicationtobestockedandconsumeofficespaceandtime.

Administrative:

Additionalpaperwork; Differentpoliciesandprocessesbythevarioushealthplans,Medicaidand

commercial,specificallyregardingcoverageofbrand‐nameMakenaorcompounded17‐P;and

Insurerrequirementforpriorapprovalcanbeveryonerous;itisunclearwhypriorapprovalisneededsincethisistheonlyrecognizedinterventionanditisunlikelyitisbeingusedbypatientsforwhomitisnotindicated.

Practitioner:

Maynotbeconvincedthat17‐Porintravaginalprogesteroneiseffective;


Aware,butnosenseofurgency; Womenmaypresentforcareoutsideofrecommendedtimeframes; Maynotbeawareof16‐24weekentryorcontinuationto36+weeks;and ConfusionoveruseofMakenavs.compounded17‐p.

Patient:

Requireshomeinjectionsorself‐administeredinjections; Lateentryintoprenatalcare; Losttofollow‐up,notclearifrestartingprogesteroneishelpful; Notawarethattreatmentisavailable–doesnotdemandtreatment; Maynotself‐identifyashavinggivenapreviouspretermbirthifnewtothepractice;

and Transportationtopractitioner’sofficeorclinic.

ExamplesfromOtherStatesof17‐PInterventions

Thesubcommitteereviewedwhatsomeotherstateshavedonetoincreasetheuseof17‐Ptoreducetheirpretermdeliveryratesandthusreducetheirperinatalmorbidityandmortalityrates.Thefollowingstateshavedevelopedprogramsutilizingdifferentstrategies.

Louisiana

Thestatedevelopedaprogramtohelptheclinicianswiththeorderingprocess.Inordertoreducetheoftentime‐consumingandcumbersomeuseofpre‐authorizationformsandthereferralprocess,Louisianadevelopedawebsitecalledthe17PLouisianaResourceCenterWebsite,www.17pla.org.Fromthiswebsitetheorderingprocess,billingprocessandreferralprocessareeasilyaccessible.Informationaboutthepretermbirthinitiativeandoutcomesarepresented.

NorthCarolina

NorthCarolinatookadifferentapproachandput17‐PtherapywithinabroaderprogramcalledthePregnancyMedicalHomeProgram.Thegoalofthisprogramwastoimproveaccessandthequalityofprenatalcaretoallpregnantwomen.Allpregnantwomenarescreenedfortheirpretermdeliveryrisksandthenappropriatetherapyisinitiatedthroughtheprogram.Theirwebsitecanbeaccessedthroughthefollowinglink:http://www.communitycarenc.com/population‐management/pregnancy‐home/.

Ohio

TheOhioPerinatalQualityCollaborative(OPQC)hasdevelopedastatewideprogesteronequalityimprovementprojectandhasstreamlinedtheaccesstoservices.Theirwebsiteis


https://www.opqc.net/projects/progesterone.Theirstrategyinvolvesenrollingphysiciansandclinicsintotheirprojectprovidernetwork.Theselocationsarethenlistedonthewebsiteasprovidersof17‐Pandthepatientswouldobtaintherapythroughtheseapprovedcenters.Allofficesandclinicsareencouragedtoenrollintheirprogramandbecomean“approved”center.ThecentersinreturnarechargedwithhelpingtheOPQCobtainaccuraterecordsandoutcomedata.TheapprovedCentersthencollectdataontheirenrollmentofpatientstoreceiveprogesteronetherapyandhaveaneasyon‐lineformtheycanfillouttoreportthebarrierstheyencounterintryingtoobtainoradministertheprogesteronetothepatients.

SouthCarolina

SouthCarolinahastheSouthCarolinaBirthOutcomeInitiative.Theirwebsiteishttps://www.scdhhs.gov/organizations/boi.FromthiswebsiteproviderswillaccesstheUniversal17‐Pauthorizationform.ItispartoftheirProgesteroneOutreachProgram;oneofthemajorobjectivesoftheBirthOutcomesInitiativeistomakeaccessto17‐P“hasslefree.”

ExpandingtheProgesteroneStrategy

ArecentIssueBrieffromMedicaidHealthPlansofAmerica(MHPA)CenterforBestPractices(availableathttp://www.mhpa.org/Education_Resources/MHPA_Center_for_Best_Practices/MHPA_Best_Practices_Compendia/)(MedicaidHealthPlansofAmerica)summarizedactionstepsforMedicaidhealthplanswantingtoaccelerateevidence‐baseduseofprogesteronetopreventpretermbirth.ThesestepsmaybehelpfulinIndiana:Improveearlyidentificationofpregnantmothers

OneofthebiggestchallengestoimprovementofallPerinataloutcomesisearlyentryintoprenatalcare.Accesstoearlyprenatalcarewillensureearlyidentificationofpatientsatriskforapretermbirththroughbothhistoryandcervicallengthscreeningstrategies.SubmissionofatimelyNotificationofPregnancy(NOP)wouldidentifythepatientsatriskandwouldallowassignmentofacasemanagertocoordinatetheappropriateservicesforthepatient.Initiating17‐Ptherapypriorto20weeksimprovesitsefficacy.Idealinitiationoftherapybeginsweeklyat16weeksofgestation.

Ensuringadequateobstetrichistory

Remindingproviderstoidentifythepatientsatriskforpretermdeliveryandtoinitiatetherapyattheappropriategestationalageiscrucialforthesuccessoftheprogram.


Referraltohighriskcasemanagementinatimelymannercanensurethepatientshaveaccesstotheappropriatetreatment.

Improveuseof17‐P

Underutilizationof17‐Pisstillthemajorconcern.17‐Piscoveredbyallmajorinsurers,thedifficultyarisesinthemannerinwhichtheprogesteroneisobtainedandadministered.Somecompaniescoverhometherapywhichisbothconvenientforthepatientandensurescomplianceaswell.Minimizingthebarrierstothereferralprocessiscrucialtotheprogram’ssuccess.

Improvepatientadherencetotherapy

Patientcompliancealwayspresentsachallengeforclinicians.Conveniencehelpsensurecomplianceinmanycircumstances.Hometherapyisidealformanyreasonsbutsomeofthemajorbenefitsincludepatientconvenience,patientsatisfactionandpatientcompliance.

EvaluateCost‐BenefitAnalysis

Identifyingandtreatingpatientsforpretermbirthhasbeenshowntobecost‐effectiveinmanystudies.(JenniferI.Bailit)Theuseof17‐OHPhasbeenassociatedwithapotential$2billionopportunity.(JoanneArmstrong)WhenevaluatingcostsMHPArecommendsthefollowingissuesshouldbeconsidered:

Costofcoveredscreeningmodalities Projectedutilizationofscreeningovertime Expectednumbersofhighriskpatientsidentifiedandtreated Potentialreductionsinpretermbirthrates Estimatedreductionsinmaternalandnewbornmedicalservices,especiallyNICU

admissions Estimatedreductioninlong‐termmedicalandothercostsonthebasisoffewer

modalities

QualityImprovementStrategies

Thefocusofeffortstoimprovepracticestopreventpretermbirthmayinclude:

ImprovetheRiskScreeningandutilizationofprogesteronetherapyintoourprenatalcareprograms

Improvetheconsistencyinthephysicianscreeningprocess


Addresstheformularygapsintheavailableformsofprogesterone,anexamplewouldbeMakenaversuscompounded17‐P

EngageALLpregnantwomenintoearlyprenatalcareandscreeningprograms Secureexecutivebuy‐in Useprojectmanagersandacross‐functionalteam Developclinicalalgorithms Reviewandupdatepolicies,processesandproviderinformation Establishmetricstotrack,uptakeandevaluateimpactonoutcomesandcosts Alertcliniciansandbuildmomentumforchange Empowerpatients Maximizecasemanagementutilizationandeffectiveness Promotegreaterawarenessofevidencebasedrecommendations

Recommendations

Thesubcommitteebelievesthereshouldbeaninitialphaseandtheaimofthatphaseshouldbetoensure100%ofeligiblewomenreceiveprogesteronetopreventarecurrentprematurebirth.Ideallythisphaseshouldbeconductedinprimaryobstetricproviders’officesasaqualityimprovementproject.WhenaPerinatalLearningCollaborativewitharapidresponsedatasystemisdevelopedinIndiana,increasingtheuseofprogesteronetopreventprematurity,aswasinstitutedinOhio,wouldbeanidealQualityImprovementProject.

TheFigurebelowshowshowtheOhioPerinatalQualityCollaborativeapproachedincreasingtheuseofProgesteronetopreventprematurity.Thekeydriverdiagramcanbefoundathttps://opqc.net/projects/progesterone%20joining


Intheinterim,thesubcommitteerecommendsdevelopingtoolstoassistobstetricprovidersandpregnantwomeninreceiving17OHprogesteroneasneeded.

ThefirststepistoidentifyALLpregnantwomenwithapriorpretermsingletonbirthdeliveredatlessthan37weeksgestationandnotinducedforamedicalindication.Thereneedstobeearlierandmoreconsistentrecognitionofrisk.Potentialinterventionsinclude:o Useapromptingsystem(suchasachecklist)atthefirstOBvisittoscreenfor

historyofspontaneouspretermbirth(SPTB)o Usesystemsthatallowforfast‐trackofthefirstprenatalvisitforwomenwith

ahistoryofSPTBo Provideearlydatingultrasoundsroutinelytopregnantwomen

Oncethesepatientsareidentifiedthenextstepistoexpeditetheinitiationofweekly17‐Pinjections.Eliminationofthebarrierstoaccess17‐Pwillbeimperativetothesuccessoftheprogram.o Thesubcommitteerecommendsthedevelopmentofaunifiedprior

authorizationprocessamongallIndianahealthinsurerssimilartotheoneMedicaidusesnow.


o Inadditionthereshouldbeaunifiedprocessfor17Pdistribution. Thedevelopmentofaunifiedpriorauthorizationprocessandunifieddistribution

processwillrequirecontinuedworkbythemembersofthissubcommitteeandrepresentativesofcommercialhealthinsuranceproviders.TheuseoftheOPQCprovidersurveyonBarriersToEfficientAdministrationofProgesteronetoPreventPretermBirth(Injectable17‐OHPCandVaginalProductsmaybehelpfultobringthegrouptogether.Thissurveyisavailableathttps://opqc.net/projects/progesterone%20data%20collection%20forms

CasemanagementisaneffectivemanagementstrategyandisavailablethroughcurrentMedicaidManagedCareEntities.Useofthemember’smanagedcareplan,ifapplicable,cansmooththepathtoauthorizationapproval.AllMCEsstronglypromoteuseof17‐P.UsemaybesimplifiedbytheuseofthegridsimilartothatattachedinAppendixA.Cooperationfromcommercialhealthinsurancecompanieswillbenecessaryforcompleteinformationonthegrid.

ThesubcommitteerecommendsinthelongtermusingBirthCertificatedatatomonitortheuseof17Pineligiblewomenannually.However,thiswouldrequiresomechangesinthewaydataiscollected:o Theremustbeaccurateinformationonthebirthcertificateaboutaprevious

pretermbirth.o Thesectionofmedicalproceduresduringpregnancywouldneedtoberevised

tospecificallyincludeuseof17P Thesubcommitteerecommendsthatqualitymeasurementoftheuseof17Pfor

eligiblewomenbedoneatthehospitallevel.o Themetricwouldbethepercentageofeligiblewomenwhoreceive17Pto

preventarecurrentSPTB.o Thegestationalageatinitiationoftherapyshouldalsoberecorded.o Anoutcomemeasurewouldbetheaveragegestationalageofbabiesofeligible

motherswhoreceived17Pandthoseeligiblewhodidnotreceive17P.o Thesemetricscouldbeusedasformeasurementoftheeffectivenessofa

qualityprogramatthehospitallevel.o Themetricscouldalsobeusedasaqualityindicatorforphysicianre‐

credentialingdecisions.o Themeasurescouldalsobeusedtodemonstratemeaningfuluseofelectronic

healthrecords. AsIndianadevelopsCoordinatedPerinatalSystemsofCare,thesubcommittee

recommendsthatObstetricPerinatalCentersincludetheappropriateuseof17PtopreventrecurrentSPTBasatrainingtopicandaqualityassurancemeasuretobeusedwithhospitalsintheirsystems.


ThesubcommitteerecommendsthattheIPQICEducationCommitteepreparematerialsformedicalpractitionersandconsumerstopromotetheuseof17PtopreventrecurrentSPTB.o PatientEducationmaterialsareavailable(e.g.,

http://www.marchofdimes.org/pregnancy/progesterone‐treatment‐to‐prevent‐preterm‐birth.aspx)andshouldbewidelydistributedespeciallytowomenwhohavehadonepretermbirth.

o MedicalpractitionermaterialsincludinganInpatientPrematurityForm,OutpatientProgesteroneCandidateForm,OutpatientDataCollectionForm,OutpatientEnrollmentLogSample,andanOutpatientMonthlySiteProfileSampleareavailableontheOPQCProgesteroneProjectsiteathttps://opqc.net/projects/progesterone%20data%20collection%20forms

o Useof17Ptopreventrecurrentspontaneouspretermbirthshouldbeintegratedwithallpreconception,interconception,andearlyprenatalcareeducationalmaterialsandtools.

Conclusion

Indianamustintegratetheuseof17Ptopreventrecurrentspontaneouspretermbirthintoguidelinesforpreconception,interconceptionandearlyprenatalcare.Promptingcliniciansontheimportanceofandprovidingtoolstoassistwiththeidentificationofpatientswithapriorspontaneouspretermbirthshouldbeobtainablewithminimaleffortandcost.Disparityofcareandclinicianresistanceshouldbeevaluatedandeliminated.Withtheplethoraofavailableliteraturesupportingtheeffectivenessandsafetyofweekly17‐Pinjections,cliniciannon‐acceptanceshouldnotbetolerated.Theuseof17‐Pinalleligiblepatientsisthestandardofcare.

Enrollmentintreatmentandacquisitionof17‐Pmayprovemorechallengingbutshouldalsobeanobtainablegoal.UniversalcoveragebyallinsuranceplansinIndiana,whetherprivateorpublic,shouldbeexpected.Eliminationofbarrierstoaccess17PwillrequirefurtherworkofIPQIC,IndianaMedicaidandIndianacommercialinsuranceproviders.MonitoringtheuseofprogesteronetopreventprematurebirthswiththeuseofvitalrecordswillrequirechangestotheIndianabirthcertificate.Intheinterimandforqualityimprovementpurposes,thesubcommitteerecommendsthathospitalsusemetricstoincreasetheuseofprogesteroneamongeligiblewomenintheirobstetricsprograms.Inaddition,themeasurementoftheappropriateuseofprogesteronetopreventpretermbirthsshouldbeusedbythedevelopingIndianaObstetricPerinatalCentersastrainingtopicsandqualityassurancemeasures.EducationalmaterialsforconsumersandtoolsformedicalpractitionersareavailableandthissubcommitteerequeststhehelpoftheIPQICEducationCommitteeindecidingoneffectivematerialsandpromotingtheirdissemination.


UniversalcervicalscreeningisalongtermgoalofthiscommitteebutimplementationstrategieswillbedeferredtoPhase2.ItisthehopeofthecommitteethatthescreeningprotocoldevisedbyJayIamsetalmaysomedaybeuniversallyimplemented.(SeealgorithmattachedinAppendixB)

ReferencesAmericanCollegeofObstetricsandGynecology.“ACOGCommitteeOpinionNo.419”in

ObstetGynecol2008;112:963‐5,October2008AmericanCollegeofObstetricsandGynecology."PredictionandPreventionofPretermBirth."PracticeBulletin.Number130,October2012.

Armstrong,JoanneMD,MPH."17Progesteroneforpretermbirthprevention:apotential$2billionopportunity."AmJObstetGynecol(2007):194‐195.

Bailit.JenniferI,MD,MPHandMarkE.Votruba,PhD,MPP."Medicalcostsavingsassociatedwith17alpha‐hydroxyprogesteronecaproate."AmJObstetGynecol(2007):219.e1‐219.e7.

HassanSS,RomeroR,VidyadhariD,etal."Vaginalprogesteronereducestherateofpretermbirthinwomenwithasonographicshortcervix:amulti‐center,randomized,double‐blind,placebo‐controlledstudy."UltrasoundObstetGynecol38(2011;38):18‐31.Document.

Iams,JayD."IdentificationofCandidatesforProgesterone.Why,Who,How,andWhen?"ObstetGynecol(2014;123):1317‐26.Document.

Iams,JayD."PreventionofPretermParturition."NEnglJMed2014;370:254‐261January16,2014DOI:10.1056/NEJMcp1103640

MackenzieR,WalkerM,ArmsonAandHannahME.“Progesteroneforthepreventionofpretermbirthamongwomenatincreasedrisk:Asystematicreviewandmeta‐analysisofrandomizedcontrolledtrials.”AmJObstetGynecol(2006)194:1234‐42.

MedicaidHealthPlansofAmerica."PretermBirthPrevention:EvidenceBasedUseofProgesteroneTreatment."LeadershipRoundtable.2014.Document.

Meis,PaulJ.MDfortheSocietyofMaternal‐FetalMedicine.“17HydroxyprogesteroneforthePreventionofPretermDelivery.”ObstetGynecol(2005);105:1128‐35.

Regmi,MohanC.,PappuRijal,AjayAgrawalandDhrubaUprety.“ProgesteroneforPreventionofRecurrentPretermLaborafterArrestedPretermLabor–ARandomized


ControlledTrial.”GynecolObstet(2012);2:125‐28.

Schindler,AldolfE.“Roleofprogestogensforthepreventionofprematurebirth.”JournalofSteroidBiochemistry&MolecularBiology.97(2005):435‐8.

Vidaeff,AlexC.andBelfort,MichaelA.“Criticalappraisaloftheefficacy,safety,andpatientacceptabilityofhydroxyprogesteronecaproateinjectiontoreducetheriskofpretermbirth.”PatientPreferenceandAdherence(2013);7:683‐91.


AppendixA

ManagedCareGrid


PlanUM

Process UM Contact Info

State of Indiana Yes

Phone: 855-577-6317 (Catamaran)Email: [email protected]: https://inm.providerportal.catamaranrx.com/providerportal /faces/PreLogin.jsp

MHS Yes

Phone: 877-647-4848Fax: 866-912-4245Website: http://www.mhsindiana.com/for-providers/provider-forms/

Anthem Yes

Phone: 866-408-7187Fax: 800-601-4829Website: http://www.anthem.com/wps/portal/ahpprovider? content_path=provider/in/f3/s4/t1/pw_ad089349.htm&state=in&rootLevel=2&label=Pharmacy%20Information

MDWise Yes

Phone: 855-491-0633Fax: 855-811-9324Website: http://www.mdwise.org/for-providers/forms/prior-authorization/

Commercial Sample: Aetna Yes

Phone: 866-503-0857Fax: 866-267-3277Website: https://www.aetna.com/health-care-professionals/precertification.html

17-P Authorization


AppendixB

IamsAlgorithm

Progesterone to Prevent Prematurity - IN.govPreterm birth is the leading cause for infant morbidity...

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