Get the free Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus
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This form is used to refer patients for the office-administered compounded medication 17 alpha-hydroxyprogesterone caproate, specifically for women with singleton pregnancies and a history of prior
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How to fill out alpha-hydroxyprogesterone caproate pharmacy referral
How to fill out Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus
01
Obtain the Alpha-Hydroxyprogesterone Caproate Pharmacy Referral form from the HealthPlus website or pharmacy.
02
Fill in the patient's full name, date of birth, and contact information in the appropriate sections.
03
Provide the prescribing physician's details including name, contact number, and NPI (National Provider Identifier) number.
04
Specify the diagnosis and the medical necessity for Alpha-Hydroxyprogesterone Caproate.
05
Indicate the prescribed dosage and frequency of the medication.
06
Attach any relevant medical records or documentation that support the referral.
07
Review the completed form for accuracy and completeness.
08
Submit the form via the specified method (fax, email, or in-person) to the designated HealthPlus referral department.
09
Contact the pharmacy or HealthPlus for confirmation and tracking of the referral status.
Who needs Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
01
Patients who are at risk for preterm labor or have other medical indications as evaluated by their healthcare provider.
02
Individuals under the care of a physician who acknowledges the need for hormonal therapy during pregnancy.
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People Also Ask about
Which condition in a patient's history is a contraindication for the administration of estrogens?
The following are contraindications for the use of natural estrogen and synthetic estrogen derivatives: Estrogen hormone receptor sensitive malignancies including cancer, ovarian cancer, and endometrial cancers. Coronary arterial disease. History of thromboembolism or thrombophlebitis.
What is the brand name for hydroxyprogesterone caproate?
Hydroxyprogesterone caproate is available alone in the form of ampoules and vials of 125 and 250 mg/mL oil solutions for intramuscular injection (brand names Proluton, Makena). It is also available alone in the form of a 250 mg/mL autoinjector for use by subcutaneous injection (brand name Makena).
Is hydroxyprogesterone caproate injection banned?
On April 5, 2023, the US Food and Drug Administration withdrew the approval of 17-alpha hydroxyprogesterone caproate, effective immediately, because of the lack of evidence that it reduces the risk of recurrent spontaneous preterm birth.
What are the side effects of hydroxyprogesterone injections?
Side effects that you should report to your doctor or health care professional as soon as possible: allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue. breathing problems. depressed mood. increase in blood pressure. increased hunger or thirst. increased urination.
What is hydroxyprogesterone caproate used for?
Hydroxyprogesterone caproate injection is a man-made progestin hormone. It is used in pregnant women to help lower the risk of giving birth too early (preterm birth or giving birth less than 37 weeks of pregnancy).
For which patient condition is hydroxyprogesterone caproate contraindicated?
cancer, active or history of or. Cholestasis (bile problem) during pregnancy or. Hypertension (high blood pressure), uncontrolled or. Liver disease, including tumors or cancer—Should not be used in patients with these conditions.
What is hydroxyprogesterone caproate pharmacology?
The mechanism of action of hydroxyprogesterone caproate in these uses is suppression of testicular androgen production via suppression of luteinizing hormone secretion, which are the result of the progestogenic and antigonadotropic activity of hydroxyprogesterone caproate.
What is hydroxyprogesterone caproate estradiol valerate used for?
Medical uses EV/OHPC is administered daily to once per week or less often for the treatment of threatened miscarriage, for use as a form of pseudopregnancy, and for other indications. EV/OHPC is used as a combined injectable contraceptive to prevent pregnancy in women under the brand name Injectable No.
What is the price of hydroxyprogesterone caproate injection 500mg?
Hydroxyprogesterone Caproate 500mg/2ml Injection, Packaging Type: Strip at ₹ 126/piece in Chandigarh.
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What is Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus is a process through which healthcare providers request prior authorization for the medication Alpha-Hydroxyprogesterone Caproate, which is used to prevent preterm birth in at-risk pregnant women.
Who is required to file Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
Healthcare providers or prescribers who are prescribing Alpha-Hydroxyprogesterone Caproate for members of the HealthPlus insurance plan are required to file the referral.
How to fill out Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
To fill out the referral, providers must complete the designated referral form, including patient information, clinical details justifying the need for the medication, and provider contact information before submitting it to HealthPlus.
What is the purpose of Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
The purpose of the referral is to ensure that patients meet the clinical criteria for receiving Alpha-Hydroxyprogesterone Caproate, allowing for appropriate medication use and adherence to insurance guidelines.
What information must be reported on Alpha-Hydroxyprogesterone Caproate Pharmacy Referral for Members of HealthPlus?
The referral must report patient demographics, medication details, clinical history relevant to the treatment, specific indications for use, and any other pertinent medical information that supports the need for Alpha-Hydroxyprogesterone Caproate.
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