[If no, no further questions.] 4. Will Makena be administered at a dosage of 250 mg intramuscularly once weekly for up to a maximum of 21 doses? [If no, no further questions.] 5. Is the patient less than 16 years of age? [If yes, no further questions.] 6. Does the patient have a current or history of thrombosis or thromboembolic disorders? [If yes, no further questions.] 7. Does the patient have known or suspected breast cancer, other hormone-sensitive cancer, or a history of these conditions? [If yes, no further questions.] 8. Does the patient have undiagnosed abnormal vaginal bleeding unrelated to pregnancy? [If yes, no further questions.] 9. Does the patient have cholestatic jaundice of pregnancy? [If yes, no further questions.] 10. Does the patient have uncontrolled hypertension? [If yes, no further questions.] 11. Has the patient had an allergic reaction to any ingredients in Makena (hydroxyprogesterone, castor oil, benzyl benzoate, and benzyl alcohol)? [If yes, no further questions.] 12. Is the current gestational age less than 16 weeks, 0 days? [If yes, no further questions.] 13. Is the current gestational age 16 weeks, 0 days up to 36 weeks, 6 days? I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date
[If no, no further questions.] 4. Will Makena be administered at a dosage of 250 mg intramuscularly once weekly for up to a maximum of 21 doses? [If no, no further questions.] 5. Is the patient less than 16 years of age? [If yes, no further questions.] 6. Does the patient have a current or history of thrombosis or thromboembolic disorders? [If yes, no further questions.] 7. Does the patient have known or suspected breast cancer, other hormone-sensitive cancer, or a history of these conditions? [If yes, no further questions.] 8. Does the patient have undiagnosed abnormal vaginal bleeding unrelated to pregnancy? [If yes, no further questions.] 9. Does the patient have cholestatic jaundice of pregnancy? [If yes, no further questions.] 10. Does the patient have uncontrolled hypertension? [If yes, no further questions.] 11. Has the patient had an allergic reaction to any ingredients in Makena (hydroxyprogesterone, castor oil, benzyl benzoate, and benzyl alcohol)? [If yes, no further questions.] 12. Is the current gestational age less than 16 weeks, 0 days? [If yes, no further questions.] 13. Is the current gestational age 16 weeks, 0 days up to 36 weeks, 6 days? I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date
ABH%20TX%20Bexar%20Makena%20(Medicaid).docx