RA Messages for December 12, 2000
PHARMACY PROVIDERS, PLEASE NOTE!!!
IF YOU ARE UNSURE ABOUT THE COVERAGE OF A DRUG PRODUCT,
PLEASE CONTACT
THE PBM HELP DESK AT 1-800-648-0790
PLEASE MAKE THE FOLLOWING CHANGES TO THE
12/9/00 VERSION OF
APPENDIX A:
| DRUG |
DOSAGE |
STRGTH |
MAC |
EFF.DATE |
| ACETAMINOPHEN/CAFF/BUTALB |
CAP |
325-40-50 |
0.23250 |
12/07/00 |
| ACETAZOLAMIDE |
TAB |
125MG |
0.07600 |
12/07/00 |
| ALBUTEROL |
AEROSOL |
90MCG |
0.34900 |
12/07/00
|
| ALBUTEROL SULFATE |
SOL |
5MG/ML |
0.34900 |
12/07/00 |
| AMITRIPTYLINE HCL |
TAB |
25MG |
0.03300 |
12/07/00 |
| AMOXICILLIN |
SUSP RECON |
125MG/5ML
80ML |
0.03787 |
12/07/00 |
| AMOXICILLIN |
SUSP RECON |
250MG/5ML
80ML |
0.05941 |
12/07/00 |
| AMPICILLIN TRIHYDRATE |
SUSP RECON |
125MG/5ML 100ML |
0.02425 |
12/07/00 |
| AMPICILLIN TRIHYDRATE |
SUSP RECON |
125MG/5ML 200ML |
0.01993 |
12/07/00 |
| AMPICILLIN TRIHYDRATE |
SUSP RECON |
250MG/5ML100ML |
0.03512 |
12/07/00 |
| AMPICILLIN TRIHYDRATE |
SUSP RECON |
250MG/5ML200ML |
0.02981 |
12/07/00 |
| BETAMETHASONE VALERATE |
OINT 0.1% |
15GM |
0.28600 |
12/07/00 |
| BETAMETHASONE VALERATE |
OINT 0.1% |
45GM |
0.16555 |
12/07/00 |
| CEFACLOR |
SUSP RECON |
125MG/5ML
75ML |
0.18760 |
12/07/00 |
| CEFACLOR |
SUSP RECON |
250MG/5ML
75ML |
0.34800 |
12/07/00 |
| CEFACLOR |
SUSP RECON |
375MG/5ML
50ML |
0.52190 |
12/07/00 |
| CEPHALEXIN MONOHYDRATE |
TAB |
250MG |
0.43675 |
12/07/00 |
| CHOLESTYRAMINE (PLAIN,W/SUCROSE,W/ASPART) |
4GM |
60S |
0.90040 |
12/07/00 |
| CLOBETASOL PROPIONATE |
FOAM |
0.05% |
|
10/13/00 |
| CLOTRIMAZOLE |
SOL |
1% |
0.66200 |
12/07/00 |
| CLOXACILLIN SODIUM |
CAP |
250MG |
0.35000 |
12/07/00 |
| CLOXACILLIN SODIUM |
CAP |
500MG |
0.65900 |
12/07/00 |
| FLUOCINONIDE |
CREAM 0.05% |
120GM |
0.22458 |
12/07/00 |
| FLUOCINONIDE |
GEL 0.05% |
60GM |
0.50483 |
12/07/00 |
| FLUOCINONIDE |
OINT |
15GM |
1.06333 |
12/07/00 |
| FLUOCINONIDE |
OINT |
60GM |
0.59374 |
12/07/00 |
| HALOPERIDOL |
TAB |
0.5MG |
0.03600 |
12/07/00 |
| HALOPERIDOL |
TAB |
5MG (CHG AGAIN) |
0.57000 |
12/07/00 |
| HALOPERIDOL |
TAB |
20MG |
0.63520 |
12/07/00 |
| HYDRALAZINE/HCTZ |
CAP |
25-25MG |
0.13450 |
12/07/00 |
| HYDRALAZINE/HCTZ |
CAP |
50-50MG |
0.20200 |
12/07/00 |
| HYDROCHLOROTHIAZIDE |
TAB |
100MG |
0.05735 |
12/07/00 |
| HYDROCORTISONE |
CREAM 2.5% |
454GM |
0.12909 |
12/07/00 |
| HYDROCORTISONE |
LOTION 1% |
60ML |
0.20816 |
12/07/00 |
| HYDROCORTISONE |
OINT 2.5% |
20GM |
0.25025 |
12/07/00 |
| INDOMETHACIN |
CAP SA |
75MG 100'S |
0.97500 |
12/07/00 |
| INDOMETHACIN |
CAP SA |
75MG ALL
OTH SZ |
1.09000 |
12/07/00 |
| ISONIAZID |
TAB |
100MG |
0.05160 |
12/07/00 |
| LEUCOVORIN CALCIUM |
TAB |
5MG |
4.72430 |
12/07/00 |
| LINDANE |
SHAMPOO |
1% |
0.16000 |
12/07/00 |
| LITHIUM CITRATE |
SYR |
8MEQ/5ML |
0.03381 |
12/07/00 |
| MECLIZINE HCL |
TAB |
12.5MG |
0.07700 |
12/07/00 |
| MECLOFENAMATE SOD |
CAP |
50MG |
0.33925 |
12/07/00 |
| MECLOFENAMATE SOD |
CAP |
100MG |
0.45900 |
12/07/00 |
| MEDROXYPROGESTERONE ACET |
TAB |
10MG |
0.28400 |
12/07/00 |
| METHYLDOPA |
TAB |
125MG |
0.12650 |
12/07/00 |
| NORETHINDRONE-ETH ESTRAD |
TAB |
0.5-0.035
21'S |
1.01942 |
12/07/00 |
| NORETHINDRONE-ETH ESTRAD |
TAB |
0.5-0.035
28'S |
0.68571 |
12/07/00 |
| NORETHINDRONE-ETH ESTRAD |
TAB |
1-0.035MG
21'S |
0.71666 |
12/07/00 |
| NORETHINDRONE-ETH ESTRAD |
TAB |
1-0.035MG
28'S |
0.49267 |
12/07/00 |
| NORETHINDONE-MESTRANOL |
TAB |
1-0.05MG
21'S |
0.83333 |
12/07/00 |
| NORETHINDONE-MESTRANOL |
TAB |
1-0.05MG
28'S |
0.53731 |
12/07/00 |
| NYSTATIN |
ORAL SUSP 100MU/ML |
60ML |
0.06200 |
12/07/00 |
| OXAZEPAM |
CAP |
30MG |
1.03810 |
10/31/99 |
| OXACILLIN SOD |
SUSP RECON |
250MG/ML |
0.05645 |
12/07/00 |
| PREDNISONE |
TAB |
50MG |
0.22670 |
12/07/00 |
| PROCAINAMIDE HCL |
TAB SA |
750MG |
0.35375 |
12/07/00 |
| PROPOXYPHENE HCL/ASA/CAFF |
CAP |
65MG |
0.24675 |
12/07/00 |
| SULFACETAMIDE SODIUM |
DROPS 10% |
2ML |
1.12500 |
12/07/00 |
| SULFACETAMIDE SODIUM |
DROPS 10% |
5ML |
0.63000 |
12/07/00 |
| SULFATHI/SULFACT/SULFABEN |
CREAM/APP |
78GM |
0.08467 |
12/07/00 |
| SULFINPYRAZONE |
CAP |
200MG |
0.28140 |
12/07/00 |
| THIOTHIXENE HCL |
ORAL CONC |
5MG/ML |
0.32033 |
09/30/97 |
| TIMOLOL MALEATE |
TAB |
20MG |
0.59400 |
12/07/00 |
PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN
INCORRECTLY PAID.
PLEASE MAKE THE FOLLOWING ADDITIONS TO THE
12/9/00 VERSION OF APP B:
| NDC |
TRADENAME
|
DOSAGE |
| 00245-0112-12 |
HEMRIL |
SUPP. RECT |
| 00245-0112-24 |
HEMRIL |
SUPP. RECT |
| 54580-0124-01 |
SPASTRIN |
TABLET |
| 61570-0504-50 |
TIGAN |
SUPP. RECT |
PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN
INCORRECTLY PAID
NOTICE TO HOSPITALS
PAGE 4-16, ISSUED JUNE 1, 1995, OF THE LOUISIANA MEDICAID HOSPITAL SERVICES
PROVIDER MANUAL LISTS THE ICD-9-CM CODES TO BE USED IN CASE OF AN
ABORTION. A TYPOGRAPHICAL ERROR WAS MADE BY INCLUDING CODE 69.52.
THE CORRECT CODE IS 69.51 - ASPIRATION CURETTAGE OF UTERUS FOR TERMINATION
OF PREGNANCY. A REVISED MANUAL PAGE WILL BE ISSUED WITHIN THE NEAR FUTURE.