RA Messages for December 19, 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 |
| CIMETIDINE HCL
|
LIQ |
39MG.5ML 240ML |
0.11400 |
12/07/00 |
| 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 |
|
DEXAMETHASONE
|
ELIX |
240ML |
0.04000 |
12/07/00 |
| DEXAMETHASONE |
ELIX |
ALL
OTH SIZ |
0.06603 |
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 |
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
|
LOT |
1%
ALL OTH SZ |
OFF
MAC |
10/14/99 |
| 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 |
| PREDNISOLONE SOD PHOS
|
SOL |
1%
5ML |
1.92000 |
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 |
|
TRIAMCINOLONE ACET
|
OINT |
0.025% 15GM |
0.08933 |
12/07/00 |
| VERAPAMIL
|
TAB
SA |
120MG |
OFF
MAC |
12/07/00 |
PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN
INCORRECTLY PAID.
NOTICE TO PROVIDERS
THE YEAR-END MEDICARE CLAIMS RECOUPMENT APPEARS ON THIS REMITTANCE
ADVICE. PROVIDERS WHO ARE AFFECTED BY THIS RECOUPMENT WILL SEE THE ACTUAL
RECOUPMENT CLAIM APPEARING ON THIS RA (WITH AN INTERNAL CONTROL NUMBER BEGINNING
WITH 0344), AS WELL AS A "REJECTED VOID" APPEARING FOR THE SAME CLAIM
(WITH AN INTERNAL CONTROL NUMBER BEGINNING WITH 0365). PLEASE DISREGARD THE
"REJECTED VOID" THAT APPEAR ON THIS RA. THESE APPEAR IN ERROR
AND DO NOT AFFECT YOUR CLAIMS PAYMENT IN ANY WAY.