RA Messages for May 3, 2005
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 APPENDIX A:
| DRUG |
DOSAGE |
STRGTH |
MAC |
EFF DATE |
| ACEBUTOLOL HCL |
CAP |
200MG |
$0.35670 |
05/08/05 |
| ACEBUTOLOL HCL |
CAP |
400MG |
$0.53150 |
05/08/05 |
| ACETAZOLAMIDE |
TAB |
250MG |
OFF MAC |
05/08/05 |
| ACYCLOVIR |
TAB |
400MG |
$0.23340 |
05/08/05 |
| ACYCLOVIR |
TAB |
800MG |
$0.46670 |
05/08/05 |
| ALBUTEROL |
AER |
90MCG 17GM |
$0.30880 |
05/08/05 |
| ALBUTEROL SULF |
SOL |
0.83MG/ML |
$0.11500 |
05/08/05 |
| ALBUTEROL SULF |
SOL |
5MG/ML |
$0.23330 |
05/08/05 |
| ALLOPURINOL |
TAB |
300MG |
$0.10130 |
05/08/05 |
| CILOSTAZOL |
TAB |
100MG |
$1.77900 |
05/08/05 |
| CITALOPRAM HBR |
TAB |
10MG |
$0.58500 |
05/08/05 |
| CITALOPRAM HBR |
TAB |
20MG |
$0.61500 |
05/08/05 |
| CITALOPRAM HBR |
TAB |
40MG |
$0.66000 |
05/08/05 |
| DEMECLOCYCLINE HCL |
TAB |
150MG |
$9.49500 |
05/08/05 |
| DEMECLOCYCLINE HCL |
TAB |
300MG |
$17.18750 |
05/08/05 |
| ETODOLAC |
CAP |
200MG |
$0.58500 |
05/08/05 |
| ETODOLAC |
TAB |
400MG |
$0.39230 |
05/08/05 |
| ETODOLAC |
TAB |
500MG |
$0.75000 |
05/08/05 |
| FLUCONAZOLE |
TAB |
50MG |
$0.50000 |
05/08/05 |
| FLUCONAZOLE |
TAB |
100MG |
$0.88250 |
05/08/05 |
| FLUCONAZOLE |
TAB |
200MG |
$1.40750 |
05/08/05 |
| FLUTICASONE PROP |
TOP OINT & CR |
0.005% |
$1.11100 |
05/08/05 |
| GLYBURIDE/METFORMIN HCL |
TAB |
1.25MG/250MG |
$0.84050 |
05/08/05 |
| GLYBURIDE/METFORMIN HCL |
TAB |
2.5 MG/500MG |
$1.00260 |
05/08/05 |
| GLYBURIDE/METFORMIN HCL |
TAB |
5MG/500MG |
$1.00260 |
05/08/05 |
| HALOBETASOL PROP |
TOP OINT |
0.05% |
$1.47660 |
05/08/05 |
| HYDROCODONE BIT/APAP |
ELIX |
2.5-167/5 |
$0.06330 |
05/08/05 |
| HYDROCODONE BIT/APAP |
TAB |
7.5/500MG |
$0.17390 |
05/08/05 |
| HYDROCODONE BIT/APAP |
TAB |
7.5/650MG |
$0.14100 |
05/08/05 |
| HYDROCODONE BIT/APAP |
TAB |
7.5/750MG |
$0.14070 |
05/08/05 |
| HYDROCORTISONE VALERATE |
TOP CRM & OINT |
0.2% |
$0.65830 |
05/08/05 |
| HYDROXYZINE HCL |
SYR |
10MG/5ML |
$0.01590 |
05/08/05 |
| HYDROXYZINE HCL |
TAB |
10MG |
$0.48650 |
05/08/05 |
| HYDROXYZINE HCL |
TAB |
25MG |
$0.67440 |
05/08/05 |
| HYDROXYZINE HCL |
TAB |
50MG |
$0.82220 |
05/08/05 |
| IBUPROFEN |
TAB |
800MG |
$0.05900 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
25MG |
$0.23180 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
50MCG |
$0.26330 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
75MCG |
$0.29100 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
88MCG |
$0.29550 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
100MCG |
$0.29850 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
112MCG |
$0.34430 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
125MCG |
$0.34950 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
150MCG |
$0.36000 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
175MCG |
$0.42750 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
200MCG |
$0.44180 |
05/08/05 |
| LEVOTHYROXINE SODIUM |
TAB |
300MCG |
$0.60230 |
05/08/05 |
| LORAZEPAM |
TAB |
2MG |
$0.84830 |
05/08/05 |
| METHIMAZOLE |
TAB |
5MG |
$0.42120 |
05/08/05 |
| METHIMAZOLE |
TAB |
10MG |
$0.71760 |
05/08/05 |
| METOPROLOL TARTRATE |
TAB |
25MG |
$0.07200 |
05/08/05 |
| OFLOXACIN |
OPH SOL |
0.3% |
$6.74700 |
05/08/05 |
| OMEPRAZOLE |
CAP DR |
10MG |
$3.54630 |
05/08/05 |
| OMEPRAZOLE |
CAP DR |
20MG |
$3.97900 |
05/08/05 |
| OXYCODONE/ACETAMINOPHEN |
TAB |
5MG/325MG |
$0.14930 |
05/08/05 |
| POTASSIUM CHLORIDE |
TAB SA |
8MEQ |
$0.10440 |
05/08/05 |
| PROMETHAZINE HCL |
SUPP |
12.5MG |
$0.96120 |
05/08/05 |
| PROMETHAZINE HCL |
SUPP |
125MG |
$1.03620 |
05/08/05 |
| PROPOXYPHENE HCL/APAP |
TAB |
65/650MG |
$0.10900 |
05/08/05 |
| PROPRANOLOL HCL |
TAB |
80MG |
$0.10200 |
05/08/05 |
| QUINAPRIL HCL/HCTZ |
TAB |
10MG/12.5MG |
$0.64500 |
05/08/05 |
| QUINAPRIL HCL/HCTZ |
TAB |
20MG/12.5MG |
$0.69830 |
05/08/05 |
| QUINAPRIL HCL/HCTZ |
TAB |
20MG/25MG |
$0.70650 |
05/08/05 |
| RANITIDINE HCL |
TAB |
150MG |
$0.10880 |
05/08/05 |
| RANITIDINE HCL |
TAB |
300MG |
$0.20250 |
05/08/05 |
| RIBAVIRIN |
CAP |
200MG |
$7.57640 |
05/08/05 |
| TERCONAZOLE |
VAG CR |
0.4% |
$0.96500 |
05/08/05 |
| TERCONAZOLE |
VAG CR |
0.8% |
$1.98680 |
05/08/05 |
| THIORIDAZINE HCL |
TAB |
10MG |
$0.33200 |
05/08/05 |
| THIORIDAZINE HCL |
TAB |
25MG |
$0.46700 |
05/08/05 |
| THIORIDAZINE HCL |
TAB |
50MG |
$0.58400 |
05/08/05 |
| THIORIDAZINE HCL |
TAB |
100MG |
$0.66500 |
05/08/05 |
| TRIAZOLAM |
TAB |
0.125MG |
$0.30120 |
05/08/05 |
| TRIAZOLAM |
TAB |
0.25MG |
$0.32510 |
05/08/05 |
PLEASE
FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID
NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES
ROUTINE CIRCUMCISIONS WILL NO LONGER BE PAYABLE EFFECTIVE APRIL 21, 2005. ALL
MEDICALLY NECESSARY CIRCUMCISIONS WILL CONTINUE TO BE PAYABLE.