H Alabama Medicaid Injectable Drug List

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Alabama Medicaid Physician Drug List Pricing of Physician Drugs For Dates of Service prior to July 1, 2005, physician drug prices were updated semi-annually by EDS. Medicaid reimbursement was calculated by averaging the Average Wholesale Prices (AWP) from the Red Book or 80-95% of DIMA (Drug, Improvement, and Modernization Act). Effective for Dates of Service July 1, 2005 and thereafter, the Alabama Medicaid Agency will adopt Medicare’s Drug Pricing Methodology using the Average Sale Price (ASP) for HCPCS injectable drug codes. H.2 Physician Drug List by Name The following table provides a listing of valid physician drug codes sorted alphabetically by name. To view this list sorted numerically, refer to Section H.3, Physician Drug List by Procedure Code. The inclusion or exclusion of a procedure code on this list does not imply Medicaid coverage, reimbursement, or lack thereof. To inquire regarding any restrictions/limits on these procedure codes, please consult the Provider Assistance Center at 1-800-688-7989. The pricing file must be verified to determine coverage and reimbursement amounts. The following drugs can be injected subcutaneously, intramuscularly, or intravenously. Effective for dates of service July 1, 2004 and thereafter, Medicaid will no longer accept X codes. Please utilize the following crosswalk when billing for services for which an X code was previously used. X Code Replacement HCPCS Code X-1015 S0016 X1090 S0077 X-1365 J1700 X-1415 J1980 X-1460 J1055 X-1525 J2680 X-1545 J1980 X-1550 J3415 X-1573 J0696 X-1574 J0696 X-1655 J0595 X-1705 J3411 X-1717 J3301 H-10 July 2006
Alabama Medicaid Physician Drug List H Replaced table Appendix H as of 05/16/06 Procedure Code J7042 J7060 J9015 J9010 J9017 J9020 J7501 90586 90585 J9031 S0116 J9040 J0585 J0587 J9045 J9050 96445 96440 96450 96423 Procedure Code Description 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 5% DEXTROSE/WATER (500 ML = 1 UNIT) ALDESLEUKIN, PER SINGLE USE VIAL ALEMTUZUMAB, 10 MG ARSENIC TRIOXIDE, 1MG ASPARAGINASE, 10,000 UNITS AZATHIOPRINE, PARENTERAL, 100 MG BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR BLADDER CANCER, LIVE, FOR INTRAVESICAL USE BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUBERCULOSIS, LIVE, FOR PERCUTANEOUS USE BCG (INTRAVESICAL) PER INSTILLATION BEVACIZUMAB, 100 MG/4ML BLEOMYCIN SULFATE, 15 UNITS BOTULINUM TOXIN TYPE A, PER UNIT BOTULINUM TOXIN TYPE B, PER 100 UNITS CARBOPLATIN, 50 MG CARMUSTINE, 100 MG CHEMOTHERAPY ADMINISTRATION INTO PERITONEAL CAVITY, REQUIRING AND INCLUDING PERITONEOCENTESIS CHEMOTHERAPY ADMINISTRATION INTO PLEURAL CAVITY, REQUIRING AND INCLUDING THORACENTESIS CHEMOTHERAPY ADMINISTRATION, INTO CNS (EG, INTRATHECAL), REQUIRING AND INCLUDING SPINAL PUNCTURE CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, EACH ADDITIONAL HOUR UP TO 8 HOURS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 96425 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING THE USE OF A PORTABLE OR 96422 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, UP TO ONE HOUR 96420 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; PUSH TECHNIQUE 96415 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL HOUR, 1 TO 8 HOURS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96417 96416 96413 96402 96401 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL INFUSION (DIFFERENT SUBSTANCE/ DRUG), UP TO 1 HOUR (LIST SEPARATELY CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF A CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; UP TO 1 HOUR, SINGLE OR INITIAL SUBSTANCE/DRUG CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; NON-HORMONAL ANTI-NEOPLASTIC July 2006 H-11
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H Alabama Medicaid Injectable Drug List

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