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Pharmacy 2009 Fee Schedule - wwweMedNYorg

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A4206 A4207 A4208 A4209 A4211 A4213 A4215 A4216 A4217 A4221 A4230 A4231 A4232 A4233 A4234 A4235 A4244 A4245 A4246 A4250 A4252 A4253 A4256 A4258 A4259 A4266 A4267 A4268 A4305 A4306 A4310 A4311 A4314 A4320 A4322 A4326 A4331 A4333 A4334 A4335 A4338 A4344 A4346 A4349 A4351 A4352 DESCRIPTION SYRINGE WITH NEEDLE, STERILE, 1 CC OR LE SYRINGE WITH NEEDLE, STERILE 2CC, EACH SYRINGE WITH NEEDLE, STERILE 3CC, EACH SYRINGE WITH NEEDLE, STERILE 5CC OR GREA SUPPLIES FOR SELF ADMINISTERED SYRINGE, STERILE, 20 CC OR GREATER, EACH NEEDLE, STERILE, ANY SIZE, EACH STERILE WATER, SALINE AND/OR DEXTROSE, D STERILE WATER/SALINE,500 ML MAINT SUPPL FOR DRUG INFUSION INFUSION SET-EXT. INS. PUMP/NO INFUSION SET-EXT. INS. PUMP/NE SYRINGE/NEEDLE-EXT. INSUL. PUM REPLACEMENT BATTERY, ALKALINE (OTHER THA REPLACEMENT BATTERY, ALKALINE, J CELL, F REPLACEMENT BATTERY, LITHIUM, FOR USE WI ALCOHOL OR PEROXIDE, PER PINT ALCOHOL WIPES, PER BOX BETADINE OR PHISOHEX SOLUTION, PER PINT URINE TEST/REAGENT STRIPS OR T BLOOD KETONE TEST OR REAGENT STRIP, EACH BLD GLUCOSE TST OR REAGENT STR NORMAL LOW & HIGH CALIBRATOR S SPRING-POWERED DEVICE FOR LANC LANCETS, PER BOX OF 100 DIAPHRAGM KIT CONDOM,MALE CONDOM,FEMALE DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RA DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RA INSERT TRAY W/O DRAIN BAG W/O INSERT TRAY W/O DRAIN BAG /CAT INSERTION TRAY FOLEY 2-WAY LAT IRRIGATION TRAY W BULB OR PIST IRRIGATION SYRINGE,BULB OR PIS MALE EXTERNAL CATHETER WITH INTEGRAL COL EXTENSION DRAINAGE TUBING URIN URINARY CATHETER ANCHORING DEV URINARY CATHETER ANCHOR;LEG ST INCONTINENCE SUPPLY MISC INDWELL CATH FOLEY TYPE TWO-WA INDWELLING CATHETER FOLEY TYPE INDWELL CATH FOLEY TYPE 3 WAY MALE EXTERNAL CATHETER, WITH OR WITHOUT INTERMITTENT URINARY CATHETER INTERMITTENT URINARY CATHETER FEE 0.19 0.34 0.21 0.30 0.62 0.34 0.37 1.58 15.05 6.27 4.63 0.71 3.25 2.34 1.12 1.39 2.96 18.85 4.45 38.79 8.62 12.95 6.56 37.08 0.39 3.50 BR MAX UNITS 200 200 200 200 30 200 200 120 10 200 30 24 30 2 1 1 5 5 3 2 100 4 1 2 2 1 108 108 12 12 10 10 10 30 50 2 5 5 12 30 10 10 10 60 250 250 PA CHANGE

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2.13 5.94 11.73 1.67 1.01 4.82 1.80 2.31 1.36 1.34 6.13 10.92 1.51 0.81 2.58

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A4353 A4354 A4356 A4357 A4358 A4361 A4362 A4363 A4364 A4365 A4366 A4367 A4368 A4369 A4371 A4372 A4373 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4397 A4398 A4399 A4400 A4402 A4404 A4405 A4406 A4407 A4408 DESCRIPTION INTERMIT URINARY CATHETER W/IN INSERTION TRAY W/DRAINAGE BAG EXT URETHRAL CLAMP OR COMPRESS BEDSIDE DRAIN BAG W/WO ANTI-RE URINARY LEG BAG VINYL WITH OR OSTOMY FACE PLATE SKIN BARRIER SOLID 4X4 OR EQUI OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY ADHESIVE FOR OSTOMY OR CATH LI ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 OSTOMY BAG, REUSABLE OR DRAINA OSTOMY BELT OSTOMY FILTER,ANY TYPE OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUS OSTOMY SKIN BARRIER,POWDER,PER OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA OSTOMY SKIN BARRIER W/FLANGE,C OSTOMY POUCH RUBBER,DRAINABLE, OSTOMY POUCH PLASTIC,DRAINABLE A4376;FOR USE ON FACEPLATE OSTOMY POUCH URINARY PLASTIC W OSTOMY POUCH, URINARY, WITH FACEPLATE AT OSTOMY POUCH PLASTIC URINARY A4381;HEAVY PLASTIC A4380;FOR USE ON FACEPLATE OSTOMY SKIN BARRIER SOLID 4X4 OSTOMY POUCH,1-PIECE,EXTEND WE OSTOMY POUCH DRAINABLE,EXT WEA A4387;DRAINABLE A4387;DRAINABLE W/EXT WEAR BAR OSTOMY POUCH URINARY W/EXT WEA A4391;STD WEAR BARRIER,CONVEX A4391;CONVEX OSTOMY DEODORANT, WITH OR WITHOUT LUBRIC OSTOMY DEODERANT SOLID PER TAB OSTOMY BELT W/PERISTOMAL HERNI IRRIGATION SUPPLY SLEEVE EACH IRRIGATION SUPPLIES, BAGS, EAC IRRIGATION SUPPLIES, CONE/CATH OSTOMY IRRIGATION SET EACH LUBRICANT(LUBRICAT OR PETROLEU OSTOMY RING NONPECTIN-BASED OSTOMY PASTE PECTIN-BASED OSTOMY PASTE EXTENDED WEAR OSTOMY SKIN BARR EXTENDED WEAR OSTOMY BARRIER 4 FEE 3.11 7.57 37.98 3.68 4.13 11.99 3.63 1.81 2.19 11.89 0.86 7.19 0.27 2.04 2.49 4.19 6.59 47.40 4.50 30.11 5.31 39.20 3.53 3.53 33.04 5.35 3.23 3.77 6.46 8.41 6.40 8.59 9.49 2.71 0.05 40.40 2.73 1.00 12.87 30.09 0.43 1.62 2.36 4.66 8.69 8.64 BR MAX UNITS 60 30 1 10 30 15 25 5 20 1 10 5 40 22 21 15 15 2 15 2 15 2 10 15 2 15 15 15 15 15 15 15 15 8 60 2 125 125 1 30 20 15 18 18 10 10 PA CHANGE

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A4409 A4410 A4411 A4412 A4413 A4414 A4415 A4416 A4417 A4418 A4419 A4420 A4421 A4423 A4424 A4425 A4426 A4427 A4450 A4452 A4455 A4458 A4463 A4481 A4495 A4500 A4510 A4554 A4565 A4570 A4605 A4614 A4615 A4616 A4619 A4620 A4623 A4624 A4625 A4626 A4628 A4629 A4635 A4636 A4637 A4649 DESCRIPTION OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO HIGH OUTPUT 2PC DRAINABLE OSTO OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY POUCH W/BARRIER & FILTE OSTOMY POUCH,CLOSED W/BARRIER, OSTOMY POUCH,CLOSED,W/O BARRIE OSTOMY POUCH,CLOSED,USE ON BAR OSTOMY POUCH CLOSED,USE W/BARR OSTOMY SUPPLY; MISCELLANEOUS OSTOMY PCH,CLOSED,USE W/BARRIE OSTOMY PCH,DRAINABLE,W/BARRIER OSTOMY PCH,DRAINABLE,USE W/BAR OSTOMY PCH,DRAINABLE,USE W/BAR OSTOMY POUCH,A4426 W/FILTER TAPE NON-WATERPROOF TAPE,WATERPROOF ADHESIVE REMOVER OR SOLVENT ENEMA BAG WITH TUBING, REUSABLE SURGICAL DRESSING HOLDER, REUSABLE, EACH TRACHEOSTOMA FILTER,ANY SIZE/T SUR STOCKING THIGH LEN (CMP 18 SUR STOCKING BL KNEE LEN (CMP SUR STOCK FUL LN (WT H1 OR PG DISPOSABLE UNDERPADS, ALL SIZES SLINGS SPLINT TRACHEAL SUCTION CATHETER,CLOS PEAK FLOW METER HAND HELD CANNULA NASAL TUBING,(OXYGEN),PER FOOT FACE TENT VARIABLE CONCENTRATION MASK TRACHEOSTOMY, INNER CANNULA TRACHEAL SUCTION CATHETER ANY TRACHEOSTOMY CARE OR CLEANING TRACHEOSTOMY CLEANING BRUSH EA SUCTION CATHETER,OROPHARYNGEAL TRACHEOSTOMY CARE KIT/ESTABLIS UNDERARM PAD,CRUTCH,REPLACEMEN REPLACEMENT,HANDGRIP,CANE,CRUT REPLACEMENT,TIP,CANE,CRUTCH,WA SURGICAL SUPPLY MISC FEE 4.80 4.80 5.10 2.84 5.78 4.54 4.54 2.61 3.82 1.90 1.77 1.55 1.90 3.15 3.52 1.76 2.75 0.06 0.11 1.28 16.26 11.15 2.73 14.97 12.41 36.39 0.28 6.47 1.97 10.63 19.24 0.75 0.07 1.27 0.62 5.61 1.40 4.25 1.51 2.02 3.08 2.83 3.53 1.64 BR MAX UNITS 10 10 10 15 15 20 20 60 60 60 60 60 30 60 20 20 20 20 300 100 40 1 5 30 4 4 2 300 1 5 15 1 4 30 4 4 5 250 90 2 5 90 2 2 5 30 PA CHANGE

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A4657 A4660 A4670 A4927 A4930 A4931 A4932 A5051 A5052 A5053 A5054 A5055 A5061 A5062 A5063 A5071 A5072 A5073 A5081 A5082 A5093 A5105 A5112 A5113 A5114 A5120 A5121 A5122 A5126 A5131 A5200 A6010 A6011 A6021 A6022 A6023 A6024 A6196 A6197 A6198 A6199 A6200 A6201 A6203 A6204 A6205 DESCRIPTION SYRINGE, WITH OR WITHOUT NEEDLE, EACH SPHYGMOMANOMETER/BLD PRESS APP AUTOMATIC BLOOD PRESSURE MONITOR GLOVES, NON-STERILE, PER 100 GLOVES,STERILE PER PAIR THERMOMETER,ORAL RECTAL THERMOMETER, REUSABLE, ANY TYPE, POUCH CLOSED W/BARRIER ATTACHE POUCH CLOSED W/O BARRIER ATTAC POUCH CLOSED FOR USE ON FACEPL POUCH CLOSED FOR USE ON BARRIE STOMA CAP EACH POUCH DRAINABLE W/BARRIER ATT POUCH DRAINABLE W/O BARRIER AT POUCH DRAIN FOR USE ON BARRIER POUCH URINARY W/BARRIER ATT (1 POUCH URINARY W/O BARRIER ATT POUCH URINARY FOR USE ON BARRI CONTINENT DEVICE PLUG FOR CONT CONTINENT DEVICE CATH FOR CONT OSTOMY ACCESSORY CONVEX INSERT URINARY SUSPENSORY WITH LEG BAG, WITH OR URINARY LEG BAG LATEX EACH LEG STRAP LATEX PER SET EACH LEG STRAP FOAM OR FABRIC PER S SKIN BARRIER, WIPES OR SWABS, EACH SKIN BARRIER SOLID 6X6 OR EQUI SKIN BARRIER SOLID 8X8 OR EQUI ADHESIVE; DISC OR FOAM PAD 10' APPLIANCE CLEANER OSTOMY/INCON PERCUTANEOUS CATH/TUBE ANCHOR COLLAGEN BASED WOUND FILLER, DRY FORM, S COLLAGEN BASED WOUND FILLER, GEL/PASTE, COLLAGEN DRESSING, STERILE, PAD SIZE 16 COLLAGEN DRESSING, STERILE, PAD SIZE MOR COLLAGEN DRESSING, STERILE, PAD SIZE MOR COLLAGEN DRESSING WOUND FILLER, STERILE, ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. COMPOSITE DRESSING, PAD SIZE MORE THAN 1 COMPOSITE DRESSING, STERILE, PAD SIZE 16 COMPOSITE DRESSING, STERILE, PAD SIZE MO COMPOSITE DRESSING, STERILE, PAD SIZE MO FEE 0.20 20.59 4.55 0.40 1.97 1.34 2.17 1.56 1.73 1.68 2.51 3.37 2.33 2.27 4.41 3.70 3.20 3.37 10.61 1.87 42.80 29.64 1.86 3.92 0.20 6.66 11.96 1.16 8.06 2.70 4.51 2.39 19.88 22.07 76.88 4.39 5.50 6.43 14.52 2.76 1.58 2.70 2.11 4.09 5.65 BR MAX UNITS 200 1 1 1 30 1 1 60 60 60 60 5 150 150 50 50 50 50 31 1 5 5 5 2 2 100 25 25 30 1 30 30 30 5 5 5 3 30 30 15 60 30 30 30 30 15 PA CHANGE 6 1 6 6

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233 A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6251 A6252 A6253 A6254 A6255 A6256 A6257 DESCRIPTION CONTACT LAYER, STERILE, 16 SQ. IN. OR LE CONTACT LAYER, STERILE, MORE THAN 16 SQ. CONTACT LAYER, STERILE, MORE THAN 48 SQ. FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD GAUZE NON-IMP NON-STER UP TO 1 A6216; MORE THAN 16 UP TO 48SQ A6216; MORE THAN 48 SQ IN GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND FILLER, PAS HYDROCOLLOID DRESSING, WOUND FILLER, DRY HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND FILLER, GEL, ST SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV TRANSPARENT FILM, STERILE, 16 SQ. IN. OR FEE 1.53 2.68 6.50 1.66 3.57 8.09 3.99 9.06 10.80 0.04 0.08 0.19 0.22 1.08 2.42 1.44 1.71 1.79 1.62 1.69 1.82 1.32 4.01 5.57 5.69 11.26 13.88 5.11 8.20 10.54 8.12 1.59 3.06 6.49 14.05 3.56 7.39 18.77 4.16 2.09 2.54 3.61 1.07 1.71 3.85 0.35 BR MAX UNITS 30 30 15 30 30 30 30 30 15 120 120 60 120 30 15 30 60 15 30 30 30 30 30 30 30 30 30 30 30 30 20 25 30 30 30 30 30 30 30 30 30 30 30 30 30 30 PA CHANGE

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE A6258 A6259 A6261 A6262 A6266 A6402 A6403 A6404 A6407 A6410 A6411 A6412 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A7000 A7002 A7003 A7004 A7005 A7007 A7013 A7014 A7015 A7038 A7039 A7523 A7525 A9275 A9999 B4034 B4035 DESCRIPTION TRANSPARENT FILM, STERILE, MORE THAN 16 TRANSPARENT FILM, STERILE, MORE THAN 48 WOUND FILLER, GEL/PASTE, STERILE, PER FL WOUND FILLER, DRY FORM, STERILE, PER GRA GAUZE, IMPREGNATED, OTHER THAN WATER, NO GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ A6217;STERILE A6218;STERILE PACKING STRIPS, NON-IMPREGNATED, STERILE EYE PAD,STERILE EYE PAD,NON-STERILE EYE PATCH, OCCLUSIVE, EACH PADDING BANDAGE,NON-ELASTIC 3CONFORMING BANDAGE,NON-ELASTIC CONFORMING BANDAGE,NON-ELASTIC CONFORMING BANDAGE,NON-ELASTIC CONFORMING STERILE BNDGE,NON-E CONFORMING BNDGE,STERILE,NON-E CONFORMING BNDGE,NON-ELAST,STE LIGHT COMRESSION BNDGE,ELASTIC LGHT COMPRESSION BNDGE,ELASTIC LIGHT COMRESSION BNDGE,ELASTIC MOD COMPRESSION BNDGE,ELASTIC, HIGH COMPRESSION BNDGE,ELASTIC SELF-ADHERENT BNDGE,ELASTIC,<3 SELF-ADHERENT BNDGE,ELASTIC,3SELF-ADHERENT BNDGE,ELASTIC,>5 ZINC IMPREGNATED BANDAGE 3-5 I TUBULAR DRESSING WITH OR WITHOUT ELASTIC DISP CANNISTER USED WITH SUCTI TUBING SUCTION PUMP (CONNECTIO ADM KIT W/SM VOL NON-FILT DISP SM VOL NON-FILTERED PNEMATIC N ADM SET SMALL VOL NEBULIZER NO LG VOL DISP NEBULIZER USE W/CO DISP FILTER USE W/COMPRESSOR NON-DISP FILTER FOR COMPRESSOR AEROSOL MASK FOR DME NEBULIZER CPAP/BIPAP DISPOSABLE FILTER CPAP/BIPAP NONDISPOSABLE FILTE TRACH SHOWER PROTECTOR,EACH TRACHEOSTOMY MASK,EACH HOME GLUCOSE DISPOSABLE MONITOR, INCLUDE MISC DME SUPPLY/ACCESSORY,NOC ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, ENTERAL FEEDING SUPPLY KIT;PUM FEE 1.16 2.46 BR MAX UNITS 30 30 30 30 30 180 120 30 30 50 50 30 30 120 120 120 120 120 120 90 90 90 90 15 30 30 30 24 25 5 30 2 5 1 5 5 1 1 5 5 1 4 2 5 30 30 PA CHANGE

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2.02 0.13 0.26 0.35 1.91 0.23 0.16 0.27 0.70 0.04 0.06 0.08 0.06 0.10 0.18 0.06 0.09 0.16 0.17 1.22 0.40 0.57 0.68 0.80 1.20 4.35 0.92 2.23 1.29 16.19 2.89 0.11 0.80 1.06 1.71 2.40 8.10 1.68 28.75 1.88 8.32

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE B4036 B4081 B4082 B4083 B4087 B4088 B4100 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9998 B9999 E0100 E0105 E0110 E0111 E0112 E0113 E0114 DESCRIPTION ENTERAL FEEDING SUPPLY KIT;GRA NASOGASTRIC TUBING WITH STYLET NASOGASTRIC TUBING WITHOUT STY STOMACH TUBE-LEVINE TYPE GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFIL FOOD THICKENER, ADMINISTERED ORALLY, PER ENTERAL FORMULA, MANUFACTURED BLENDERIZE ENTERAL FORMULA, NUTRITIONALLY COMPLETE ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY INCOMPLET ENTERAL FORMULA INHERITED META ENTERAL FORMULA PEDIATRIC COMP ENTERAL FORMULA PEDIATRIC SOY ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI ENTERAL FORMULA PEDIATRIC HYDR ENTERAL FORMULA PEDIATRIC INHE PAR NUT SOL CAR 50 % OR LESS-5 PAR NUT SOL AMINO ACID 3.5% 50 PAR NUT SOL AM AC 5.5%-7% 500M PR NT SOL AA 7-8.5% 500ML=1 U PAR NUT SOL AA GREATER TH 8.5% PR NT SOL CRB DX GREAT TH 50% PARENTERAL NUTRITION SOLUTION, PER 10 GR P NT SL CP AA & CB W EL TE V S P NT SL CP AA & CB W EL TE V S P NT SL CP AA + CB W EL TE V S P NT SL CP AA + CB W EL TE V S P NT ADD VT TE HEP EL HOMEMIX PARENTERAL NUT SUPPLY KIT;PREM PARENTERAL NUT SUPPLY KIT;HOME PARENTERAL NUT ADMINISTRATION P NT SL C AA CB W EL TE U ST R P NT SL C AA C W EL TE V ST HE P NT SL C AA C W EL TE V ST ST NOT OTERWISE CLASSIFIED ENTERA NOT OTHERWISE CLASSIFIED PAREN CANE INCL CANES ALL MATERIALS CANE QUAD/3 PRONG ALL MATERIAL CRUTCHES,FOREARM,PAIR,COMPLETE CRUTCH FOREARM VARI MATERIAL A CRUTCHES UNDERARM WOOD ADJ/FIX CRUTCH UNDERARM WOOD CRUTCHES UNDERARM ALUMIN ADJUS FEE 5.16 16.17 10.06 1.07 22.89 134.58 0.53 1.21 0.49 0.38 1.85 0.85 2.30 4.58 0.73 0.84 0.60 1.35 4.58 13.26 18.59 30.50 43.22 43.22 18.30 8.50 84.28 140.58 158.13 229.21 11.65 BR MAX UNITS 30 1 2 2 1 1 180 600 600 600 600 600 300 600 600 600 600 600 600 90 90 90 90 90 90 450 90 90 90 90 90 90 90 90 90 90 90 90 90 1 1 1 1 1 1 1 PA CHANGE 6 6 6 6 6 6 6 4 4 4 4 4 4 4 4 4 4 4 4

BR SC BR SC BR SC

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE E0116 E0160 E0167 E0188 E0191 E0210 E0215 E0220 E0238 E0275 E0276 E0325 E0326 E0602 E0603 E0605 E0607 E0710 E2100 K0552 L0120 L1825 L1901 L3701 L3909 L3911 L8000 L8001 L8002 L8020 L8030 L8512 L8513 S5560 S5561 S8100 S8101 S8189 S8265 S8460 S8490 T4521 T4522 T4523 T4524 T4529 DESCRIPTION CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUS SITZ BATH PORTABLE PAIL OR PAN FOR USE WITH COMMODE CHAIR, SYNTHETIC SHEEPSKIN PAD HEEL OR ELBOW PROTECTOR EACH ELECTRIC HEATING PADS ELECTRIC HEAT PAD MOIST HOT WATER BOTTLE NON-ELECTRIC HEAT PAD MOIST BED PAN STANDARD METAL OR PLAS BED PAN FRACTURE METAL OR PLAS URINAL MALE JUG-TYPE ANY MATER URINAL FEMALE JUG-TYPE ANY MAT BREAST PUMP ALL TYPES BREAST PUMP ELECTRIC (AC/DC), VAPORIZER,ROOM TYPE HOME BLOOD GLUCOSE MONITOR RESTRAINTS ANY TYPE BLOOD GLUCOSE MONITOR W/VOICE SYRINGE/CARTRIDGE FOR EXT DRUG CERVICAL FLEXIBLE NON-ADJUST F KO, ELASTIC KNEE CAP ANKLE ORTHOSIS,ELASTIC,PREFAB ELBOW ORTHOSIS,ELASTIC,PREFAB WRIST ORTHOSIS,ELASTIC,PREFAB HAND-FINGER ORTHOSIS,ELASTIC,P BREAST PROSTHESES, MASTECTOMY BREAST PROSTHESIS,BRA W/FORM,U BREAST PROSTHESIS,BRA W/FORM,B BREAST PROSTHESES, MASTECTOMY BREAST PROSTHESIS,SILICONE OR GEL CAPS FOR TRACH VOICE PROST CLEANING DEVICE FOR TRACH VOIC INSULIN PEN REUSABLE 1.5 ML INSULIN PEN REUSABLE 3ML SPACER WITHOUT MASK SPACER WITH MASK TRACHEOSTOMY SUPPLY,NOT OTHERW HABERMAN FEEDER FOR CLEFT PALA CAMISOLE,POST-MASTECTOMY INSULIN SYRINGES (100'S) (LOW ADULT SMALL DIAPER ADULT MEDIUM DIAPER ADULT LARGE DIAPER ADULT DIAPER EXTRA LARGE PEDIATRIC DIAPER SMALL/MEDIUM FEE 11.69 4.31 6.08 19.50 2.81 14.40 20.93 4.88 10.44 3.78 4.25 2.99 7.20 17.31 40.63 16.73 76.58 13.65 2.65 6.80 12.41 8.09 8.99 6.99 11.25 31.22 93.74 123.74 180.63 180.63 1.67 3.13 34.98 30.66 16.50 27.75 19.13 37.49 19.65 0.47 0.51 0.68 0.72 0.30 BR MAX UNITS 1 1 1 1 5 1 1 1 1 1 1 1 1 1 1 1 1 4 1 30 1 2 2 2 2 2 5 5 5 2 2 9 6 1 1 2 2 1 2 5 2 250 250 250 250 250 PA CHANGE 6 6

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NYS Medicaid Pharmacy Services Fee Schedule Effective Date: April 1, 2009
CODE T4530 T4533 T4535 T4537 T4539 T4540 T4543 T5999 DESCRIPTION PEDIATRIC DIAPER LARGE YOUTH DIAPER >35 LBS DISPOSABLE INCONTINENCE LINER/ UNDERPAD REUSABLE BED SIZE DIAPER REUSABLE ANY SIZE UNDERPAD REUSABLE CHAIR SIZE DISPOSABLE INCONTINENCE PRODUCT, BRIEF/D SUPPLY,NOT OTHERWISE SPECIFIED Plastic strips Basal thermometer Sterile 6” wood applicator w/cotton tips Incentive spirometer Nasal aspirator BATTERY FOR USE IN HEARING DEV FEE 0.36 0.39 0.28 13.44 6.65 7.19 1.38 2.81 10.41 2.97 5.88 2.40 0.75 BR MAX UNITS 250 250 250 3 5 3 250 5 PA CHANGE 6 6 6 6 6 6 1 1 *

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