Pharmacy FS 2010

Document Sample
Pharmacy FS 2010 Powered By Docstoc
					                                                                                     Page 1 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                      DESCRIPTION               FEE      BR   UNITS PA CHANGE
           90470    H1N1 IMMUNIZATION ADMINISTRATION (INTRAM    13.23           1        *
           90473    IMMUNIZATION ADMINISTRATION BY INTRANASA     8.57           1        *
           90656    INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PR     cost           1        *
           90658    INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WH     cost           1        *
           90660    INFLUENZA VIRUS VACCINE, LIVE, FOR INTRA     cost           1        *
           90663    INFLUENZA VIRUS VACCINE, PANDEMIC FORMUL     0.00           1        *
           90732    PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-     cost           1        *
           A4206    SYRINGE WITH NEEDLE, STERILE, 1 CC OR LE     0.19         200
           A4207    SYRINGE WITH NEEDLE, STERILE 2CC, EACH       0.34         200
           A4208    SYRINGE WITH NEEDLE, STERILE 3CC, EACH       0.21         200
           A4209    SYRINGE WITH NEEDLE, STERILE 5CC OR GREA     0.30         200
           A4211    SUPPLIES FOR SELF ADMINISTERED                             30   1
           A4213    SYRINGE, STERILE, 20 CC OR GREATER, EACH     0.62         200
           A4215    NEEDLE, STERILE, ANY SIZE, EACH              0.34         200
           A4216    STERILE WATER, SALINE AND/OR DEXTROSE, D     0.37         120
           A4217    STERILE WATER/SALINE,500 ML                  1.58          10
           A4221    MAINT SUPPL FOR DRUG INFUSION                             200   6
           A4230    INFUSION SET-EXT. INS. PUMP/NO             15.05           30   6
           A4231    INFUSION SET-EXT. INS. PUMP/NE              6.27           24   6
           A4232    SYRINGE/NEEDLE-EXT. INSUL. PUM              4.63           30   6
           A4233    REPLACEMENT BATTERY, ALKALINE (OTHER THA    0.71            2   6
           A4234    REPLACEMENT BATTERY, ALKALINE, J CELL, F    3.25            1   6
           A4235    REPLACEMENT BATTERY, LITHIUM, FOR USE WI    2.34            1   6
           A4244    ALCOHOL OR PEROXIDE, PER PINT               1.12            5
           A4245    ALCOHOL WIPES, PER BOX                      1.39            5
           A4246    BETADINE OR PHISOHEX SOLUTION, PER PINT     2.96            3
           A4250    URINE TEST/REAGENT STRIPS OR T             18.85            2
           A4252    BLOOD KETONE TEST OR REAGENT STRIP, EACH    4.45          100   6
           A4256    NORMAL LOW & HIGH CALIBRATOR S              8.62            1   6
           A4258    SPRING-POWERED DEVICE FOR LANC             12.95            2
           A4259    LANCETS, PER BOX OF 100                     6.56            2
           A4266    DIAPHRAGM KIT                              37.08            1
           A4267    CONDOM,MALE                                 0.39          108
           A4268    CONDOM,FEMALE                               3.50          108
           A4305    DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RA                   12   1
           A4306    DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RA                   12   1
           A4310    INSERT TRAY W/O DRAIN BAG W/O               2.13           10
           A4311    INSERT TRAY W/O DRAIN BAG /CAT              5.94           10
           A4314    INSERTION TRAY FOLEY 2-WAY LAT             11.73           10
           A4320    IRRIGATION TRAY W BULB OR PIST              1.67           30
           A4322    IRRIGATION SYRINGE,BULB OR PIS              1.01           50
           A4326    MALE EXTERNAL CATHETER WITH INTEGRAL COL    4.82            2
           A4331    EXTENSION DRAINAGE TUBING URIN              1.80            5
           A4333    URINARY CATHETER ANCHORING DEV              2.31            5
           A4334    URINARY CATHETER ANCHOR;LEG ST              1.36           12
           A4335    INCONTINENCE SUPPLY MISC                                   30   1
           A4338    INDWELL CATH FOLEY TYPE TWO-WA               1.34          10
                                                                                     Page 2 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                      DESCRIPTION               FEE      BR   UNITS PA CHANGE
           A4344    INDWELLING CATHETER FOLEY TYPE               6.13          10
           A4346    INDWELL CATH FOLEY TYPE 3 WAY               10.92          10
           A4349    MALE EXTERNAL CATHETER, WITH OR WITHOUT      1.51          60
           A4351    INTERMITTENT URINARY CATHETER                0.81         250
           A4352    INTERMITTENT URINARY CATHETER                2.58         250   1
           A4353    INTERMIT URINARY CATHETER W/IN               3.11          60
           A4354    INSERTION TRAY W/DRAINAGE BAG                7.57          30
           A4356    EXT URETHRAL CLAMP OR COMPRESS              37.98           1
           A4357    BEDSIDE DRAIN BAG W/WO ANTI-RE               3.68          10
           A4358    URINARY LEG BAG VINYL WITH OR                4.13          30
           A4361    OSTOMY FACE PLATE                           11.99          15
           A4362    SKIN BARRIER SOLID 4X4 OR EQUI               3.63          25
           A4363    OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY     1.81           5
           A4364    ADHESIVE FOR OSTOMY OR CATH LI               2.19          20
           A4366    OSTOMY BAG, REUSABLE OR DRAINA               0.86          10
           A4367    OSTOMY BELT                                  7.19           5
           A4368    OSTOMY FILTER,ANY TYPE                       0.27          40
           A4369    OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUS     2.04          22
           A4371    OSTOMY SKIN BARRIER,POWDER,PER               2.49          21
           A4372    OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA     4.19          15
           A4373    OSTOMY SKIN BARRIER W/FLANGE,C               6.59          15
           A4376    OSTOMY POUCH RUBBER,DRAINABLE,              47.40           2   6
           A4377    OSTOMY POUCH PLASTIC,DRAINABLE               4.50          15
           A4378    A4376;FOR USE ON FACEPLATE                  30.11           2   6
           A4379    OSTOMY POUCH URINARY PLASTIC W               5.31          15
           A4380    OSTOMY POUCH, URINARY, WITH FACEPLATE AT    39.20           2   6
           A4381    OSTOMY POUCH PLASTIC URINARY                 3.53          10
           A4382    A4381;HEAVY PLASTIC                          3.53          15
           A4383    A4380;FOR USE ON FACEPLATE                  33.04           2   6
           A4385    OSTOMY SKIN BARRIER SOLID 4X4                5.35          15
           A4387    OSTOMY POUCH,1-PIECE,EXTEND WE               3.23          15
           A4388    OSTOMY POUCH DRAINABLE,EXT WEA               3.77          15
           A4389    A4387;DRAINABLE                              6.46          15
           A4390    A4387;DRAINABLE W/EXT WEAR BAR               8.41          15
           A4391    OSTOMY POUCH URINARY W/EXT WEA               6.40          15
           A4392    A4391;STD WEAR BARRIER,CONVEX                8.59          15
           A4393    A4391;CONVEX                                 9.49          15
           A4394    OSTOMY DEODORANT, WITH OR WITHOUT LUBRIC     2.71           8
           A4395    OSTOMY DEODERANT SOLID PER TAB               0.05          60
           A4396    OSTOMY BELT W/PERISTOMAL HERNI              40.40           2   6
           A4397    IRRIGATION SUPPLY SLEEVE EACH                2.73         125
           A4398    IRRIGATION SUPPLIES, BAGS, EAC               1.00         125
           A4399    IRRIGATION SUPPLIES, CONE/CATH              12.87           1
           A4400    OSTOMY IRRIGATION SET EACH                  30.09          30
           A4402    LUBRICANT(LUBRICAT OR PETROLEU               0.43          20
           A4404    OSTOMY RING                                  1.62          15
           A4405    NONPECTIN-BASED OSTOMY PASTE                 2.36          18
                                                                                     Page 3 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                     DESCRIPTION                FEE      BR   UNITS PA CHANGE
           A4406    PECTIN-BASED OSTOMY PASTE                    4.66          18
           A4407    EXTENDED WEAR OSTOMY SKIN BARR               8.69          10
           A4408    EXTENDED WEAR OSTOMY BARRIER 4               8.64          10
           A4409    OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,     4.80          10
           A4410    OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,     4.80          10
           A4411    OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA     5.10          10
           A4412    OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO     2.84          15
           A4413    HIGH OUTPUT 2PC DRAINABLE OSTO               5.78          15
           A4414    OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,     4.54          20
           A4415    OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,     4.54          20
           A4416    OSTOMY POUCH W/BARRIER & FILTE               2.61          60
           A4417    OSTOMY POUCH,CLOSED W/BARRIER,               3.82          60
           A4418    OSTOMY POUCH,CLOSED,W/O BARRIE               1.90          60
           A4419    OSTOMY POUCH,CLOSED,USE ON BAR               1.77          60
           A4420    OSTOMY POUCH CLOSED,USE W/BARR               1.55          60
           A4421    OSTOMY SUPPLY; MISCELLANEOUS                               30   1
           A4423    OSTOMY PCH,CLOSED,USE W/BARRIE              1.90           60
           A4424    OSTOMY PCH,DRAINABLE,W/BARRIER              3.15           20
           A4425    OSTOMY PCH,DRAINABLE,USE W/BAR              3.52           20
           A4426    OSTOMY PCH,DRAINABLE,USE W/BAR              1.76           20
           A4427    OSTOMY POUCH,A4426 W/FILTER                 2.75           20
           A4450    TAPE NON-WATERPROOF                         0.06          300
           A4452    TAPE,WATERPROOF                             0.11          100
           A4455    ADHESIVE REMOVER OR SOLVENT                 1.28           40
           A4456    ADHESIVE REMOVER, WIPES, ANY TYPE, EACH     0.24           50
           A4458    ENEMA BAG WITH TUBING, REUSABLE            16.26            1   6
           A4463    SURGICAL DRESSING HOLDER, REUSABLE, EACH   11.15            5
           A4481    TRACHEOSTOMA FILTER,ANY SIZE/T              2.73           30   1
           A4495    SUR STOCKING THIGH LEN (CMP 18             14.97            4   6
           A4500    SUR STOCKING BL KNEE LEN (CMP              12.41            4   6
           A4510    SUR STOCK FUL LN (WT H1 OR PG              36.39            2   6
           A4554    DISPOSABLE UNDERPADS, ALL SIZES             0.28          300   6
           A4565    SLINGS                                      6.47            1
           A4570    SPLINT                                      1.97            5
           A4605    TRACHEAL SUCTION CATHETER,CLOS             10.63           15
           A4614    PEAK FLOW METER HAND HELD                  19.24            1
           A4615    CANNULA NASAL                               0.75            4
           A4616    TUBING,(OXYGEN),PER FOOT                    0.07           30
           A4619    FACE TENT                                   1.27            4
           A4620    VARIABLE CONCENTRATION MASK                 0.62            4
           A4623    TRACHEOSTOMY, INNER CANNULA                 5.61            5
           A4624    TRACHEAL SUCTION CATHETER ANY               1.40          250
           A4625    TRACHEOSTOMY CARE OR CLEANING               4.25           90
           A4626    TRACHEOSTOMY CLEANING BRUSH EA              1.51            2
           A4628    SUCTION CATHETER,OROPHARYNGEAL              2.02            5
           A4629    TRACHEOSTOMY CARE KIT/ESTABLIS              3.08           90
           A4635    UNDERARM PAD,CRUTCH,REPLACEMEN              2.83            2
                                                                                     Page 4 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                      DESCRIPTION               FEE      BR   UNITS PA CHANGE
           A4636    REPLACEMENT,HANDGRIP,CANE,CRUT               3.53           2
           A4637    REPLACEMENT,TIP,CANE,CRUTCH,WA               1.64           5
           A4649    SURGICAL SUPPLY MISC                                       30   1
           A4657    SYRINGE, WITH OR WITHOUT NEEDLE, EACH       0.20          200
           A4660    SPHYGMOMANOMETER/BLD PRESS APP             20.59            1   6
           A4670    AUTOMATIC BLOOD PRESSURE MONITOR                            1   1
           A4927    GLOVES, NON-STERILE, PER 100                4.55            1   6
           A4930    GLOVES,STERILE PER PAIR                     0.40           30   6
           A4931    THERMOMETER,ORAL                            1.97            1
           A4932    RECTAL THERMOMETER, REUSABLE, ANY TYPE,     1.34            1
           A5051    POUCH CLOSED W/BARRIER ATTACHE              2.17           60
           A5052    POUCH CLOSED W/O BARRIER ATTAC              1.56           60
           A5053    POUCH CLOSED FOR USE ON FACEPL              1.73           60
           A5054    POUCH CLOSED FOR USE ON BARRIE              1.68           60
           A5055    STOMA CAP EACH                              2.51            5
           A5061    POUCH DRAINABLE W/BARRIER ATT               3.37          150
           A5062    POUCH DRAINABLE W/O BARRIER AT              2.33          150
           A5063    POUCH DRAIN FOR USE ON BARRIER              2.27           50
           A5071    POUCH URINARY W/BARRIER ATT (1              4.41           50
           A5072    POUCH URINARY W/O BARRIER ATT               3.70           50
           A5073    POUCH URINARY FOR USE ON BARRI              3.20           50
           A5081    CONTINENT DEVICE PLUG FOR CONT              3.37           31
           A5082    CONTINENT DEVICE CATH FOR CONT             10.61            1
           A5093    OSTOMY ACCESSORY CONVEX INSERT              1.87            5
           A5105    URINARY SUSPENSORY WITH LEG BAG, WITH OR   42.80            5   6
           A5112    URINARY LEG BAG LATEX EACH                 29.64            5
           A5113    LEG STRAP LATEX PER SET EACH                1.86            2
           A5114    LEG STRAP FOAM OR FABRIC PER S              3.92            2
           A5120    SKIN BARRIER, WIPES OR SWABS, EACH          0.20          100
           A5121    SKIN BARRIER SOLID 6X6 OR EQUI              6.66           25
           A5122    SKIN BARRIER SOLID 8X8 OR EQUI             11.96           25
           A5126    ADHESIVE; DISC OR FOAM PAD 10'              1.16           30
           A5131    APPLIANCE CLEANER OSTOMY/INCON              8.06            1
           A5200    PERCUTANEOUS CATH/TUBE ANCHOR               2.70           30
           A6010    COLLAGEN BASED WOUND FILLER, DRY FORM, S    4.51           30   6
           A6011    COLLAGEN BASED WOUND FILLER, GEL/PASTE,     2.39           30   6
           A6021    COLLAGEN DRESSING, STERILE, PAD SIZE 16    19.88            5   6
           A6022    COLLAGEN DRESSING, STERILE, PAD SIZE MOR   22.07            5   6
           A6023    COLLAGEN DRESSING, STERILE, PAD SIZE MOR   76.88            5   6
           A6024    COLLAGEN DRESSING WOUND FILLER, STERILE,    4.39            3   6
           A6196    ALGINATE OR OTHER FIBER GELLING DRESSING    5.50           30
           A6197    ALGINATE OR OTHER FIBER GELLING DRESSING    6.43           30
           A6198    ALGINATE OR OTHER FIBER GELLING DRESSING   14.52           15
           A6199    ALGINATE OR OTHER FIBER GELLING DRESSING    2.76           60
           A6203    COMPOSITE DRESSING, STERILE, PAD SIZE 16    2.11           30
           A6204    COMPOSITE DRESSING, STERILE, PAD SIZE MO    4.09           30
           A6205    COMPOSITE DRESSING, STERILE, PAD SIZE MO    5.65           15
                                                                                     Page 5 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                     DESCRIPTION                FEE      BR   UNITS PA CHANGE
           A6206    CONTACT LAYER, STERILE, 16 SQ. IN. OR LE     1.53          30
           A6207    CONTACT LAYER, STERILE, MORE THAN 16 SQ.     2.68          30
           A6208    CONTACT LAYER, STERILE, MORE THAN 48 SQ.     6.50          15
           A6209    FOAM DRESSING, WOUND COVER, STERILE, PAD     1.66          30
           A6210    FOAM DRESSING, WOUND COVER, STERILE, PAD     3.57          30
           A6211    FOAM DRESSING, WOUND COVER, STERILE, PAD     8.09          30
           A6212    FOAM DRESSING, WOUND COVER, STERILE, PAD     3.99          30
           A6213    FOAM DRESSING, WOUND COVER, STERILE, PAD     9.06          30
           A6214    FOAM DRESSING, WOUND COVER, STERILE, PAD    10.80          15
           A6216    GAUZE NON-IMP NON-STER UP TO 1               0.04         120
           A6217    A6216; MORE THAN 16 UP TO 48SQ               0.08         120
           A6218    A6216; MORE THAN 48 SQ IN                    0.19          60
           A6219    GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ     0.22         120
           A6220    GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ     1.08          30
           A6221    GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ     2.42          15
           A6222    GAUZE, IMPREGNATED WITH OTHER THAN WATER     1.44          30
           A6223    GAUZE, IMPREGNATED WITH OTHER THAN WATER     1.71          60
           A6224    GAUZE, IMPREGNATED WITH OTHER THAN WATER     1.79          15
           A6228    GAUZE, IMPREGNATED, WATER OR NORMAL SALI     1.62          30
           A6229    GAUZE, IMPREGNATED, WATER OR NORMAL SALI     1.69          30
           A6230    GAUZE, IMPREGNATED, WATER OR NORMAL SALI     1.82          30
           A6231    GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT     1.32          30
           A6232    GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT     4.01          30
           A6233    GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT     5.57          30
           A6234    HYDROCOLLOID DRESSING, WOUND COVER, STER     5.69          30
           A6235    HYDROCOLLOID DRESSING, WOUND COVER, STER    11.26          30
           A6236    HYDROCOLLOID DRESSING, WOUND COVER, STER    13.88          30
           A6237    HYDROCOLLOID DRESSING, WOUND COVER, STER     5.11          30
           A6238    HYDROCOLLOID DRESSING, WOUND COVER, STER     8.20          30
           A6239    HYDROCOLLOID DRESSING, WOUND COVER, STER    10.54          30
           A6240    HYDROCOLLOID DRESSING, WOUND FILLER, PAS     8.12          20
           A6241    HYDROCOLLOID DRESSING, WOUND FILLER, DRY     1.59          25
           A6242    HYDROGEL DRESSING, WOUND COVER, STERILE,     3.06          30
           A6243    HYDROGEL DRESSING, WOUND COVER, STERILE,     6.49          30
           A6244    HYDROGEL DRESSING, WOUND COVER, STERILE,    14.05          30
           A6245    HYDROGEL DRESSING, WOUND COVER, STERILE,     3.56          30
           A6246    HYDROGEL DRESSING, WOUND COVER, STERILE,     7.39          30
           A6247    HYDROGEL DRESSING, WOUND COVER, STERILE,    18.77          30
           A6248    HYDROGEL DRESSING, WOUND FILLER, GEL, ST     4.16          30
           A6251    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     2.09          30
           A6252    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     2.54          30
           A6253    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     3.61          30
           A6254    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     1.07          30
           A6255    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     1.71          30
           A6256    SPECIALTY ABSORPTIVE DRESSING, WOUND COV     3.85          30
           A6257    TRANSPARENT FILM, STERILE, 16 SQ. IN. OR     0.35          30
           A6258    TRANSPARENT FILM, STERILE, MORE THAN 16      1.16          30
                                                                                     Page 6 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                      DESCRIPTION               FEE      BR   UNITS PA CHANGE
           A6259    TRANSPARENT FILM, STERILE, MORE THAN 48      2.46          30
           A6261    WOUND FILLER, GEL/PASTE, STERILE, PER FL                   30   1
           A6262    WOUND FILLER, DRY FORM, STERILE, PER GRA                   30   1
           A6266    GAUZE, IMPREGNATED, OTHER THAN WATER, NO    2.02           30
           A6402    GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ    0.13          180
           A6403    A6217;STERILE                               0.26          120
           A6404    A6218;STERILE                               0.35           30
           A6407    PACKING STRIPS, NON-IMPREGNATED, STERILE    1.91           30
           A6410    EYE PAD,STERILE                             0.23           50
           A6411    EYE PAD,NON-STERILE                         0.16           50
           A6412    EYE PATCH, OCCLUSIVE, EACH                  0.27           30
           A6441    PADDING BANDAGE,NON-ELASTIC 3-              0.70           30
           A6442    CONFORMING BANDAGE,NON-ELASTIC              0.04          120
           A6443    CONFORMING BANDAGE,NON-ELASTIC              0.06          120
           A6444    CONFORMING BANDAGE,NON-ELASTIC              0.08          120
           A6445    CONFORMING STERILE BNDGE,NON-E              0.06          120
           A6446    CONFORMING BNDGE,STERILE,NON-E              0.10          120
           A6447    CONFORMING BNDGE,NON-ELAST,STE              0.18          120
           A6448    LIGHT COMRESSION BNDGE,ELASTIC              0.06           90
           A6449    LGHT COMPRESSION BNDGE,ELASTIC              0.09           90
           A6450    LIGHT COMRESSION BNDGE,ELASTIC              0.16           90
           A6451    MOD COMPRESSION BNDGE,ELASTIC,              0.17           90
           A6452    HIGH COMPRESSION BNDGE,ELASTIC              1.22           15
           A6453    SELF-ADHERENT BNDGE,ELASTIC,<3              0.40           30
           A6454    SELF-ADHERENT BNDGE,ELASTIC,3-              0.57           30
           A6455    SELF-ADHERENT BNDGE,ELASTIC,>5              0.68           30
           A6456    ZINC IMPREGNATED BANDAGE 3-5 I              0.80           24
           A6457    TUBULAR DRESSING WITH OR WITHOUT ELASTIC    1.20           25   1
           A7000    DISP CANNISTER USED WITH SUCTI              4.35            5
           A7002    TUBING SUCTION PUMP (CONNECTIO              0.92           30
           A7003    ADM KIT W/SM VOL NON-FILT DISP              2.23            2
           A7004    SM VOL NON-FILTERED PNEMATIC N              1.29            5
           A7005    ADM SET SMALL VOL NEBULIZER NO             16.19            1   6
           A7007    LG VOL DISP NEBULIZER USE W/CO              2.89            5
           A7013    DISP FILTER USE W/COMPRESSOR                0.11            5
           A7014    NON-DISP FILTER FOR COMPRESSOR              0.80            1
           A7015    AEROSOL MASK FOR DME NEBULIZER              1.06            1
           A7038    CPAP/BIPAP DISPOSABLE FILTER                1.71            5
           A7039    CPAP/BIPAP NONDISPOSABLE FILTE              2.40            5
           A7523    TRACH SHOWER PROTECTOR,EACH                 8.10            1
           A7525    TRACHEOSTOMY MASK,EACH                      1.68            4
           A9275    HOME GLUCOSE DISPOSABLE MONITOR, INCLUDE   28.75            2   6
           A9999    MISC DME SUPPLY/ACCESSORY,NOC                               5   1
           B4034    ENTERAL FEEDING SUPPLY KIT; SYRINGE FED,    1.88           30   6
           B4035    ENTERAL FEEDING SUPPLY KIT;PUM              8.32           30   6
           B4036    ENTERAL FEEDING SUPPLY KIT;GRA              5.16           30   6
           B4081    NASOGASTRIC TUBING WITH STYLET             16.17            1   6
                                                                                        Page 7 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                                 MAX
           CODE                       DESCRIPTION              FEE       BR     UNITS PA CHANGE
           B4082    NASOGASTRIC TUBING WITHOUT STY              10.06              2   6
           B4083    STOMACH TUBE-LEVINE TYPE                     1.07              2   6
           B4087    GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD,     22.89              1   6
           B4088    GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFIL   134.58              1   6
           B4100    FOOD THICKENER, ADMINISTERED ORALLY, PER     0.53            180   6
           B4149    ENTERAL FORMULA, MANUFACTURED BLENDERIZE     1.21            600   4
           B4150    ENTERAL FORMULA, NUTRITIONALLY COMPLETE      0.49            600   4
           B4152    ENTERAL FORMULA, NUTRITIONALLY COMPLETE,     0.38            600   4
           B4153    ENTERAL FORMULA, NUTRITIONALLY COMPLETE,     1.85            600   4
           B4154    ENTERAL FORMULA, NUTRITIONALLY COMPLETE,     0.85   BR SC    600   4
           B4155    ENTERAL FORMULA, NUTRITIONALLY INCOMPLET     2.30   BR SC    300   4
           B4157    ENTERAL FORMULA INHERITED META               4.58   BR SC    600   4
           B4158    ENTERAL FORMULA PEDIATRIC COMP               0.73            600   4
           B4159    ENTERAL FORMULA PEDIATRIC SOY                0.84            600   4
           B4160    ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI     0.60            600   4
           B4161    ENTERAL FORMULA PEDIATRIC HYDR               1.35   BR SC    600   4
           B4162    ENTERAL FORMULA PEDIATRIC INHE               4.58   BR SC    600   4
           B4164    PAR NUT SOL CAR 50 % OR LESS-5              13.26             90
           B4168    PAR NUT SOL AMINO ACID 3.5% 50              18.59             90
           B4172    PAR NUT SOL AM AC 5.5%-7% 500M              30.50             90
           B4176    PR NT SOL AA 7-8.5% 500ML=1 U               43.22             90
           B4178    PAR NUT SOL AA GREATER TH 8.5%              43.22             90
           B4180    PR NT SOL CRB DX GREAT TH 50%               18.30             90
           B4185    PARENTERAL NUTRITION SOLUTION, PER 10 GR     8.50            450
           B4189    P NT SL CP AA & CB W EL TE V S              84.28             90
           B4193    P NT SL CP AA & CB W EL TE V S             140.58             90
           B4197    P NT SL CP AA + CB W EL TE V S             158.13             90
           B4199    P NT SL CP AA + CB W EL TE V S             229.21             90
           B4216    P NT ADD VT TE HEP EL HOMEMIX               11.65             90
           B4220    PARENTERAL NUT SUPPLY KIT;PREM                                90   1
           B4222    PARENTERAL NUT SUPPLY KIT;HOME                                90   1
           B4224    PARENTERAL NUT ADMINISTRATION                                 90   1
           B5000    P NT SL C AA CB W EL TE U ST R             113.37             90
           B5100    P NT SL C AA C W EL TE V ST HE             133.49             90
           B5200    P NT SL C AA C W EL TE V ST ST             145.40             90
           B9998    NOT OTERWISE CLASSIFIED ENTERA                                90   1
           B9999    NOT OTHERWISE CLASSIFIED PAREN                                90   1
           E0100    CANE INCL CANES ALL MATERIALS               12.00              1   6
           E0105    CANE QUAD/3 PRONG ALL MATERIAL              18.75              1   6
           E0110    CRUTCHES,FOREARM,PAIR,COMPLETE              58.93              1
           E0111    CRUTCH FOREARM VARI MATERIAL A              29.46              1
           E0112    CRUTCHES UNDERARM WOOD ADJ/FIX              23.93              1
           E0113    CRUTCH UNDERARM WOOD                        11.96              1
           E0114    CRUTCHES UNDERARM ALUMIN ADJUS              23.38              1
           E0116    CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUS    11.69              1
           E0160    SITZ BATH PORTABLE                           4.31              1   6
           E0167    PAIL OR PAN FOR USE WITH COMMODE CHAIR,      6.08              1   6
                                                                                     Page 8 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                     DESCRIPTION                FEE      BR   UNITS PA CHANGE
           E0188    SYNTHETIC SHEEPSKIN PAD                     19.50           1
           E0191    HEEL OR ELBOW PROTECTOR EACH                 2.81           5
           E0210    ELECTRIC HEATING PADS                       14.40           1   6
           E0215    ELECTRIC HEAT PAD MOIST                     20.93           1   6
           E0220    HOT WATER BOTTLE                             4.88           1
           E0238    NON-ELECTRIC HEAT PAD MOIST                 10.44           1
           E0275    BED PAN STANDARD METAL OR PLAS               3.78           1
           E0276    BED PAN FRACTURE METAL OR PLAS               4.25           1   6
           E0325    URINAL MALE JUG-TYPE ANY MATER               2.99           1   6
           E0326    URINAL FEMALE JUG-TYPE ANY MAT               7.20           1   6
           E0602    BREAST PUMP ALL TYPES                       17.31           1
           E0603    BREAST PUMP ELECTRIC (AC/DC),               40.63           1   6
           E0605    VAPORIZER,ROOM TYPE                         16.73           1   6
           E0710    RESTRAINTS ANY TYPE                         13.65           4
           E2100    BLOOD GLUCOSE MONITOR W/VOICE                               1   1
           G0008    ADMINISTRATION OF INFLUENZA VIRUS VACCIN    13.23           1        *
           G0009    ADMINISTRATION OF PNEUMOCOCCAL VACCINE      13.23           1        *
           K0552    SYRINGE/CARTRIDGE FOR EXT DRUG               2.65          30   6
           L0120    CERVICAL FLEXIBLE NON-ADJUST F               6.80           1
           L8000    BREAST PROSTHESES, MASTECTOMY               31.22           5
           L8001    BREAST PROSTHESIS,BRA W/FORM,U              93.74           5
           L8002    BREAST PROSTHESIS,BRA W/FORM,B             123.74           5
           L8020    BREAST PROSTHESES, MASTECTOMY              180.63           2
           L8030    BREAST PROSTHESIS,SILICONE OR              180.63           2
           L8031    BREAST PROSTHESIS,SILICONE OR              180.63           2        *
           L8512    GEL CAPS FOR TRACH VOICE PROST               1.67           9
           L8513    CLEANING DEVICE FOR TRACH VOIC               3.13           6
           S5001    PRESCRIPTION DRUG, BRAND NAME                               1   1    *
           S5560    INSULIN PEN REUSABLE 1.5 ML                 34.98           1   6
           S5561    INSULIN PEN REUSABLE 3ML                    30.66           1   6
           S8100    SPACER WITHOUT MASK                         16.50           2   6
           S8101    SPACER WITH MASK                            27.75           2   6
           S8189    TRACHEOSTOMY SUPPLY,NOT OTHERW                              1   1
           S8265    HABERMAN FEEDER FOR CLEFT PALA              19.13           2   6
           S8460    CAMISOLE,POST-MASTECTOMY                    37.49           5
           S8490    INSULIN SYRINGES (100'S) (LOW               19.65           2
           T4521    ADULT SMALL DIAPER                           0.47         250   6
           T4522    ADULT MEDIUM DIAPER                          0.51         250   6
           T4523    ADULT LARGE DIAPER                           0.68         250   6
           T4524    ADULT DIAPER EXTRA LARGE                     0.72         250   6
           T4529    PEDIATRIC DIAPER SMALL/MEDIUM                0.30         250   6
           T4530    PEDIATRIC DIAPER LARGE                       0.36         250   6
           T4533    YOUTH DIAPER >35 LBS                         0.39         250   6
           T4535    DISPOSABLE INCONTINENCE LINER/               0.28         250   6
           T4537    UNDERPAD REUSABLE BED SIZE                  13.44           3   6
           T4539    DIAPER REUSABLE ANY SIZE                     6.65           5   6
           T4540    UNDERPAD REUSABLE CHAIR SIZE                 7.19           3   6
                                                                                     Page 9 of 9


         NYS Medicaid Pharmacy Services Fee Schedule
Effective Date: April 1, 2010

                                                                              MAX
           CODE                           DESCRIPTION          FEE      BR   UNITS PA CHANGE
           T4543    DISPOSABLE INCONTINENCE PRODUCT, BRIEF/D     1.38         250   1
           T5999    SUPPLY,NOT OTHERWISE SPECIFIED                             5    1
                    Plastic strips                              2.81
                    Basal thermometer                          10.41
                    Sterile 6” wood applicator w/cotton tips    2.97
                    Incentive spirometer                        5.88
                    Nasal aspirator                             2.40
           V5266    BATTERY FOR USE IN HEARING DEV              0.75          24