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NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
65862-0945-24 | J7614 | LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG | LEVALBUTEROL (2X12 POUCHES,PF) 1.25 MG/3 ML | IH |
66105-0507-01 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | ZITHROMAX 250 MG | PO |
66105-0507-03 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | ZITHROMAX 250 MG | PO |
66105-0507-06 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | ZITHROMAX 250 MG | PO |
66105-0507-09 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | ZITHROMAX 250 MG | PO |
66105-0507-10 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | ZITHROMAX 250 MG | PO |
66105-0549-10 | J7507 | TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG | PROGRAF 1 MG | PO |
66105-0670-01 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN 250 MG | PO |
66105-0670-03 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN 250 MG | PO |
66105-0670-05 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN 250 MG | PO |
66105-0670-06 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN 250 MG | PO |
66105-0670-18 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN 250 MG | PO |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
E0435 | Portable liquid oxygen system, purchase, includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter | Each | Y |
E0439 RR | Stationary liquid oxygen system, rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing (Coverage of home oxygen must be preauthorized by DMAS for members with arterial PO2 levels at or above 60 mm Hg or whose arterial blood oxygen saturation is at or above 90% (or at or above 95% for children.) The practitioner must submit documentation, in addition to the CMN, which specifies why oxygen is medically necessary.) | Day | N See note for exception on Service auth |
E0441 | Stationary oxygen contents, gaseous, 1 month supply = 1 unit | 1 Unit | Y |
E0442 | Stationary oxygen contents, liquid, one month�s supply = 1 unit | 1 Unit | N |
E0443 | Portable oxygen contents, gaseous one month�s supply = 1 unit | 1 Unit | N |
E0444 | Portable oxygen contents, liquid, one month's suppley = 1 unit | 1 Unit | Y |
E0447 | Portable oxygen contents, liquid, one month's suppley = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm) | 1 Unit | Y |
K0738 RR | Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifer, cannula or mask, and tubing (Coverage of home oxygen must be preauthorized by DMAS for members with arterial PO2 levels at or above 60 mm Hg or whose arterial blood oxygen saturation is at or above 90% (or at or above 95% for children.) The practitioner must submit documentation, in addition to the CMN, which specifies why oxygen is medically necessary.) | Day | N See note for exception on Service auth |
E0445 | Oximeter device for measuring blood oxygen levels, non-invasively | Each | Y |
E0445 RR | Oximeter device for measuring blood oxygen levels, non-invasively | Day | Y |
E0465 | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) | Each | Y |
E0465 RR | Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) | Day | Y |
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