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NDC | HCPCS | HCPCS Description | NDC Label | Route of Administration |
|---|---|---|---|---|
64679-0964-09 | Q0144 | AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM | AZITHROMYCIN (FILM COATED) 500 MG | PO |
64679-0983-02 | J0696 | INJECTION, CEFTRIAXONE SODIUM, PER 250 MG | CEFTRIAXONE (USP) 1 GM | IJ |
64764-0300-20 | J3380 | INJECTION, VEDOLIZUMAB, 1 MG | ENTYVIO (SDV,PF,LYOPHILIZED) 300 MG | IV |
64980-0276-06 | None | CAPECITABINE, 150 MG, ORAL | CAPECITABINE (USP,FILM COATED) 150 MG | PO |
64980-0277-12 | None | CAPECITABINE, 500 MG, ORAL | CAPECITABINE (USP,FILM COATED) 500 MG | PO |
64980-0290-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (FILM COATED) 2 MG | PO |
64980-0291-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (FILM COATED) 4 MG | PO |
64980-0292-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (FILM COATED) 8 MG | PO |
64980-0293-01 | Q0175 | PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN | PERPHENAZINE (FILM COATED) 16 MG | PO |
64980-0333-05 | None | TEMOZOLOMIDE, 5 MG, ORAL | TEMOZOLOMIDE 5 MG | PO |
64980-0333-14 | None | TEMOZOLOMIDE, 5 MG, ORAL | TEMOZOLOMIDE 5 MG | PO |
64980-0334-05 | None | TEMOZOLOMIDE, 20 MG, ORAL | TEMOZOLOMIDE 20 MG | PO |
HCPCS Code | Description | Billing Unit | SA Type |
|---|---|---|---|
E0601 RR | Continuous Positive Airway Pressure (CPAP) Device | Day | Y |
E0606 | Postural Drainage Board/Reflux Wedge | Each | N |
E0606 RR | Postural Drainage Board/Reflux Wedge | Day | N |
E1352 | Oxygen accessory, flow regulator capable of positive inspiratory pressure | Each | Y |
E1353 | Regulator | Each | Y |
E1355 | Stand/Rack | Each | Y |
E1372 | Immersion external heater for nebulizer | Each | Y |
E1372 RR | Immersion Heater For Nebulizer | Day | Y |
E1390 RR | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (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 |
E1391 RR | Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (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 |
E1392 RR | Portable oxygen concentrator, rental (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 |
E1392RR U1 | Portable oxygen concentrator, rental (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.) High Intensity code must have O2 rate above 4 LPM | Day | Y |
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