ancillary services - oxhp · medical care, and to limit your patients’ unnecessary out-of-pocket...

6A n c i l l a r y S e r v i c e s

Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . .79

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . .83

Physical and Occupational Therapy . . . . . .101

Acupuncture and Chiropractic Guidelines . .103

Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . .104

78 www.oxfordhealth.com

Section 6 — Ancillary Services

www.oxfordhealth.com 79

Ancillary Services — Section 6

Laboratory

Through Oxford’s laboratory network, we intend toprovide you access to the tests you need to treat yourpatients, to reasonably control the increasing cost ofmedical care, and to limit your patients’ unnecessaryout-of-pocket costs.

Oxford’s outpatient laboratory network is managed by Quest Diagnostic and is composed of:

• Full-service labs, including Quest labs andsubcontracted labs

• Niche labs (i.e., esoteric/specialty labs)

• Hospital labs (not all participating hospitals haveparticipating outpatient laboratories)

Outpatient Laboratory

Policies and Procedures

• All outpatient laboratory specimens must be sent toQuest or one of the other contracted Quest Networklaboratories (QuestNet)* as listed in these pages andon our web site at www.oxfordhealth.com

• A referral is not required for lab specimens sent to QuestNet participating laboratories (only aphysician’s prescription or lab order form is required)

• When billing for laboratory services performed in the office, specimen handling and/or venipuncture:

• If you bill specimen handling and venipuncture codes, in conjunction with a lab code, for a labprocedure performed in your office, only the lab and venipuncture codes will be reimbursed (pleaseremember that for the lab code to be reimbursed,the code must be on the In-office Laboratory Testing List)

• If you bill specimen handling and venipuncturecodes without a lab code, the specimen handlingand venipuncture codes will be reimbursedaccording to Oxford’s fee schedule

• If you are unable to find a necessary laboratoryservice through Oxford’s network of laboratories,please call Oxford customer service at 1-800-377-8448;they will provide direction on how to obtain therequired service on an in-network basis

• Oxford reviews laboratory ordering information on a periodic basis in an effort to support full use of

Oxford’s contracted laboratory network; if our datashows a pattern of out-of-network utilization for yourpractice, we will contact you to share this informationand engage you to utilize the contracted network

* You are not required to use the QuestNet laboratories for procedures listed on the Laboratory In-office Testing List

Full Service Laboratories

Acu-Path Laboratories, Inc.Client services 1-888-228-7284

Bayside Diagnostics LaboratoryClient services 1-718-886-8500

Clinical Lab PartnersClient services 1-860-696-8222

Enzo Clinical LabsClient services 1-631-755-5500 or 1-800-522-5052

GJL Medical LabsClient services 1-516-326-0700 or 1-800-924-1650

Laboratory Corporation of America Holdings(LabCorp) Client services, home blood draws, STAT testing services:

New Jersey 1-800-223-0631

New York 1-800-745-0233

Connecticut 1-800-342-2475

Patient service center locator number for Members 1-888-LABCORP

Quest Diagnostics, IncorporatedClient services, home blood draws, STAT testing services:

Northern and Central New Jersey 1-800-631-1390

Southern New Jersey 1-800-825-7330

Long Island, New York 1-800-877-7530

All other New York areas 1-800-631-1390

Connecticut 1-800-982-6810

Patient service center locator number for Members 1-800-377-8448

Quest web site: www.questdiagnostics.com



Full Service Laboratories(continued)

Quentin Medical Laboratory, Inc.Client services 1-718-492-2600

Shiel Medical Laboratory, Inc.Client services 1-718-714-5700 or

1-800-553-0873 ext. 900

Specialty Laboratories

Ackerman Academy of Dermatopathology 1-212-889-6225 or 1-800-553-6621

Dianon Systems, Inc.Client services 1-800-328-2666

Genzyme Genetics 1-800-848-4436

Home Healthcare Laboratory of America 1-888-522-4452

1-888-LAB-HHLA

Pathology Associates, P.C.Client services 1-800-388-3995

Hospital Laboratories

Barnert Hospital Client services 1-973-977-6647

Continuum Health Partners, Inc.Beth Israel Medical Center Pathology and Laboratory Medicine 1-800-420-LABS

Long Island Medical College Pathology and Laboratory Medicine 1-800-420-LABS

St. Luke’s – Roosevelt Hospital Pathology and Laboratory Medicine 1-800-420-LABS

Greenwich Hospital LaboratoryClient services 1-203-863-3380

Griffin HospitalClient services 1-203-732-7280

Hackensack University Medical Center Totalab 1-877-868-2522

Client services 1-201-996-4881

Milford Hospital LaboratoryClient Services 1-203-876-4256

Mount Sinai Medical Center

Mount Sinai Hospital of New York 1-212-241-4675

Mount Sinai Hospital of Queens 1-212-241-4675

Mount Sinai Hospital Clinic 1-212-241-4675

Mount Sinai Center for Clinical Laboratories 1-212-241-4675

Mount Sinai Pathology Associates 1-212-241-3985

Mount Sinai Pathology Consultants 1-212-241-8014

Mount Sinai Medical Center, Department of Dermatopathology 1-212-241-6064

New York University Medical CenterNYU Medical Center Laboratories 1-212-263-7313

NYU Pathology Associates 1-212-263-5475

NYU Dermatopathology Associates 1-212-263-7250

North Shore University Hospital — Long Island Jewish Medical Health SystemClient Services:

Nassau and Suffolk counties 1-516-719-1000

Brooklyn and Richmond counties 1-718-226-5227

Participating hospitals in the North Shore system include:

North Shore University Hospital Manhasset

North Shore Hospital System Central Laboratories

Long Island Jewish Medical Center

Long Island Jewish Medical Center — Schneider Children’s Hospital Lab

Staten Island University Hospital

New York Presbyterian Healthcare SystemNew York Presbyterian Hospital:

New York Weill Center/New York Hospital Laboratories 1-212-746-0675

Columbia Presbyterian Center/Clinical Lab Services 1-212-305-2155

The Brooklyn Hospital Center, Department of Pathology 1-718-250-8000



Laboratory of Dermatopathology, Department of Dermatopathology College of Physicians and Surgeons of Columbia University 1-212-305-2155

New York Community Hospital of Brooklyn, Department of Pathology and Lab Medicine 1-718-692-5372

New York Methodist Hospital — Outpatient Laboratory 1-718-780-3645

New York United Hospital Medical Center Lab 1-914-934-3083

New York Westchester Square Medical Center Laboratory 1-718-430-7300

NYHQ/Charter Diagnostics Laboratory 1-718-670-2575

Palisades Medical Hospital/Clinical Laboratory 1-201-854-5054

Wyckoff Heights Medical Center Laboratories 1-718-963-7519

University Pathology, P.C. 1-914-594-4150

In-office Laboratory

Testing List

The In-office Laboratory Testing List includes codes for laboratory procedures reimbursed tophysicians when performed in their offices. All otherlaboratory procedures must be performed by one of the participating laboratories in Oxford’s networkconsisting of Quest and other subcontracted generaland specialty laboratories.

Primary Care Physicians and Specialists

*81000 Urinalysis, with microscopy

*81002 Urinalysis, non-automated, without microscopy

*81003 Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods

82270 Blood, occult; feces screening, 1-3 simultaneous determinations

82273 Blood, occult; other sources,qualitative

82274 Blood, occult, by fecal hemoglobindetermination by immunoassay,qualitative, feces, 1-3 simultaneousdeterminations

82948 Glucose; blood, reagent strip

82962 Glucose, blood sugar by glucometer

83014 Helicobacter pylori, breath testanalysis; drug administration and sample collection (Note: Dianon provides test kit free of charge — call 1-800-328-2666.)

83026 Hemoglobin; by copper sulfatemethod, non-automated

85013 Spun microhematocrit

85018 Blood count, hemoglobin

85651 Sedimentation rate, erythrocyte; non-automated

****86403 Particle agglutination, screen, each antibody

86485-86586 Skin tests; various

**87070 Culture, bacterial; any other source but urine, blood or stool, with isolation and presumptiveidentification of isolates

**87081 Culture, bacterial, screening only, for single organisms

87177 Ova and parasites, direct smears,concentration and identification

87210 Smear, wet mount with simple stain, for bacteria, fungi, ova, and/or parasites

87220 Tissue examination for fungi (e.g., KOH slide)

****87880 Infectious agent detection byimmunoassay — streptococcus group A

89100 Duodenal intubation and aspirationsingle specimen plus appropriate test

89105 Duodenal intubation and aspiration;collection of multiple fractionalspecimens with pancreatic orgallbladder stimulation, single or double lumen tube



Primary Care Physicians and Specialists (continued)

89130-89141 Gastric intubation and aspiration; various

89350 Sputum, obtaining specimen, aerosol-induced technique

99195 Phlebotomy, therapeutic (separate procedure)

For STAT Purposes Only, claim must be marked STAT

***85023 Hemogram and platelet count,automated and manual differentialWBC count (CBC)

***85024 Hemogram and platelet count,automated and partial differentialWBC count (CBC)

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

***85027 Complete WBC, automated

*, **, ***, **** Reimbursement is limited to one procedure (within the relatedfamily of codes) per visit.

Pediatricians Only

82247 Bilirubin, Total

Pulmonologist Only

82803 Gases, blood, any combination of pH,pCO2, pO2, CO2, HCO3 (includingcalculated O2 saturation)

Obstetricians, Gynecologists, ReproductiveEndocrinologists and Infertility Specialists Only

82670 Estradiol

83001 Gonadotropin; follicle stimulatinghormone (FSH)

83002 Gonadotropin; luteinizing hormone (LH)

84144 Progesterone

84702 Gonadotropin, chorionic (hCG); quantitative

+89250 Culture and fertilization of oocyte(s)

+89251 Culture and fertilization of oocyte(s)with co-culture of embryos

+89252 Assisted oocyte fertilization,microtechnique (any method)

+89253 Assisted embryo hatching,microtechniques (any method)

+89254 Oocyte identification from follicular fluid

+89255 Preparation of embryo for transfer(any method)

+89257 Sperm identification from aspiration(other than seminal fluid)

+89260 Sperm isolation; simple prep (e.g., sperm wash, swim-up) forinsemination or diagnosis w/semen analysis

+89261 Sperm isolation; complex prep (e.g.,Percoll gradient, albumin gradient)for insemination or diagnosis withsemen analysis

+89300 Semen analysis; presence and/ormotility of sperm including Huhner test (post coital)

89310 Semen analysis; motility and count

89320 Semen analysis; complete (volume,count, motility, and differential)

89321 Semen analysis; presence and/ormotility of sperm

+89325 Sperm antibodies

+89329 Sperm evaluation; hamsterpenetration test

+89330 Sperm evaluation; cervical mucuspenetration test, with or withoutspinnbarkeit test

+ Member must have the infertility benefit

Rheumatologists Only

89060 Crystal identification by lightmicroscopy with or without polarizinglens analysis, and body fluid (except urine)

Hematologists and Oncologists Only

85007 BL Smear w/diff WBC count

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

85027 Complete WBC, automated



85097 Bone marrow; smear interpretationonly, with or without differential cell count

86077 Blood bank physician services; difficult cross-match and/or evaluation of irregular antibody(s),interpretation and written report

86078 Blood bank physician services;investigation of transfusion reaction,including suspicion of transmissibledisease, interpretation and written report

86079 Blood bank physician services;authorization for deviation fromstandard blood-banking procedures,with written report

86927-86999 Transfusion medicine

*** Reimbursement is limited to one procedure per visit.

Urologists Only

89300 Semen analysis; presence and/ormotility of sperm including Huhnertest (post coital)

89310 Semen analysis; motility and count

89320 Semen analysis; complete (volume,count, motility and differential)

89321 Semen analysis; presence and/ormotility of sperm

Radiology

CareCore National, a physician-owned radiology networkcomprised of leading board-certified radiologists, isOxford’s network manager for all outpatient commercialand Medicare imaging services. Please be aware that

inpatient, ambulatory surgery, emergency room radiologyservices, radiation therapy, radionuclide therapy,ophthalmic ultrasound, and any delegated physicianarrangement are not included in this arrangement.Oxford has eliminated the need to submit referrals foroutpatient radiology procedures performed byparticipating radiologists or radiology facilities.

Privileging by Specialty

Oxford’s privileging program is designed to improve the quality of imaging services by limiting coverage toservices provided in the most appropriate setting. Belowis a list of imaging CPT codes for services that physicians,other than radiologists, can perform in their office.

Please note: The privileging program applies to office andoutpatient (non-ambulatory surgery) procedures.

Privileging List* These following procedures require precertification; call 1-877-PRE-AUTH.

*** Any studies beyond three (3) require precertification; call 1-877-PRE-AUTH.

Physician Type CPT Codes Description

Primary Care Physicians: 71010-71030 Chest imagingInternal Med., Family Practice 76075,76076 DEXA studies, bone densitometry

General Surgeons: 76942 Ultrasonic guidance for needle biopsyAIUM-accredited



Privileging List (continued)


Cardiologists 71010-71030 Chest imaging

78464*, 78465*, 78469* Tomographic SPECT studies

78472*, 78473* Cardiac blood pool imaging

78478* Wall motion study

78480 Ejection fraction study

Cardiologists — Pediatric only 76825, 76826, 76827, 76828 Echocardiography, fetal

Chiropractors 72010, 72040, 72069, 72070, Spine imaging

72080, 72100 Spine imaging

Endocrinologists 76075, 76076 DEXA studies, bone densitometry

76942 Ultrasonic guidance for needle biopsy

76536 (AACE Accredited Thyroid ultrasoundEndocrinologists only)

Gastroenterologists 76975* Endoscopic ultrasound

General Surgeons, Vascular 75940 Percutaneous placement of IVC Surgeons, Cardiovascular Surgeons filter, radiological supervision

and interpretation

75952 Endovascular repair of infrarenalabdominal aortic aneurysm

75953 Placement of proximal or distal extensionprosthesis for endovascular repair

Hand Surgeons 76000, 73000-73140 Fluoroscopy

Maternal Fetal Medicine 76085 Digitization of radiographic images

Perinatologists-Neonatologists 76092 Screening mammography

76801*** thru 76828***, Ultrasounds — pelvis

76830-76857 Ultrasounds — pelvis

76930, 76941, 76945, 76946 Ultrasonic guidance

76948 Ultrasonic guidance for aspiration of ova

76075, 76076 DEXA studies, bone densitometry

OB/GYNS 76085 Digitization of radiographic images


76092 Screening mammography

76815***, 76816***, Ultrasounds — pelvis

76817***, 76830 Ultrasounds — pelvis

76831, 76856, 76857, Ultrasonic guidance

76930, 76941, 76945, 76946 Ultrasonic guidance





OB/GYNS (AIUM/ACR Accredited) 76801***, 76802***, Ultrasounds — pelvis





76827***, 76828*** Ultrasounds — pelvis

Oral Surgeons 70100, 70110, 70140, 70150 Mandible and facial bone imaging

70300, 70310, 70320 Teeth imaging

70328, 70330 TMJ imaging

70350 Cephalogram, orthodontic

70355 Orthopantogram

Orthopedists 71100-71111 Radiologic examination, ribs

71120-71130 Radiologic examination, sternum

72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003, 76005 Fluoroscopies

76006 Radiologic examination, any joint

76040 Bone length studies

76066 Joint survey

Pain Management Specialists: 76000, 76005 FluoroscopyPhysiatrists, Anesthesiologists, Neurologists, and Neurosurgeons

Pediatricians 71010-71030 Chest imaging

Podiatrists 73620, 73630, 73650, 73660 Lower extremity imaging

Pulmonologists 71010-71030 Chest imaging

Radiation Oncologists 76950 Ultrasonic guidance for placementof radiation therapy fields

76965 Ultrasonic guidance for interstitialradioelement application

76370 Computerized tomography guidance

76873 Determinate of prostate volumefor brachytherapy





Reproductive Endocrinologists 76085 Digitization of radiographic images

76092 Screening mammography

76801-76857 Ultrasounds — pelvis

76941, 76945, 76946 Ultrasonic guidance


76948 Ultrasonic guidance for aspirationof ova, imaging supervisionand interpretation

Rheumatologists 72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003 Fluoroscopies

76040, 76066 Bone length studies, joint survey


G0188 Full length radiography of lower extremity

Urologists 76870, 76872 Ultrasounds — echography,genitalia, bladder

76942 Ultrasonic guidance for needle biopsy

Imaging Requiring

Precertification

CareCore National Precertification Policy for Urgent Cases It is the imaging facility’s responsibility to confirm thatan authorization number has been issued prior toproviding a service. In the case of urgent examinations,in which there is no time to obtain an authorizationnumber and in cases in which, in the opinion of theattending physician, a change is required from theprecertified examination, the services may beperformed, and you may request a new or modifiedauthorization number. Please make your requestswithin two (2) business days of the date of servicethrough the Imaging Care Management Department in the usual manner by calling or faxing your request.Clinical justification for the request will be reviewedusing the same criteria as a routine request.

CareCore National Precertification OnlineCareCore now provides a secure web based process to initiate clinical certification for diagnostic imagingrequests. Log onto www.carecorenational.com and theautomated system will guide you through a series ofcomputer screen prompts to collect routine demographicdata. Each web initiated request is evaluated promptly byCareCore clinical review staff. A short return call to youfrom CareCore completes the certification process. Thiseliminates the need for a call to CareCore's Intake staffand allows you to enter multiple clinical certificationrequests at your convenience.

CareCore National Utilization Review ProcessThe utilization review process involves matching thepatient clinical history and diagnostic information with the approved criteria for each imaging procedurerequested. Utilization review decisions are made byqualified health professionals including board-certifiedradiologists. Data collection for clinical certification of imaging services may be assigned to non-medicalpersonnel working under the direction of qualified



health professionals. You will receive notification ofreview determinations for non-urgent care by telephonewithin two (2) working days of receiving all the necessaryinformation. Notification for a determination involvingan urgent request is given within three (3) hours. For non-urgent care requests for Oxford MedicareAdvantageSM Members, a determination must be issuedwithin 14 calendar days of the request for service.

For commercial Members, requests for retrospectiveclinical certification review of medically urgent care areaccepted up to two (2) business days after the care hasbeen given. Retrospective review decisions are madewithin 30 business days of receiving all of the necessaryinformation. If your request is not authorized, thereview determination will be sent in writing to theMember and the requesting physician within five (5)business days of the decision.

Below is a list of imaging CPT codes that requireauthorization for commercial and Oxford MedicareAdvantage Members.

Please note: Oxford will inform you of any new proceduresor other changes to this list on the Oxford web page and in our quarterly Program and Policy Update.

To precertify a procedure, you can call CareCoreNational at 1-877-PRE-AUTH (1-877-773-2884), fax to 1-845-298-1490 or log onto www.carecorenational.com.

When you call or fax a request to the CareCoreNational Precertification unit, please provide thefollowing information:

Patient Identifiers:

• Oxford ID number and health plan

• Name

• Date of birth

• Address

Medical Identifiers:

• Ordering doctor’s name and address

• Facility to which the patient is being referred and its address

• Contact person at your office

Clinical Information:

• Examination(s) being requested, with CPT codes if available

• Presumptive diagnosis or “rule out,” with ICD-9 codes if available

• Patient’s signs and symptoms, listed in some detail,with severity and duration

• Any treatments that have been tried, including dosageand duration for drugs and dates for other therapies

• Any other information that you believe will help inevaluating the request, including prior diagnostictests, consultation reports, etc.

All authorization reference numbers are issued at the time of approval. CareCore National uses thereference CPT code as the last five (5) digits of theauthorization number. Please provide the authorizationreference number to the imaging provider whenscheduling the procedure.

Clinical notes must be submitted for specificprocedures. Oxford requires the submission of clinical office notes for specific procedures.

Clinical notes include the patient’s medical recordand/or letters received from specialists that indicate:

• Patient symptoms, with duration and severity

• Patient medical history

• Previous imaging studies and findings

• Prior treatment and/or therapy, including surgery,with history

• Drug dosage prescribed and duration

Please note: Effective January 1, 2003,radiopharmaceuticals in excess of $50.00 will bereimbursed. Submission of an invoice detailing the costand name of the administered material is still required.

If you choose to fax your authorization request, please include all of the information mentionedabove, including the request form, to CareCoreNational at 1-845-298-1490.



CT Scans (Effective February 2, 2004, all CT units must be ACR accredited)** Study requires the submission of clinical notes to CareCore National.

Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.

CPT Code Clinical Notes Required Description

70450 CT Head/Brain w/o Contrast

70460 CT Head/Brain w/Contrast

70470 CT Head/Brain w/o and w/Contrast

70480 CT Orbit w/o Contrast

70481 CT Orbit w/Contrast

70482 CT Orbit w/o and w/Contrast

70486 CT Maxllfcl w/o Contrast

70487 CT Maxllfcl w/Contrast

70488 CT Maxllfcl w/o and w/Contrast

70490 CT Soft Tissue w/o Contrast

70491 CT Soft Tissue w/Contrast

70492 CT Soft Tissue w/o and w/Contrast

70496 CT Angiography, Head

70498 CT Angiography, Neck

71250 CT Thorax w/o Contrast

71260 CT Thorax w/Contrast

71270 CT Thorax w/o and w/Contrast

71275 CT Angiography Chest

72125 CT C Spine w/o Contrast

72126 CT C Spine w/Contrast

72127 CT C Spine w/o and w/Contrast

72128 CT T Spine w/o Contrast

72129 CT T Spine w/Contrast

72130 CT T Spine w/o and w/Contrast

**72131 Yes CT L Spine w/o Contrast

**72132 Yes CT L Spine w/Contrast

**72133 Yes CT L Spine w/o and w/Contrast

72191 CT Angiography Pelvis

72192 CT Pelvis w/o Contrast

72193 CT Pelvis w/Contrast



CT Scans (continued)


72194 CT Pelvis w/o and w/Contrast

73200 CT Upper Extremity w/o Contrast

73201 CT Upper Extremity w/Contrast

73202 CT Upper Extremity w/o and w/Contrast

73206 CT Angiography Upper Extremity

73700 CT Lower Extremity w/o Contrast

73701 CT Lower Extremity w/Contrast

73702 CT Lower Extremity w/o and w/Contrast

73706 CT Angiography Lower Extremity

74150 CT Abdomen w/o Contrast

74160 CT Abdomen w/Contrast

74170 CT Abdomen w/o and w/Contrast

74175 CT Angiography Abdomen

75635 CT Angiography Abdominal Aorta

76013 X-ray Supervision and Interpretation, Percutaneous Vertebralplasty Per Vertebral Body under CT Guidance

76362 CT Guidance for and Monitoring of Tissue Ablation

76380 CT Limited or Localized Follow-up Study

MRI Procedures (All MRI units must be ACR accredited)Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.


70336 MRI TMJ

70540 MRI Face, Orbit, Neck w/o Contrast

70542 MRI Face, Orbit, Neck with Contrast

70543 MRI Face, Orbit, Neck w/and w/o Contrast

70551 MRI Head w/o Contrast

**70552 Yes MRI Head w/Contrast

**70553 Yes MRI Head w/and w/o Contrast

71550 MRI Chest w/o Contrast



MRI Procedures (continued)


71551 MRI Chest w/Contrast

71552 MRI Chest w/and w/o Contrast

**72141 Yes MRI Cervical Spine w/o Contrast

**72142 Yes MRI Cervical Spine w/Contrast

**72146 Yes MRI Thoracic Spine w/o Contrast

**72147 Yes MRI Thoracic Spine w/Contrast

**72148 Yes MRI Lumbar Spine w/o Contrast

**72149 Yes MRI Lumbar Spine w/Contrast

**72156 Yes MRI C Spine w/and w/o Contrast

**72157 Yes MRI T Spine w/and w/o Contrast

**72158 Yes MRI L Spine w/and w/o Contrast

72195 MRI Pelvis w/o Contrast

72196 MRI Pelvis w/Contrast

72197 MRI Pelvis w/and w/o Contrast

**73218 Yes MRI Upper Extremity other than Joint w/o Contrast

**73219 Yes MRI Upper Extremity other than Joint w/Contrast

**73220 Yes MRI Upper Extremity other than Joint w/and w/o Contrast

**73221 Yes MRI Upper Extremity Joint w/o Contrast

**73222 Yes MRI Upper Extremity Joint w/Contrast

**73223 Yes MRI Upper Extremity Joint w/ and w/o Contrast

**73718 Yes MRI Lower Extremity other than Joint w/o Contrast

**73719 Yes MRI Lower Extremity other than Joint w/Contrast

**73720 Yes MRI Lower Extremity other than Joint w/and w/o Contrast

**73721 Yes MRI Lower Extremity Joint w/o Contrast

**73722 Yes MRI Lower Extremity Joint w/Contrast

**73723 Yes MRI Lower Extremity Joint w/and w/o Contrast

74181 MRI Abdomen w/o Contrast

74182 MRI Abdomen w/Contrast

74183 MRI Abdomen w/and w/o Contrast



MRI Procedures (continued)


75552 Cardiac MRI for Morphology w/o Contrast (Gated Heart)

75553 Cardiac MRI Morphology w/Contrast

75554 Cardiac MRI Complete w/or w/o Morphology

75555 Cardiac MRI Limited

75556 Cardiac MRI Velocity Flow

**76093 Yes MRI Breast w/and/or w/o Contrast

**76094 Yes MRI Breast Bilateral

76390 MRI Spectroscopy

76393 MRI Guidance for Placement Radiological Supervision and Interpretation

76394 MRI Guidance for and Monitoring of Tissue Ablation

76400 MRI Bone Marrow Blood Supply

76499 Unlisted Procedure

MRA Procedures

CPT Code Description

70544 MRA Head w/o Contrast

70545 MRA Head w/Contrast

70546 MRA Head w/and w/o Contrast

70547 MRA Neck w/o Contrast

70548 MRA Neck w/Contrast

70549 MRA Neck w/and w/o Contrast

71555 MRA Chest (Exc. Myocardium) w/or w/o Contrast

72159 MRA Spinal Canal w/or w/o Contrast

72198 MRA Pelvis w/or w/o Contrast

73225 MRA Upper Extremity w/or w/o Contrast

73725 MRA Lower Extremity w/or w/o Contrast

74185 MRA Abdomen w/or w/o Contrast



PET Scans (Effective February 2, 2004, all PET units must be ACR accredited)** Study requires the submission of clinical notes to CareCore National.

Please note: Clinical notes are required for all PET scans.


**78459 Yes Myocardial Imaging, Positron Emission Tomography (PET) Metabolic Eval

**78491 Yes Myocardial Imaging, Positron Emission Tomography (PET),Perfusion; Single Study at Rest or Stress

**78492 Yes Myocardial Imaging, Positron Emission Tomography (PET),Perfusion; Multiple Studies at Rest or Stress

**78608 Yes Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation

**78609 Yes Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation, Perfusion Evaluation

**78810 Yes Tumor Imaging (PET Scan)

**G0030 Yes PET Myocardial Perfusion Imaging; (Following Previous PET,G0030-G0047); Single Study, Rest or Stress

**G0031 Yes PET Myocardial Perfusion Imaging; (Following Previous PET, G0030-G0047); Multiple Studies, Rest or Stress

**G0032 Yes PET Myocardial Perfusion Imaging, (Following Rest SPECT,78464); Single Study, Rest or Stress

**G0033 Yes PET Myocardial Perfusion Imaging, (Following Rest SPECT, 78464); Multiple Studies, Rest or Stress

**G0034 Yes PET Myocardial Perfusion Imaging, (Following SPECT, 78465); Single Study, Rest or Stress

**G0035 Yes PET Myocardial Perfusion Imaging, (Following SPECT, 78465); Multiple Studies, Rest or Stress

**G0036 Yes PET Myocardial Perfusion Imaging, (Following Coronary Angiography, 93510-93529); Single Study, Rest or Stress

**G0037 Yes PET Myocardial Perfusion Imaging, (Following Coronary Angiography, 93510-93529); Multiple Studies, Rest or Stress

**G0038 Yes PET Myocardial Perfusion Imaging, (Following Stress PlanarMyocardial Perfusion, 78460); Single Study, Rest or Stress

**G0039 Yes PET Myocardial Perfusion Imaging, (Following Stress Planar Myocardial Perfusion, 78460); Multiple Studies, Rest or Stress

**G0040 Yes PET Myocardial Perfusion Imaging, (Following Stress Echocardiogram, 93350); Single Study, Rest or Stress

**G0041 Yes PET Myocardial Perfusion Imaging, (Following Stress Echocardiogram, 93350); Multiple Studies, Rest or Stress



PET Scans (continued)


**G0042 Yes PET Myocardial Perfusion Imaging, (Following Stress Nuclear Ventriculogram, 78481 or 78483); Single Study, Rest or Stress

**G0043 Yes PET Myocardial Perfusion Imaging, (Following Stress Nuclear Ventriculogram, 78481 or 78483); Multiple Studies, Rest or Stress

**G0044 Yes PET Myocardial Perfusion Imaging, (Following Rest ECG, 93000); Single Study, Rest or Stress

**G0045 Yes PET Myocardial Perfusion Imaging, (Following Rest ECG, 93000); Multiple Studies, Rest or Stress

**G0046 Yes PET Myocardial Perfusion Imaging, (Following Stress ECG, 93015); Single Study, Rest or Stress

**G0047 Yes PET Myocardial Perfusion Imaging, (Following Stress ECG, 93015); Multiple Studies, Rest or Stress

**G0125 Yes PET Lung Imaging of Solitary Pulmonary Nodules, Using 2-(Fluorine-18) Fluoro-2-Deoxy-D-Glucose (FDG), Following CT (71250/71260 or 71270)

**G0210 Yes PET Imaging Whole Body; Diagnosis; Lung Cancer, Non-Small Cell

**G0211 Yes PET Imaging Whole Body; Initial Staging; Lung Cancer, Non-Small Cell

**G0212 Yes PET Imaging Whole Body; Restaging; Lung Cancer, Non-Small Cell

**G0213 Yes PET Imaging Whole Body; Diagnosis; Colorectal Cancer

**G0214 Yes PET Imaging Whole Body; Initial Staging; Colorectal Cancer

**G0215 Yes PET Imaging Whole Body; Restaging; Colorectal Cancer

**G0216 Yes PET Imaging Whole Body; Diagnosis; Melanoma

**G0217 Yes PET Imaging Whole Body; Initial Staging; Melanoma

**G0218 Yes PET Imaging Whole Body; Restaging; Melanoma

**G0219 Yes PET Imaging Whole Body; Full and Partial Ring PET Scanners Only, Non Covered Indications

**G0220 Yes PET Imaging Whole Body; Diagnosis; Lymphoma

**G0221 Yes PET Imaging Whole Body; Initial Staging; Lymphoma

**G0222 Yes PET Imaging Whole Body; Restaging; Lymphoma

**G0223 Yes PET Imaging Whole Body or Regional; Diagnosis; Head and Neck Cancer; Excluding Thyroid and CNS Cancers



PET Scans (continued)


**G0224 Yes PET Imaging Whole Body or Regional; Initial Staging; Head and Neck Cancer; Excluding Thyroid and CNS Cancers

**G0225 Yes PET Imaging Whole Body or Regional; Restaging; Head and Neck Cancer; Excluding Thyroid and CNS Cancers

**G0226 Yes PET Imaging Whole Body; Diagnosis; Esophageal Cancer

**G0227 Yes PET Imaging Whole Body; Initial Staging; Esophageal Cancer

**G0228 Yes PET Imaging Whole Body; Restaging; Esophageal Cancer

**G0229 Yes PET Imaging; Metabolic Brain Imaging for Pre-Surgical Evaluation of Refractory Seizures

**G0230 Yes PET Imaging; Metabolic Assessment for Myocardial Viability Following Inconclusive SPECT Study

**G0231 Yes PET, Whole Body, for Recurrence of Colorectal Metastatic Cancer; Gamma Cameras Only

**G0232 Yes PET, Whole Body, for Recurrence of Lymphoma; Gamma Cameras Only

**G0233 Yes PET, Whole Body, for Recurrence of Melanoma; Gamma Cameras Only

**G0234 Yes PET, Regional or Whole Body, for Solitary Pulmonary Nodule Following CT or for Initial Stating of Pathologically Diagnosed Non Small Cell Lung Cancer; Gamma Cameras Only

**G0252 Yes PET Imaging, Full and Partial Ring PET Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer (e.g., Initial Staging of Ancillary Lymph Nodes)

**G0253 Yes PET Imaging for Breast Cancer, Full and Partial Ring PET Scanners Only, Staging/Re-staging of Local Regional Recurrence or Distant Metastases (i.e., Staging/Re-staging After or Prior to Course of Treatment)

**G0254 Yes PET Imaging for Breast Cancer, Full and Partial Ring PET Scanners Only, Evaluation of Response to Treatment Performed During Course of Treatment



Nuclear MedicinePlease note: Effective February 2, 2004, all nuclear cardiology providers interpreting nuclear cardiology examinations will be required to meet one of the following standards in order to receive reimbursement for nuclear cardiology claims: • Certification by the Certification Board for Nuclear Cardiology (CBNC)1

• Board certification in Nuclear Medicine by the American Board of Nuclear Medicine (ABNM) • Board certification in Radiology by the American Board of Radiology (ABR)

1 Effective February 2, 2004, all nuclear cardiology facilities must be accredited by either the Intersocietal Commission for the Accreditation of Nuclear Laboratories(ICANL) or the American College of Radiology (ACR) in order to receive reimbursement for nuclear cardiology claims.


78000 Thyroid RAI Uptake

78001 Thyroid, Multiple Uptakes

78003 Thyroid Suppress or Stimulation

78006 Thyroid Uptake and Scan

78007 Thyroid, Image, Multiple Uptakes

78010 Thyroid Scan Only

78011 Thyroid Imaging with Flow

78015 Thyroid Met Imaging

78016 Thyroid Met Imaging with Additional Studies

78018 Thyroid Scan Whole Body

78020 Thyroid Carcinoma Metastases Uptake

78070 Parathyroid Nuclear Imaging

78075 Adrenal Nuclear Imaging

78099 Unlisted Endocrine Procedure, Diagnostic Nuclear Medicine

78102 Bone Marrow Imaging, Limited

78103 Bone Marrow Imaging, Multiple

78104 Bone Marrow Imaging, Whole Body

78110 Plasma Volume, Single

78111 Plasma Volume, Multiple Sampling

78120 Red Cell Volume Determination, Single Sampling

78121 Red Cell Volume Determination, Multiple Sampling

78122 Whole Blood Volume Determination, SEP Plasma and Red Cell

78130 Red Cell Survival Study

78135 Differential Organ/Tissues Kinetic

78140 Labeled Red Cell Sequestration



Nuclear Medicine (continued)


78160 Plasma Radioiron Disappearance

78162 Radioiron Oral Absorption

78170 Red Cell Iron Utilization

78172 Total Body Iron Estimation

78185 Spleen Imaging w and w/o VAS Flow

78190 Platelet Survival, Kinetics

78191 Platelet Survival

78195 Lymph System Imaging

78199 Unlisted Hematopoietic Diagnostic Nuclear Med

78201 Liver Imaging

78202 Liver Imaging with Flow

78205 Liver Imaging SPECT (3-D)

78206 Liver Imaging SPECT w/Vascular Flow

78215 Liver and Spleen Imaging

78216 Liver and Spleen Imaging with Flow

78220 Liver Function Study

78223 HIDA Scan

78230 Salivary Gland Imaging

78231 Serial Salivary Gland

78232 Salivary Gland Function Exam

78258 Esophageal Motility Study

78261 Gastric Mucosa Imaging

78262 Gastroesophageal Reflux Exam

78264 Gastric Emptying Study

78270 VIT-B12 Absorption Exam

78271 VIT-B12 Absorption Exam, lF

78272 VIT-B12 Absorption Exam Combined

78278 GI Bleeder Scan

78282 GI Protein Loss Exam

78290 Meckel’s Diverticulum Imaging

78291 Leveen Shunt Patency Exam





79299 Unlisted Gastrointestinal

78300 Bone or Joint Imaging LTD

78305 Bone or Joint Imaging Multiple

78306 Bone Scan Whole Body

78315 Bone Scan 3-Phase Study

78320 Bone Joint Imaging Tomo Test

78399 Unlisted Musculoskeletal

78414 Non-Imaging Heart Function

78428 Cardiac Shunt Imaging

78445 Radionuclide Venogram Non-Cardiac

78455 Venous Thrombosis Study

78456 Acute Venous Thrombosis Imaging

78457 Venous Thrombosis Imaging Unilateral

78458 Venous Thrombosis Images, Bilateral

78460 Thallium Scan Rest Only

78461 Myocardial Perf Stress or Rest Multiple Study

78464 Heart Image (3-D) Single

78465 Myocardial Perf w/SPECT Multiple

78466 Myocardial Infarction Scan

78468 Heart Infarct Image EF

78469 Heart Infarct Image 3-D

78472 Gated Heart, Resting

78473 Cardiac Blood Pool Muga Scan

78478 Myocardial Wall Motion Study

78480 Ejection Fraction Study

78481 Heart First Pass Single

78483 Cardiac Blood Pool Imaging — Multiple

78494 Cardiac Blood Pool Imaging, SPECT

78496 Cardiac Blood Pool Imaging — Single Study at Rest(Use with 78472)

78499 Unlisted Cardiovascular Nuclear Exam





78580 Pulmonary Perfusion Imaging

78584 Pulmonary Perfusion with Vent Single Breath

78585 Pulmonary Perfusion w/Washout, w/or w/o Single Breath

78586 Pulmonary Ventilation Imaging

78587 Pulmonary Ventilation Multi

78588 Pulmonary Perfusion w/Ventilation

78591 Vent Image 1 Breath, 1 Projection

78593 Vent Image 1 Projection, Gas

78594 Vent Image Multi Projection, Gas

78596 Lung Differential Function

78599 Unlisted Respiratory Nuclear Exam

78600 Brain Imaging LTD Static

78601 Brain LTD Imaging and Flow

78605 Brain Imaging Complete

78606 Brain Imaging Complete with Flow

78607 Brain Imaging 3-D

78610 Brain Flow Imaging Only

78615 Cerebral Blood Flow Imaging

78630 Cisternogram (Cerebrospinal Fluid Flow)

78635 Cerebrospinal Ventriculography

78645 CSF Shunt Evaluation

78647 Cerebrospinal Fluid Scan

78650 CSF Leakage Detection and Localization

78660 Radiopharmaceutical Dacryocystography

78699 Unlisted Diagnostic Nuclear Med Procedure

78700 Kidney Imaging (Static)

78701 Kidney Imaging w/Vascular Flow

78704 Kidney Imaging w/Function Study

78707 Kidney Imaging w/Vascular Flow and Functional Single Study

78708 Kidney Imaging Single Study w/Pharm. Intervention





78709 Kidney Imaging — Multiple Studies w/ and w/o Pharm. Intervention

78710 Kidney Imaging — Tomographic (SPECT)

78715 Kidney Vascular Flow Only

78725 Kidney Function Study — Non-Imaging Radioisotopic

78730 Urinary Bladder Residual Study

78740 Ureteral Reflux Study

78760 Testicular Imaging

78761 Testicular Imaging w/Vascular Flow

78799 Unlisted Genitourinary Procedure

78800 Radiopharm Localization of Tumor, Limited Area

78801 Radiopharm Localization of Tumor, Multiple Areas

78802 Radiopharm Localization of Tumor, Whole Body

78803 Radiopharm Localization of Tumor Tomographic (SPECT)

78805 Radiopharm Localization of Abscess, Limited Area

78806 Radiopharm Localization of Abscess, Whole Body

78807 Radiopharm Localization of Abscess, Tomographic SPECT

78999 Unlisted Misc. Procedure

Obstetrical Ultrasounds (Authorization required for fourth and subsequent procedures)Please note: OBGYNs must have AIUM or ACR accreditation in order to be reimbursed for CPT codes 76801, 76802,76805, 76810, 76818, 76819, 76825, 76826, 76827, and 76828


76801 Ultrasound, Pregnant Uterus, Real Time with ImageDocumentation, Fetal and Maternal Evaluation, FirstTrimester (<14 Weeks 0 Days), Transabdominal Approach; Single or First Gestation

76802 Ultrasound, Pregnant Uterus, Real Time with ImageDocumentation, Fetal and Maternal Evaluation, FirstTrimester (<14 Weeks 0 Days), Transabdominal Approach;Each Additional Gestation (List separately in addition to Code for Primary ProcedurePerformed) [Use 76802 in conjunction with 76801]



Obstetrical Ultrasounds (continued)


76805 Echography, Pregnant Uterus, B-Scan and/or Real Timew/Image Documentation, Complete Fetal and Maternal Evaluation

76810 Complete — Fetal and Maternal Evaluation, Multiple Gestation, after the First Trimester

76811 Ultrasound, Pregnant Uterus, Real Time with ImageDocumentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination, TransabdominalApproach; Single or First Gestation

76812 Ultrasound, Pregnant Uterus, Real Time with ImageDocumentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination, TransabdominalApproach; Each Additional Gestation (List separately in addition to Code for Primary ProcedurePerformed) [Use 76812 in conjunction with Code 76811]

76815 Limited — Fetal Size, Heart Beat, Placental Location, Fetal Position or Emergency in the Delivery Room

76816 Follow-up or Repeat

76817 Ultrasound, Pregnant Uterus, Real Time with ImageDocumentation, Transvaginal [For Non-obstetrical Transvaginal Ultrasound, use 76830] [If TransvaginalExamination is done in addition to Transabdominal Obstetrical Ultrasound Exam, use 76817 in addition to appropriate Transabdominal Exam Code]

76818 Fetal Biophysical Profile

76819 Fetal Biophysical Profile; Without Stress or Non-Stress Testing

76825 Echocardiography, Fetal, Cardiovascular System, Real Timew/Image Documentation (2d), w/or w/o M-Mode Recording

76826 Follow-up or Repeat Study

76827 Doppler Echocardiography, Fetal, Cardiovascular System, Pulsed Wave and/or Continuous Wave w/Spectral Display, Complete

76828 Follow-up or Repeat Study

76975 Endoscopic Ultrasound



Physical and Occupational Therapy

OrthoNet, a musculoskeletal disease managementcompany, is Oxford’s network manager for allcommercial outpatient physical and occupationaltherapy services. OrthoNet is a local company with an office in White Plains, New York. Physical andoccupational therapy provided by a chiropractor is managed by TRIAD Healthcare, Inc.

All commercial physical and occupational therapyservices following the initial evaluation (CPT codes97001 and 97003) in the CPT code list below requirean OrthoNet authorization (Chiropractors shouldrefer to Chiropractic Guidelines in this section). Areferral is required for the initial evaluation (excludesnon-gatekeeper Members). Providers will receive aresponse by fax. The goal is to provide responses

within two (2) business days of receipt of all requiredclinical documentation. The CPT codes listed below require utilization review.

Authorization requests can be made by faxing the necessary documentation to OrthoNet at 1-800-216-0810.

For urgent requests or inquiries about clinical care,treatment plans, status, and outcomes, you can speakwith OrthoNet Medical Management Department by calling 1-800-201-4872.

For PCPs, there are no changes to the current Oxfordreferral process for the first therapy visit (CPT codes97001 and 97003); simply refer the Member. Do notindicate the number of visits for which the Member isapproved, since that will be determined as part of theutilization review process.

Please note: Electronic referral receipts, which show thenumber of visits, cannot be used in lieu of OrthoNet’sauthorization. All visits beyond the initial evaluationsmust still be precertified with OrthoNet regardless of thenumber of visits that may be listed on the electronic referral receipt.

For providers of physical and occupational therapy,there are no changes to the existing claims submissionprocess or the Oxford fee schedule. Remember thatfailure to comply with the new medical managementpolicy for therapy services after the initial evaluationmay result in non-payment.

If you have any questions on how to obtain thenecessary forms, please call OrthoNet’s ProviderServices Department at 1-800-201-4891.

CPT Codes Requiring OrthoNet Precertification * Cannot be billed by an occupational therapist (also applies to CPT code 97001).


*97002 Physical therapy re-evaluation

97004 Occupational therapy re-evaluation

97010 Application of a modality — does not require direct patient-provider contact, hot or cold packs

*97012 Application of a modality — does not require direct patient-provider contact, traction — mechanical

97014 Application of a modality — does not require direct patient-provider contact, electrical stimulation (unattended)

97016 Application of a modality — does not require direct patient-provider contact, vasopneumatic devices



CPT Codes (continued)


97018 Application of a modality — does not require direct patient-provider contact, paraffin bath

97020 Application of a modality — does not require direct patient-provider contact, microwave

97022 Application of a modality — does not require direct patient-provider contact, whirlpool

*97024 Application of a modality — does not require direct patient-provider contact, diathermy

*97026 Application of a modality — does not require direct patient-provider contact, infrared

*97028 Application of a modality — does not require direct patient-provider contact, ultraviolet

*97032 Application of a modality — requires direct patient-provider contact, electrical stimulation(manual)

*97033 Application of a modality — requires direct patient-provider contact, iontophoresis

97034 Application of a modality — requires direct patient-provider contact, contrast baths

*97035 Application of a modality — requires direct patient-provider contact, ultrasound

*97036 Application of a modality — requires direct patient-provider contact, Hubbard tank

97039 Application of a modality — requires direct patient-provider contact, unlisted modality (specify)

97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 Neuromuscular re-education of movement

*97113 Aquatic therapy with therapeutic exercises

97116 Gait training (included stair climbing)

97124 Massage, including effleurage, petrissage and/or tapotement

97139 Unlisted therapeutic procedure (specify)

97140 Manual therapy techniques, one or more regions

97150 Therapeutic procedures, group (2 or more individuals)

97504 Orthotics, fitting and training, upper and/or lower extremities

97520 Prosthetic training, upper and/or lower extremities

97530 Therapeutic activities — direct patient-provider contact, use of dynamic activities toimprove functional performance

97532 Development of cognitive skills to improve attention, memory, problem solving

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands

97535 Self-care/home management training — direct patient-provider contact

97537 Community/work re-integration training — direct patient-provider contact

97542 Wheelchair management/propulsion training

97545 Work hardening/conditioning, initial 2 hours

97546 Work hardening/conditioning, each additional hour



CPT Codes (continued)


97703 Checkout for orthotic/prosthetic use, established patient

97750 Physical performance test or measurement

97799 Unlisted physical medicine/rehabilitation service or procedure

Acupuncture andChiropractic Guidelines

Acupuncture Guidelines

Acupuncture is covered for commercial Members onlyon an in-network basis and must be performed by oneof following provider types:

• Participating licensed acupuncturist (LAC)

• Participating licensed naturopaths

• Participating physician (MD or DO) who has beencredentialed as physician acupuncturist

Oxford covers acupuncture as a benefit only for thoseMembers who have the alternative medicine rider, andwill deny all requests for acupuncture if the rider is notpart of the Member’s benefit package, even if a letter of medical necessity has been submitted.

Chiropractic Guidelines

To receive the standard insured chiropractic benefitcoverage, Members must obtain an electronic referralfrom their PCP. Under Oxford’s Complementary &Alternative Medicine (CAM) Program, choosing achiropractor is easy, as Oxford has an extensive network of credentialed chiropractors throughout your service area.

To help facilitate referrals for chiropractic care, Oxfordhas developed the following guidelines, which are basedon current medical literature.1 PCPs should performthe customary initial comprehensive differentialdiagnosis with the necessary and appropriate work-up.

1 Meeker,W.C.; Haldeman, S. Chiropractic: a profession at the crossroads ofmainstream and alternative medicine. [Review] [164 refs] [Historical Article.Journal Article. Review. Review,Academic] Annuals of Internal Medicine. 136(3):216-27, 2002 Feb 5.

For patients with conditions that may respond well tochiropractic care, such as acute low back pain, neck painor other neuromusculoskeletal problems, you shoulddiscuss conventional and chiropractic treatment optionswith your patient, describing the risks and benefits ofeach. If a patient requests a referral to a chiropractorand there is no compelling medical contraindication,you can make the referral for an initial evaluation.

For commercial Members only: One visit within 180days (six months) is the maximum number of visits forwhich a chiropractic referral can be generated. Oxfordrequires all participating chiropractors to submit aninitial care plan (ICP) to TRIAD Healthcare, Inc. forservices performed beyond the initial evaluation visit.You will need to obtain approval of the plan as acondition of reimbursement for subsequent visits.

Chiropractic services can be precertified by completing an ICP and faxing it directly to TRIAD at 1-866-225-1033.

An ICP must be submitted to TRIAD within 14 businessdays following the patient’s initial evaluation, or priorto the second visit, whichever occurs first. The careplan must include the initial visit. If TRIAD does notreceive an ICP within this time frame, your claim willbe denied. Once the completed ICP is received, TRIADwill review the services requested for medical necessity,and Oxford will make any denial determinations. If apatient’s care requires additional visits or more timethan was precertified on the ICP, you may submit anextension of care (EOC) form after the initiallyapproved visits have occurred.

Please note: According to your contract with Oxford, ifservices are not precertified and claims are denied, youcannot bill the patient for these services. However, you may file an appeal.

For Oxford Medicare AdvantageSM Members:The initial referral is valid for one visit.



After the first visit, the chiropractor will fax a care plan to Oxford’s Complementary & AlternativeMedicine Department at 1-800-201-7025.

The care plan will be thoroughly reviewed by anexperienced chiropractic reviewer, who will deny orapprove the plan based on the appropriate number ofvisits for treatment. The PCP should schedule a follow-upvisit or phone call with the patient to monitor progress.

Absolute Contraindications to Chiropractic Care

• Vertebral malignancy

• Infection or inflammation

• Cauda equina syndrome

• Myelopathy or severe spondylosis

• Multiple adjacent radiculopathies

• Vertebral bone diseases

• Vertebral bony joint instability (e.g., fractures, dislocations)

• Rheumatoid disease in the cervical region

Relative Contraindications

• Presence of spinal deformity and most skeletal anomalies

• Systemic anticoagulation, either disease-related or pharmacologic severe diabetes

• Atherosclerosis

• Severe degenerative joint disease

• Vertigo or symptoms and signs of vertebral-basilarartery disease or insufficiency

• Spondyloarthropathies (e.g., psoriatic, ankylosingspondylitis, Reiter syndrome)

• Inactive rheumatoid disease

• Ligamentous joint instability or congenital joint laxity

• Syndromes such as Marfan and Ehlers-Danlos

• Aseptic necrosis

• Local aneurysm

• Osteomalacia

• Osteoporosis

Pharmacy

Pharmacy Benefits Manager

Medco Health is Oxford’s pharmacy benefits manager.Medco Health has a dedicated service line to addressall physician questions. This line is available 24 hours a day, seven days a week (excluding Thanksgiving andChristmas Day).

To contact Medco Health, please call 1-800-905-0201.

Pharmacy and

Therapeutics Committee

The Pharmacy and Therapeutics Committee (P&TCommittee) provides direction and establishes policy for activities related to the delivery of pharmaceuticalproducts to Oxford Members. The P&T Committee is responsible for developing and updating Oxford’spolicies and procedures for pharmaceuticalmanagement including overseeing all pharmacy-related quality management activities, makingrecommendations and providing final approvals, as well as ongoing evaluation of any formularies andclinical management programs used by Oxford. TheP&T Committee meets quarterly, and is composed of Oxford Medical Directors, participating planphysicians, pharmacists, and additional staff, as required.Appropriate specialists are consulted as necessary.

Pharmacy Management

Programs

Oxford’s prescription drug plan is comprised of acomprehensive package of benefits that includes acomplete drug formulary and pharmacy managementprograms. These programs are updated as new drugproducts are approved by the Food and DrugAdministration (FDA) or when new pharmaceuticalinformation becomes available.

Along with benefit changes, Oxford will continue toimplement clinical pharmacy management programsthat not only improve quality of care but also bettermanage costs by reducing drug and hospital expenseincurred through unnecessary drug use and waste, and by limiting exposure to medical costs due toadverse drug reactions. Together with Medco Health,Oxford has established programs to encourage drugtherapy that is appropriate and economical for our



Members. These programs are largely based onguidelines established by the FDA.

Quality Management and Patient Safety Programs

Drug Utilization Review (DUR)

Pharmacists submit almost all prescriptionselectronically. Within seconds, the Member’s claimregisters and the past prescription history is reviewedfor potential drug-related problems. DUR helpssafeguard patients from potentially harmful druginteractions, overutilization and other adverse drugevents in an effort to maximize therapy effectivenesswith the appropriate drug and dosing parameters.

There are two types of DUR programs, concurrent and retrospective:

1) Concurrent DUR

Concurrent DUR (CDUR) is a point-of-sale, system-based review process that screens the incomingprescription for a broad range of safety considerations,prior to dispensing, by comparing the prescription to the patient’s drug history. The system identifiespotential drug utilization issues and sends an alert to the dispensing pharmacists to reduce patient risk of adverse drug events, improve quality of care andreduce any unnecessary costs. There are two types of alert messages:

Warning alert — sends an online warning message tothe pharmacists. Examples of warning alerts include:

• Drug interaction

• Underutilization

• Duplicate therapy

• Drug-allergy

• Drug-gender

• Drug-disease

• Drug-age

• Drug-pregnancy

• Under minimum

• Look-alike/sound-alike daily dose

Reject alert — the claim is rejected at the point-of-sale, which prevents the prescription claim frombeing paid. Examples of reject alerts include:

• Early refill (refill too soon)

• Maximum daily dose (over maximum dose)

• Cyclic max dose

• Severe drug interaction

2) Retrospective DUR

Retrospective DUR (RDUR) is a quarterly review thatalerts physicians to drug utilization issues that warranttheir considerations. These reviews provide physicianswith timely, relevant information to ensure Membersreceive the right drug at the right dose for the rightamount of time.

RDUR functions by focusing on the categories anddrugs that are most likely to be prescribed or usedinappropriately. Claims are reviewed to identify patternsof inappropriate prescribing and consumption that do not comply with best clinical practices. Physiciansare informed of potential issues and opportunities, and are provided clinical considerations for reference.Physicians are provided with patient-level data that theymight not normally have access to along with clinicalconsiderations. Physician satisfaction and acceptanceare tracked, and changes in therapy are identified and reported based on subsequent claims information.Examples of RDUR include dose considerations withnon-steroidal anti-inflammatory drugs (NSAIDs),migraine therapy and prophylaxis, and dose andduration considerations with an H2-receptorantagonist (H2RA)/proton pump inhibitor (PPI).

RDUR helps improve the quality of care bysafeguarding patients against potentiallyinappropriate utilization and harmful interactions,promoting awareness of clinically-based guidelinesand plan policies, and better managing costs.

FDA Alerts and Product Recalls

Oxford Health Plan’s pharmacy benefit manager (PBM)has a formal process to address FDA and manufacturerdrug recalls ensuring that the health and safety ofpatients is considered with every event. Where possible,patients affected by FDA-required or voluntary drugwithdrawals are identified and notified by mail. Patientsare provided the drug product lot numbers affected bythe recall and asked to share this information with theirphysician or other healthcare professional. Patients areinstructed on where to send the recalled productreceived from the PBM. Information on drug recalls is also posted on the PBM’s web site.



Controlled Drug Use Evaluation (DUE)

The objective of DUE is to promote medicallyappropriate drug therapy for our Members. On aquarterly basis, Oxford reviews the medication profilesof Members who receive frequent prescriptions fornarcotic analgesics and other controlled drugs at highdoses. Members are identified based on the repetitiveuse of an anxiolytic, barbiturate sedative/hypnotic ornarcotic analgesics in doses and/or quantities over 120days, which may indicate overutilization through eitheran excessive daily dose (misuse) or prescriptions frommultiple physicians (abuse) without therapeutic benefitto the patient. Oxford will notify you by mail if anypatients for whom you prescribe controlled drugs meet these criteria. This notification letter is intended to provide information and, when indicated (in youropinion), help modify your patient’s drug use behavior.If you are contacted, please review this informationcarefully to verify that your patient is taking themedication according to your instructions.

Utilization ManagementEnsuring that patients receive the appropriate drug atthe right dose for the length of time necessary to treata particular medical condition is key to providingappropriate pharmacy care. Guidelines for diagnosisand treatment for some of the most common chronicconditions have been established by the FDA and othergovernment and medical subspecialty societies.

Medications Requiring Precertification

Based on plan designs, selected high-risk or high-costdrugs may require precertification by Oxford in orderto be eligible for coverage. Precertification criteria havebeen established by the P&T Committee with inputfrom plan physicians and considerations of the currentmedical literature. For most Members with pharmacybenefit coverage through Oxford, the medications onthe following list (including their generic, if available)generally require precertification through MedcoHealth, based on Oxford’s coverage criteria.Precertification (also known as prior authorization)requires that you formally submit a request to, andreceive approval from, Medco Health in order for the Member to receive coverage for a prescription for certain medications.

You may be asked to provide information explainingmedical necessity and past therapeutic failures. Arepresentative will collect all pertinent clinical data forthe service requested. For those requests that do notmeet the criteria for approval, you will be informed

that coverage determination requires further review byan Oxford Medical Director. Notification of decisions is made within one (1) business day of receipt of the request. If the necessary information required to render a decision is not received with your initialrequest, Medco Health will contact you within 24 hours and ask that you provide the information.

If you have any questions regarding the medicationson this list or any other medications, please callPharmacy Customer Service at 1-800-905-0201.

Drugs Requiring Precertification (subject to plan design)

Anabolic Steroids*/Androgens*

• Anadrol-50

• Androderm Patches

• Androgel

• Android

• Deca-Durabolin

• Delatestryl

• Depo-Testosterone

• Halotestin

• Methyltestosterone

• Oxandrin

• Striant

• Testim

• Testoderm

• Testosterone

• Testred

• Winstrol

CNS Stimulants

• Adderall1

• Concerta1

• Desoxyn1

• Dexedrine1

• Dextrostat1

• Provigil



Acne Drugs

• Avita2

• Differin2

• Retin A2

Proton Pump Inhibitors*

• Aciphex

• Nexium

• Prevacid

• Prilosec

• Protonix

Erectile Dysfunction Drugs**

• Caverject

• Cialis

• Levitra

• Edex

• Muse

• Viagra

Arthritis Medications

• Bextra*

• Celebrex*

• Enbrel

• Humira

• Kineret

• Vioxx*

Specialized OB/GYN Drugs

• Lupron Depot (3.75 mg and 11.25 mg)

Miscellaneous Drugs

• Forteo

• Nutritional Therapies3

• Serostim

• Singulair*4

• Strattera

• Vitamin D preparations (i.e., Hectorol, Rocaltrol, etc.)

Miscellaneous Gastrointestinal Drugs*

• Lotronex

• Zelnorm

1 Applies only to Members age 19 or older2 Applies only to Members age 40 or older3 For coverage information, Members should contact Oxford Customer Service

at the number on their ID card4 Applies only to Members age 12 or older

* Precertification is not required for Oxford Medicare AdvantageSM Members

** Medication is not covered for Oxford Medicare Advantage Members

Please note: Precertification requirements may varydepending on the Member’s benefits. This list is subject to change without notice.

To obtain precertification, please call Medco Health at 1-800-753-2851, Mon. – Fri. 8 AM to 9 PM (EasternStandard Time).

Quantity Limits

For certain medications, and based on plan design, a limitation in the quantity covered at one time is inplace, often reflecting the maximum FDA-recommendeddosage for a drug or use of the most efficient drugstrength for the fully prescribed daily dose. In thesesituations, an electronic message specifying quantitylimits will be sent to the pharmacist instructing that theprescription be reviewed with the prescribing physician.In all cases, the goal is to encourage medicallyappropriate and economic use of drugs.



Three-tier Prescription Drug Benefit

Oxford has a three-tier prescription drug benefit for many commercial and Medicare plans. The preferred drug listfor this benefit was carefully designed to promote medically appropriate, cost-effective healthcare while preservingyour ability to prescribe specific drugs of choice for your patients. The three tiers include generic drugs (Tier 1),preferred brand drugs (Tier 2) and non-preferred brand drugs (Tier 3), with an increase in copayment (cost share) to our Members with each tier. Members covered by the three-tier prescription plan benefit may have one of thefollowing plan designs, depending on the benefit chosen by their employer:

Plan Design* Tier 1: Tier 2: Tier 3: Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs

Rx Plan A copayments $5 $15 $35

Rx Plan B copayments $5 $15 $50

Rx Plan C copayments $7 $20 $50

Rx Plan D copayments $5 $10 $20

Rx Plan E copayments $7 $15 $35

Rx Plan F copayments $10 $20 $50

* Plan designs are not available in all states. Not all Members have a three-tier pharmacy benefit: Oxford Medicare AdvantageSM may have either no pharmacy benefit,a generic drug only benefit or a three-tier pharmacy benefit.

Please note: This is not a complete listing.

You may continue to choose from the many qualitydrugs available, using your patient’s out-of-pocket cost as a consideration when prescribing.

Please review Oxford’s preferred drug list and, whereappropriate for your patients, consider changing Tier 3 prescriptions to generic or preferred branddrugs. The preferred drug list can be found at the end of this section. Look for Oxford’s complete drug formulary at www.oxfordhealth.com.

Please note: This three-tier drug benefit structure may be extended to other groups. Please refer to our Programand Policy Updates for any changes.

Mail-order Through Medco

Health Home Delivery

Pharmacy Service

Oxford offers Members the ability to obtain up to a 90-day supply of certain medications within severaltherapeutic categories of medications through theMedco Health Home Delivery Pharmacy Service.™

Maintenance medications are prescription medications

associated with the treatment of certain chronicconditions, such as diabetes, hypertension and epilepsy.All Members whose plans include the mail-orderbenefit are entitled to use Medco Health HomeDelivery Pharmacy Service.™

Medco Health Home Delivery Pharmacy Service™

P.O. Box 747000Cincinnati, OH 45274-7000

For more information on specific drug coveragethrough the Medco Health Home Delivery Pharmacy Service™ please call Pharmacy Customer Service at 1-800-905-0201.

OOXF O R D | I M PO RTA NT A D D R ES S



The Prescription Drug

Formulary

Oxford’s prescription drug formulary is a dynamiclisting of medications that is reviewed at least annuallyand updated quarterly to reflect advances in medicalcare. The Pharmacy and Therapeutics Committee (P&TCommittee), which consists of Oxford’s participatingphysicians, Medical Directors and pharmacists, isresponsible for developing and maintaining this list.P&T Committee quarterly updates appear in the Programand Policy Update. Available at www.oxfordhealth.com, thedrug formulary details inclusions, drug quantity limitsand precertification requirements.

Please note: The listing of a drug product does notguarantee coverage, as certain products are excluded due to benefit plan design limitations that are specific to Member’s individual or group benefits. In addition,diabetic supplies that are available through the Member’sbase medical benefit are subject to the applicable copayment(cost share) noted on the Member’s Summary of Benefits.

The following preferred drug list includes generic andpreferred brand drugs. If a brand name drug is notlisted, it is a non-preferred brand drug and subject to the three-tier pharmacy benefit (if the Member has athree-tier benefit). The list is alphabetized by the nameof the drug. Generic drugs are listed in lower case lettersand preferred brand drugs are listed in CAPITAL letters.Drugs affected by quantity limits are preceded by anasterisk (*). Drugs requiring precertification aredesignated as (PAR).

Please note: This list of drugs is subject to changes. Any changes will be posted in the quarterly Program and Policy Update.

The Preferred Drug List

ACCUPRIL

ACCURETIC

acebutolol

acetaminophen/butalbital

acetaminophen/caffeine/butalb

acetazolamide

acetic acid

acetic acid/aluminum acetate

acetic acid/hydrocortisone

acetohexamide

ACETOHEXAMIDE

acetylcysteine

* ACTONEL 35 MG

* ACTOS

ACULAR/PF

acyclovir

* ADVAIR

AGENERASE

AGRYLIN

ALBENZA

* albuterol inhaler

albuterol (tablet, solution)

ALDARA

ALESSE

ALKERAN

allopurinol

ALPHAGAN P

alprazolam

aluminum chloride

amantadine

AMARYL

* AMERGE

amiloride

amiloride/HCTZ

aminocaproic acid

aminophylline

amiodarone

amitriptyline

amitriptyline HCl/perphenazine

amitriptyline/chlordiazepoxide

ammonium lactate



amoxapine

amoxicillin

amoxicillin/potassium clavulanate

amphetamine/dextroamphetamine (PAR)

ampicillin

* ANA-KIT

ANDRODERM (PAR)

ANDROGEL (PAR)

antipyrine/benzocaine

ARICEPT

ARIMIDEX

AROMASIN

ASACOL

aspirin/caffeine/butalbital

atenolol

atropine sulfate

ATROVENT inh

AUGMENTIN ES

* AVANDAMET

* AVANDIA

AVC

AVELOX

* AVONEX

azathioprine

azelaic acid

AZOPT

bacitracin/polymixin B ophthalmic

baclofen

BACTROBAN CREAM

* BECONASE

* BECONASE AQ

belladonna alkaloids/phenobarb

BENICAR

BENICAR HCT

benzoyl peroxide

benztropine

betamethasone dipropionate

betamethasone valerate

* BETASERON

betaxolol

bethanechol

BETOPTIC S

BILTRICIDE

bisoprolol

bisoprolol fumarate/HCTZ

BLEPHAMIDE

Brimonidine tartrate

bromocriptine mesylate

bumetanide

bupropion immediate release

buspirone

* butorphanol NS

CAFERGOT

calciferol (PAR)

calcitriol (PAR)

CANASA

CAPITROL SHAMPOO

captopril

captopril/HCTZ

carbamazepine

CARBATROL

carbidopa/levodopa

carbidopa/levodopa (extended-release)

carisoprodol



CARNITOR

carteolol

CASODEX

* CATAPRESS TTS

CEENU

cefaclor

cefadroxil

CEFTIN (susp only)

cefuroxime

CELLCEPT

CELONTIN

cephalexin

cephradine

CERUMENEX

CHEMET

chloral hydrate

chlordiazepoxide HCl

chlorhexidine gluconate

chloroquine phosphate

chlorothiazide

chlorpromazine

chlorpropramide

chlorthalidone

chlorthalidone/atenolol

chlorzoxazone

chol sal/magnesium salicylate

cholestyramine

cholestyramine/aspartame

cholestyramine/sucrose

* chorionic gonadotropin

cimetidine

* CIPRO

clemastine fumarate

CLEOCIN VAGINAL

clidinium/chlordiazepoxide

* CLIMARA

clindamycin

clobetasol propionate

clomiphene citrate

clomipramine

clonazepam

clonidine HCl

clonidine HCl/chlorthalidone

clorazepate

clotrimazole/betamethasone dipropionate

clozapine

codeine sulfate

colchicine

COMBIVIR

COMTAN

CONDYLOX

* COPAXONE

CORDRAN/SP

COREG

CORTIFOAM

cortisone acetate

COTAZYM

COUMADIN

COZAAR

CREON

CRIXIVAN

cromolyn nebulizer solution

CUPRIMINE

cyclobenzaprine



cyclopentolate

cyclosporine

cyproheptadine

CYTADREN

CYTOVENE

CYTOXAN

danazol

DANTRIUM

DAPSONE

DARAPRIM

DDAVP Tablets

deltasone

DENAVIR

DEPAKENE

DEPAKOTE

DEPEN TITRATABS

* DEPO-PROVERA 150 MG

DERMA-SMOOTHE/FS 0.01%

desipramine

desmopressin acetate solution

desmopressin acetate spray

desogestrel/ethinyl estradiol

desonide

desoximetasone

dexamethasone

dexamethasone sod phosphate

dexchlorpheniramine maleate (extended release)

dextroamphetamine (PAR)

dextromethorphan/pseudoephedrineHCl/carbinoxamine

* DIASTAT

diazepam

DIBENZYLINE

diclofenac potassium

diclofenac sodium

dicloxacillin

dicyclomine

diethylpropion HCl

diflorasone

DIFLUCAN

* DIFLUCAN 150MG TAB

diflunisal

digoxin

DILANTIN

diltiazem

diltiazem, sustained release

diphenhydramine

diphenoxylate/atropine sulfate

dipivefrin

DIPROSONE 0.1% top spray

dipyridamole

disopyramide

disulfiram

DOVONEX

doxazosin

doxepin

doxycycline hyclate

doxycycline monohydrate

DRITHOCREME/HP

DRITHO-SCALP

DURAGESIC

DYNAPEN (susp only)

econazole nitrate

EFFEXOR

EFFEXOR XR

EFUDEX



ELMIRON

ELOXATIN

EMCYT

* EMEND

EMTRIVA

enalapril

* ENBREL (PAR)

ENTOCORT EC

EPIFRIN

* EPI E-Z PEN/JR

* EPIPEN/JR

EPIVIR

EPIVIR HBV

ergoloid mesylates

ERGOMAR

ERYPED SUSPENSION

erythromycin base

erythromycin base/ethanol

erythromycin ethylsuccinate

erythromycin stearate

erythromycin/sulfisoxazole

ESKALITH CR

estazolam

* estradiol patch

estradiol tablet

* ESTRING

estropipate

ESTROSTEP FE

ethambutol

ETHMOZINE

ethosuximide

ethynodiol diacetate/ethinyl estradiol

etodolac

etoposide

EULEXIN

EURAX

* EVISTA

famotidine

FANSIDAR

FARESTON

FELBATOL

FEMARA

FEMHRT

fenoprofen

FIORICET WITH CODEINE #3

flecainide

* FLONASE

* FLOVENT

* FLOVENT ROTADISK

FLOXIN OTIC

fludrocortisone

* flunisolide nasal solution

fluocinolone

fluocinonide

fluorometholone

FLUOROPLEX

* fluoxetine

fluoxymesterone (PAR)

fluphenazine HCl

flurazepam

flurbiprofen

flutamide

* fluvoxamine

FML-S



folic acid

FORTOVASE

* FOSAMAX

fosinopril

furosemide

FUROXONE

* FUZEON

GABITRIL

gemfibrozil

gentamicin sulfate

GLEEVEC

Glipizide

Glipizide (extended-release)

GLUCAGON

GLUCOVANCE

glyburide

glyburide micronized

GONAL F

griseofulvin ultramicrosize

guaifenesin (extended release)

guaifenesin/codeine phosphate

guaifenesin/dextromethorphan (extended release)

guaifenesin/pseudoephedrine HCl (extended release)

guaifenesin/pseudoephedrine HCl/codeine phosphate

guaifenesin/pseudoephedrine HCl/hydrocodone bitartrate

guanabenz

guanfacine

HALOG/E

haloperidol

HALOTESTIN (PAR)

heparin

HEXALEN

HIVID

homatropine hbr

HUMALOG

HUMALOG MIX

* HUMIRA (PAR)

HUMULIN 50/50

HUMULIN 70/30

HUMULIN L

HUMULIN N

HUMULIN R

HUMULIN U

hydralazine

hydralazine/HCTZ

hydrochlorothiazide

hydrocodone bitartrate/apap

hydrocortisone

hydrocortisone acetate

hydrocortisone valerate

hydromorphone

hydroquinone

hydroquinone/ferric oxide

hydroxychloroquine

hydroxyurea

hydroxyzine HCl

hydroxyzine pamoate

hyoscyamine

hyoscyamine sulfate

hyoscyamine sulfate/phenobarb

HYZAAR

ibuprofen

ibuprofen/hydrocodone

ILETIN II REGULAR(PORK)



ILETIN INSULIN

ILETIN LENTE PORK ZINC

ILETIN NPH PORK ZINC

ILETIN REGULAR PORK ZINC

Imipramine HCl

* IMITREX

indapamide

INDERAL LA

indomethacin

INVIRASE

ipratropium nebulizer solution

isoetharine HCl solution for inhalation

isometheptene/dichloralphenazone/apap

isoniazid

ISOPTO CARBACHOL

isosorbide dinitrate

isosorbide mononitrate

isotretinoin

isoxsuprine

KALETRA

ketoconazole

ketoprofen

* ketorolac tablet

KLARON

K-LYTE/CL

* KYTRIL

* KYTRIL ORAL SOLUTION

labetalol

lactulose

LAMICTAL

LAMPRENE

LANOXIN

LANTUS

LARODOPA

LEUCOVORIN

leucovorin calcium

LEUKERAN

leuprolide acetate injection (PAR)

LEVAQUIN

levobunolol

levonorgestrel/ethinyl estradiol

levothyroxine

LEXIVA

lidocaine viscous solution

* LIPITOR

lisinopril

lisinopril/HCTZ

lithium carbonate

lithium citrate

LIVOSTIN

LOESTRIN/FE

LO/OVRAL

lorazepam

LOTEMAX

LOTREL

LOTRISONE LOTION

* lovastatin

loxapine

LYSODREN

maprotiline

MATULANE

* MAXAIR

* MAXAIR AUTOHALER

* MAXALT



* MAXALT MLT

MEBARAL

mebendazole

meclizine HCl

meclofenamate

medroxyprogesterone

* mefloquine

megestrol

meperidine

meprobamate

MEPRON

MESTINON TIMESPAN

METAGLIP

metaproterenol

metformin

metformin (extended-release)

methadone

methazolamide

methenamine mandelate

METHERGINE

methimazole

methocarbamol

methocarbamol/aspirin

methotrexate

methyclothiazide

methyldopa

methyldopa/hctz

methylphenidate

methylphenidate HCI (extended-release)

methylprednisolone

methyltestosterone/estrogens,esterified

metoclopramide

metoprolol tartrate

METROCREAM

METROGEL

METROGEL-VAGINAL

METROLOTION

metronidazole

metronidazole, sustained action

mexiletine

MICRONOR

minocycline

minoxidil tabs

MINTEZOL

MIRALAX

MIRAPEX

mirtazapine

misoprostol

MOBAN

MODICON

moexipril

mometasone furoate

* MONUROL

morphine sulfate suppository

morphine sulfate tablet,solution

morphine sulfate (extended-release)

MUCOMYST

mupirocin

MYCOBUTIN

MYLERAN

MYSOLINE

nabumetone

nadolol

naphazoline HCI



naproxen

naproxen sodium

NARDIL

* NEBUPENT

nefazodone

neomycin sulfate

neomycin sulfate/bacitracin/polymyxin B ointment

neomycin sulfate/dexamethasone sodium phosphate

neomycin sulfate/gramicidin D/polymyxin B drops

neomycin sulfate/polymyxin B sulfate/dexamethasone

neomycin sulfate/polymyxin B sulfate/hydrocortisone

NEORAL

NEURONTIN

nicotine patch

nifedipine

NILANDRON

NIMOTOP

NITRO-DUR

nitrofurantoin

nitroglycerin (topical,SR casules, SL, patch)

nizatidine

NOLVADEX

norethindrone

norethindrone/ethinyl estradiol

norethindrone/mestranol

norgestimate/ethinyl estradiol

norgestrel/ethinyl estradiol

nortriptyline

NORVASC

NORVIR

NOVOLIN

NOVOLIN INNOLET

NOVOLOG

nystatin

nystatin/triamcinolone

OCUFLOX

* omeprazole (PAR)

OMNICEF

ORAP

orphenadrine

orphenadrine/aspirin/caffeine

ORTHO NOVUM 1/35

ORTHO NOVUM 1/50

ORTHO NOVUM 10/11

ORTHO NOVUM 7/7/7

ORTHO TRI-CYCLEN

ORTHO TRI-CYCLEN LO

ORTHO-CEPT

ORTHO-CYCLEN

ORTHO-EVRA

OSMOGLYN

OVRETTE

oxaprozin

oxazepam

OXSORALEN-ULTRA

oxybutynin

oxycodone

oxycodone/acetaminophen

oxycodone/aspirin

OXYCONTIN

PANCREASE/MT

PANCRECARB MS-8

PANDEL

paregoric



PARNATE

paromomycin

* paroxetine

PASER

PEGANONE

pemoline

penicillin v potassium

PENTASA

pentazocine HCI/acetaminophen

pentazocine HCI/naloxone

pentoxifylline

pergolide mesylate

permethrin

perphenazine

phenazopyridine

phendimetrazine

phenobarbital

phentermine

phenylephrine HCl

phenytoin

PHOSPHOLINE IODIDE

pilocarpine HCl

PILOPINE H.S.

pindolol

piroxicam

* PLAN B

PLAVIX

polymyxin b sulfate/tmp

POLY-PRED

potassium bicarbonate/citric acid

potassium chloride capsule (extended-release)

potassium chloride liquid 10%

potassium chloride powder

potassium chloride tablet (extended-release)

potassium chloride (extended-release)

potassium chloride/potassium bicarbonate/citric acid

potassium iodide

pramoxine/hc acetate

PRANDIN

prazosin

PRECOSE

PRED MILD

PRED-G

prednisolone

prednisolone acetate

prednisolone sodium phosphate

prednisone

PREDNISONE (1 MG)

PREMARIN

PREMARIN VAGINAL

PREMPHASE

PREMPRO

* PREVPAC

PRIFTIN

PRIMAQUINE PHOSPHATE

primidone

PROAMATINE

probenecid

procainamide

PROCANBID

prochlorperazine

PROCTOFOAM-HC

PROGRAF

promethazine



propafenone HCl

propoxyphene HCl

propoxyphene HCl/acetaminophen

propoxyphene HCl/asa/caffeine

propoxyphene napsylate

propoxyphene napsylate/apap

propranolol

propranolol/HCTZ

propylthiouracil

pseudoephedrine HCl/brompheniramine maleate

pseudoephedrine HCl/brompheniramine/dextromethorphan

pseudoephedrine HCl/carbinoxamine maleate

pseudoephedrine HCl/chlorpheniramine maleate

PSORCON E

* PULMICORT RESPULES

PURINETHOL

pyrazinamide

pyridostigmine bromide

quinidine gluconate

quinidine sulfate

quinine sulfate

ranitidine

RAPAMUNE

REBETOL

* REBIF

REPRONEX

REQUIP

RESCRIPTOR

reserpine

reserpine/hydrochlorothiazide

RETROVIR

REYATAZ

RHEUMATREX

* RHINOCORT/AQ

RIDAURA

RIFAMATE

rifampin

RIFATER

RILUTEK

RISPERDAL

ROWASA

ROXICODONE

SALAGEN

salsalate

SANDIMMUNE

selegiline

selenium sulfide

* SEREVENT DISKUS

SEROMYCIN

silver sulfadiazine

SINGULAIR (PAR)

sodium citrate/citric acid

sodium fluoride

sodium polystyrene sulfonate

sodium sulfacetamide/fluorometholone

sodium sulfacetamide/prednisolone acetate

sodium sulfacetamide/prednisolone sodium phosphate

sodium sulfacetamide/sulfur

sodium sulfate/sodium/sodiumbicarbonate/potassium chloride/PEG 3350

* SONATA

SORIATANE

sotalol

spironolactone



spironolactone/hctz

STARLIX

sucralfate

sulfacetamide sodium

sulfadiazine

sulfamethoxazole/trimethoprim

sulfanilamide cream

sulfasalazine

sulfathiaz/sulfacet/sulfabenz

sulfinpyrazone

sulfisoxazole

sulindac

SUSTIVA

SYNALAR HP

SYNTHROID

tamoxifen

TARGRETIN

TASMAR

TAZORAC

TEGRETOL

TEGRETOL XR

temazepam

TEMODAR

TEQUIN

terazosin

terbutaline

TESLAC

testosterone (PAR)

tetracycline

theophylline

THIOGUANINE

thioridazine

thiothixene

ticlopidine

* TILADE

timolol

tizanidine

tobramycin

tolazamide

tolbutamide

tolmetin

TONOCARD

TOPAMAX

TOPROL XL

TRACLEER

tramadol

trazodone

TRECATOR-SC

tretinoin (PAR)

TREXALL

triamcinolone

triamterene/HCTZ

triazolam

trifluoperazine

trifluridine

trihexyphenidyl

TRI-K

trimethobenzamide (capsule, suppository)

trimethoprim

TRIPHASIL

TRIZIVIR

tropicamide

ULTRASE/MT

UNIPHYL



URISED

URISPAS

UROCIT-K

ursodiol

VALCYTE

valproate sodium

valproic acid

* VALTREX

VANCOCIN

VELOSULIN

VEPESID

verapamil

verapamil, sustained action

VESANOID

VIDEX/EC

VIOKASE

VIRA-A

VIRACEPT

VIRAMUNE

VIREAD

VIROPTIC

* VIVELLE

* VIVELLE-DOT

warfarin sodium

WELLBUTRIN SR

XALATAN

XELODA

XYLOCAINE ORAL SPRAY

YASMIN

YODOXIN

yohimbine

ZAROXOLYN

* ZELNORM (PAR)

ZERIT

ZIAGEN

* ZITHROMAX

* ZOCOR

* ZOFRAN

* ZOFRAN ODT

* ZOLOFT

ZYPREXA

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