Medicaid Pharmacy Program

Medicaid Child (Foster) Care Drug Carve-out List

The following listing contains the names of drugs that have been determined not to be included within the drug cost component of Child (Foster) Care Agency Rates. Claims for drugs on this list may be billed directly to Medicaid by an MMIS enrolled pharmacy.

DRUG NAME
AGENERASE
ALPHANINE
APTIVUS
ARANESP
ATRIPLA
AUTOPLEX-T
AVONEX
BETASERON
CARIMUNE
CLOZAPINE
CLOZARIL
COMBIVIR
COPAXONE
CRIXIVAN
CYCLOSPORINE
CYTOGAM
CYTOVENE
DDAVP
DEPAKENE
DEPAKOTE
DESMOPRESSIN
DIDANOSINE
DIVALPROEX
EMTRIVA
EDURANT
EPIVIR
EPOGEN
EPZICOM
FEIBA
FORTOVASE
FUZEON
GAMIMUNE
GAMMAGARD
GAMMAR
GANCICLOVIR
GENGRAF
GENOTROPIN
HEMOFIL M
HIVID
HUMATE-P
HUMATROPE
HYATE:C
IMMUNE GLOBULIN VIAL
INTELENCE
INVIRASE
ISENTRESS
KALETRA
KOATE
DRUG NAME
KONYNE
LEXIVA
MONARC-M
MONOCLATE-P
NEBUPENT
NEORAL
NORDITROPIN
NORVIR
NUTROPIN
OMNITROPE
PANGLOBULIN
PENTACARINATE
PENTAM 300
PENTAMIDINE 300 MG
PREZISTA
PROCRIT
PROFILATE
PROFILNINE
PROGRAF
PROPLEX T
RESCRIPTOR
RESPIGAM
RETROVIR
REYATAZ
RILUTEK
RISPERDAL
RISPERIDONE
SAIZEN
SANDIMMUNE
SELZENTRY
SEROQUEL
STAVUDINE
SUSTIVA
SYNAGIS
TACROLIMUS
TRIZIVIR
TRUVADA
VALPROIC ACID
VENOGLOBULIN
VIDEX
VIRACEPT
VIRAMUNE
VIREAD
XYNTHA
ZERIT
ZIAGEN
ZIDOVUDINE
ZYPREXA
EFFECTIVE DATE PRODUCT CODE
07/27/1992 Parenteral nutrition solution; carbohydrates (Dextrose), 50% or less (500 ml =1 unit) - Homemix. B4164
07/27/1992 Parenteral nutrition solution; Amino Acid, 3.5%, (500 ml = I Unit) - Homemix. B4168
07/27/1992 Parenteral nutrition solution; Amino Acid, 5.5% through 7%, (500 ml = I Unit) - Homemix. B4172
07/27/1992 Parenteral nutrition solution; Amino Acid, 7% through 8.5%, (500 ml = I Unit) - Homemix. B4176
07/27/1992 Parenteral nutrition solution; Amino Acid, greater than 8.5% (500 ml = I Unit) - Homemix. B4178
07/27/1992 Parenteral nutrition solution; carbohydrates (Dextrose), greater than 50% (500 ml = I Unit) - Homemix. B4180
1/1/2006 Parenteral Nutrition Solution, Per 10 grams Lipids. B4185
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 Grams of protein - Premix. B4189
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 Grams of protein - Premix. B4193
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 Grams of protein - Premix. B4197
07/27/1992 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 Grams of protein - Premix. B4199
07/27/1992 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) Homemix, per day. B4216
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - (Aminosyn-RF, NephrAmine, RenAmine) - Premix (per liter) B5000
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - (Freamine HBC, HepatAmine) - Premix (per liter) B5100
07/27/1992 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - (Branch Chain Amino Acids) - Premix (per liter) B5200

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