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Medicaid Pharmacy Program

Medicaid Nursing Home/Child (Foster) Care Drug Carve-out List

The following listing includes the names of drugs that have been determined not to be included within the drug cost component of Article 28 Nursing Facility Rates and Child (foster) Care Agency Rates. Claims for drugs on this list may be billed directly to Medicaid by an MMIS enrolled pharmacy.

If a drug has an "NH" indicator, it is included on the Nursing Home Carveout List. If a drug has an "FC" indicator, it is included on the Child (Foster) Care Agency Carve-Out List.

DRUG NAME	NH	FC
AGENERASE	NH	FC
ALPHANINE	NH	FC
APTIVUS	NH	FC
ARANESP	NH	FC
ATRIPLA	NH	FC
AUTOPLEX-T	NH	FC
AVONEX	NH	FC
BETASERON	NH	FC
CARIMUNE		FC
CLOZAPINE	NH	FC
CLOZARIL	NH	FC
COMBIVIR	NH	FC
COPAXONE	NH	FC
CRIXIVAN	NH	FC
CYCLOSPORINE	NH	FC
CYTOGAM		FC
CYTOVENE	NH	FC
DDAVP	NH	FC
DEPAKENE	NH	FC
DEPAKOTE	NH	FC
DESMOPRESSIN	NH	FC
DIDANOSINE	NH	FC
DIVALPROEX	NH	FC
EMTRIVA	NH	FC
EPIVIR	NH	FC
EPOGEN	NH	FC
EPZICOM	NH	FC
FEIBA VH	NH	FC
FOSCAVIR	NH	FC
FUZEON	NH	FC
GAMIMUNE N		FC
GAMMAGARD S/D		FC
GAMMAR-P		FC
GANCICLOVIR	NH	FC
GENGRAF	NH	FC
GENOTROPIN		FC
HEMOFIL M	NH	FC
HIVID	NH	FC
HUMATE-P	NH	FC
HUMATROPE		FC
HYATE:C	NH	FC
IMMUNE GLOBULIN VIAL		FC
INTELENCE	NH	FC
INVIRASE	NH	FC

DRUG NAME	NH	FC
ISENTRESS	NH	FC
KALETRA	NH	FC
KOATE DVI	NH	FC
LEXIVA	NH	FC
MONARC-M	NH	FC
MONOCLATE-P	NH	FC
NEBUPENT	NH	FC
NEORAL	NH	FC
NORDITROPIN		FC
NORVIR	NH	FC
NUTROPIN		FC
OMNITROPE		FC
PANGLOBULIN		FC
PENTAM 300	NH	FC
PENTAMIDINE 300 MG	NH	FC
PREZISTA	NH	FC
PROCRIT	NH	FC
PROFILNINE	NH	FC
PROGRAF	NH	FC
PROPLEX T	NH	FC
RESCRIPTOR	NH	FC
RETROVIR	NH	FC
REYATAZ	NH	FC
RILUTEK	NH	FC
RISPERDAL	NH	FC
RISPERIDONE	NH	FC
SAIZEN		FC
SANDIMMUNE	NH	FC
SELZENTRY	NH	FC
SEROQUEL	NH	FC
STAVUDINE	NH	FC
SUSTIVA	NH	FC
SYNAGIS	NH	FC
TRIZIVIR	NH	FC
TRUVADA	NH	FC
VALPROIC ACID	NH	FC
VIDEX	NH	FC
VIRACEPT	NH	FC
VIRAMUNE	NH	FC
VIREAD	NH	FC
ZERIT	NH	FC
ZIAGEN	NH	FC
ZIDOVUDINE	NH	FC
ZYPREXA	NH	FC

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