J0136
Injection, acetaminophen (b braun), not therapeutically equivalent to j0131, 10 mg
Injection, acetaminophen (b braun), not therapeutically equivalent to j0131, 10 mg
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J0173
Injection, epinephrine (belcher), not therapeutically equivalent to j0171, 0.1 mg
Injection, epinephrine (belcher), not therapeutically equivalent to j0171, 0.1 mg
J0689
Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg
Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg
J1643
Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units
Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units
J3371
Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg
Injection, vancomycin hcl (mylan), not therapeutically equivalent to j3370, 500 mg
13474
Empastes de resina compuesta de una sola superficie en dientes posteriores para premolares y molares (según la tabla de tolerancia dental del grupo). Un empaste para cada superficie dental cada 12 meses.
13474
Single surface composite resin fillings on back teeth for bicuspids and molars (based on the group's dental table of allowance). One filling for each tooth surface each 12 months.
13473
Los servicios del grupo 2 son servicios dentales prestados por un dentista, en general para recuperar o extraer piezas dentales naturales enfermas o fracturadas, reemplazar reparaciones dañadas o defectuosas, tratar enfermedades de la boca, reparar, rebasar o realinear dentaduras postizas o reparar coronas y puentes y recementar coronas, onlay y puentes fijos. Dichos servicios dentales cubiertos son:
13473
Group 2 Services are dental services furnished by a Dentist generally to restore or remove diseased or fractured natural teeth, replace damaged or defective restorations, treat oral disease, repair, rebase or reline dentures or repair crowns and bridges and recement crowns, onlays and fixed bridgework. These covered dental services include:
13478
Certain generic or brand name prescription drugs for asthma, diabetes and specific heart conditions, may have reduced or waived cost share as required by state law. Refer to rider for more information.