Wisconsin Medicaid Pharmacy Data Tables

BadgerCare Plus-Covered Drug-Related Supplies

Effective: 2/1/08

The following is a list of procedure codes, modifiers, and descriptions for BadgerCare Plus-covered drug-related supplies.

Procedure Code Modifier Description
A4206   Syringe with needle; sterile 1cc, each
A4207  

sterile 2cc, each

A4208  

sterile 3cc, each

A4209  

sterile 5cc or greater, each

A4213   Syringe, sterile, 20cc or greater, each
A4215   Needle, sterile, any size, each
A4215 22 Insulin pen needles
A4215 59 Huber needles
A4233   Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each
A4234   Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each
A4235   Replacement battery, Lithium, for use with medically necessary home blood glucose monitor owned by patient, each
A4236   Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each
A4244   Alcohol or peroxide, per pint
A4250   Urine test or reagent strips or tablets (100 tablets or strips)
A4253 KS Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips, TYPE II Diabetics
A4253 KX Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips, TYPE I Diabetics
A4256   Normal, low and high calibrator solution/chips
A4258   Spring Powered Device for lancet, each
A4258 22 Insulin pen
A4259 KS Lancets, per box of 100, Type II Diabetics
A4259 KX Lancets, per box of 100, Type I Diabetics
A4261   Cervical cap for contraceptive use
A4266   Diaphragm for contraceptive use
A4267   Contraceptive supply, condom, male, each
A4268   Contraceptive supply, condom, female, each
A4269   Contraceptive supply, spermacide (e.g., foam, gel), each
A4614   Peak expiratory flow rate meter, hand held
A4627   Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
A7003   Administration set, with small volume non-filtered pneumatic nebulizer, disposable
A7004   Small volume nonfiltered pneumatic nebulizer, disposable
A7005   Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable
A7006   Administration set, with small volume filtered pneumatic nebulizer
A7015   Aerosol mask, used with DME nebulizer
A7016   Dome and mouthpiece, used with small volume ultrasonic nebulizer
A7018   Water, distilled, used with large volume nebulizer, 1000 ml
A7018 22 Sterile water irrigation solution, 1000 ml
A7018 59 Sterile saline irrigation solution, 1000 ml
E0570   Nebulizer; With Compressor e.g., Devilbiss Pulmo-Aid
E0570 RR Nebulizer; With Compressor e.g., Devilbiss Pulmo-Aid
E0571   Aerosol Compressor, Battery Powered, For Use With Small Volume Nebulizer
E0571 RR Aerosol Compressor, Battery Powered, For Use With Small Volume Nebulizer
E0575   Nebulizer, Ultrasonic, Large Volume
E0575 RR Nebulizer, Ultrasonic, Large Volume
E0580   Nebulizer, With Compressor, Durable, Glass Or Autoclavable Plastic, Bottle Type, For Use With Regulator Or Flowmeter
E0585   Nebulizer; With Compressor And Heater
E0585 RR Nebulizer; With Compressor And Heater
E0607   Home blood glucose monitor
E1372   Immersion External Heater For Nebulizer
E1372 RR Immersion External Heater For Nebulizer
E2100   Blood glucose monitor with integrated voice synthesizer
E2101   Blood glucose monitor with integrated lancing/blood sample
S5000 U1-U5 Prescription drug, generic
S5001 U1-U5 Prescription drug, brand name
S8101   Holding chamber or spacer for use with an inhaler or nebulizer; with mask
S8490   Insulin syringes (100 syringes, any size)

Back to Pharmacy Data Tables