AHCCCS Fee-for-Service Rates
Hemophilia Factor Pricing

Effective January 1, 2006 - March 31, 2006

FACTOR NAME MANUFACTURER FACTOR ASSAY RANGE NDC# 1st Quarter Cost
ADVATE BAXTER 200-400 00944-2940-01 $0.9570
ADVATE BAXTER 401-800 00944-2940-02 $0.9570
ADVATE BAXTER 801-1200 00944-2940-03 $0.9570
ADVATE BAXTER 1201-1800 00944-2940-04 $0.9570
         
ALPHANATE-SD-HT GRIFOLS 250-999 68516-4600-01 $0.6458
ALPHANATE-SD-HT GRIFOLS 1000+ 68516-4600-02 $0.6458
         
ALPHANINE-SD-VF GRIFOLS 500-1500 68516-3600-02 $0.7464
         
BEBULIN BAXTER 500-700 64193-0244-02 $0.7290
         
BENEFIX WYETH 250 58394-0003-01 $0.8690
BENEFIX WYETH 500 58394-0002-01 $0.8740
BENEFIX WYETH 1000 58394-0001-01 $0.8720
         
FEIBA-VH BAXTER 400-650 64193-0222-03 $1.0740
FEIBA-VH BAXTER 651-1200 64193-0222-04 $1.0740
         
HELIXATE-FS ZLB/BEHRING 250 00053-8130-01 $0.8750
HELIXATE-FS ZLB/BEHRING 500 00053-8130-02 $0.8750
HELIXATE-FS ZLB/BEHRING 1000 00053-8130-04 $0.8750
         
HEMOFIL-M BAXTER ALL 00944-2935-01 $0.6330
         
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) AVENTIS 500 00053-7620-05 $0.7650
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) AVENTIS 1000 00053-7620-10 $0.7650
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) AVENTIS 2000 00053-7620-20 $0.7650
         
KOATE DVI BAYER 250 00026-0665-20 $0.5450
KOATE DVI BAYER 500 00026-0665-30 $0.5450
KOATE DVI BAYER 1000 00026-0665-50 $0.5450
         
KOGENATE-FS BAYER 250 00026-0372-20 $0.8750
KOGENATE-FS BAYER 500 00026-0372-30 $0.8750
KOGENATE-FS BAYER 1000 00026-0372-50 $0.8750
         
MONARC-M AMERICAN RED CROSS/BAXTER ALL 52769-0460-01 $0.5350
         
MONOCLATE-P ZLB/BEHRING 250 00053-7656-01 $0.5650
MONOCLATE-P ZLB/BEHRING 500 00053-7656-02 $0.5650
MONOCLATE-P ZLB/BEHRING 1000 00053-7656-04 $0.5650
MONOCLATE-P ZLB/BEHRING 1500 00053-7656-05 $0.5650
         
MONONINE ZLB/BEHRING 250 00053-7668-01 $0.7950
MONONINE ZLB/BEHRING 500 00053-7668-02 $0.7950
MONONINE ZLB/BEHRING 1000 00053-7668-04 $0.7950
         
NOVOSEVEN 1.2MG VIAL NOVO NORDISK 1.2 mg vial 00169-7060-01 $1,113.88
NOVOSEVEN 2.4MG VIAL NOVO NORDISK 2.4 mg vial 00169-7061-01 $2,083.21
NOVOSEVEN 4.8MG VIAL NOVO NORDISK 4.8 mg vial 00169-7062-01 $4,405.43
         
PROFILNINE-SD GRIFOLS 450-999 68516-3200-02 $0.4387
PROFILNINE-SD GRIFOLS 1000-1500 68516-3200-03 $0.4387
         
PROPLEX-T BAXTER 700-3900 00944-0581-01 $0.3650
         
RECOMBINATE BAXTER 220-400 00944-2938-01 $0.9100
RECOMBINATE BAXTER 401-800 00944-2938-02 $0.9100
RECOMBINATE BAXTER 801-1240 00944-2938-03 $0.9100
         
REFACTO WYETH 250 58394-0007-02 $0.9250
REFACTO WYETH 500 58394-0006-02 $0.9250
REFACTO WYETH 1000 58394-0005-02 $0.9250
REFACTO WYETH 2000 58394-0011-02 $0.8510
 

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