AHCCCS Fee-for-Service Rates
Hemophilia Factor Pricing

Effective April 1, 2007 - June 30, 2007

FACTOR NAME MANUFACTURER FACTOR ASSAY RANGE NDC# 2nd Quarter Cost
ADVATE BAXTER 200-400 00944-2940-01 $0.9590
ADVATE BAXTER 401-800 00944-2940-02 $0.9590
ADVATE BAXTER 801-1200 00944-2940-03 $0.9590
ADVATE BAXTER 1201-1800 00944-2940-04 $0.9590
ADVATE BAXTER 1801-2400 00944-2940-10 $0.9590
ADVATE BAXTER 200-400 00944-2941-10 $0.9590
ADVATE BAXTER 401-800 00944-2942-10 $0.9590
ADVATE BAXTER 801-1200 00944-2943-10 $0.9590
ADVATE BAXTER 1201-1800 00944-2944-10 $0.9590
ADVATE BAXTER 1801-2400 00944-2945-10 $0.9590
         
ALPHANATE-SD-HT GRIFOLS 400-624 68516-4600-01 $0.6550
ALPHANATE-SD-HT GRIFOLS 900-1800 68516-4600-02 $0.6550
         
ALPHANINE-SD-VF GRIFOLS 500-1500 68516-3600-02 $0.7450
         
BEBULIN BAXTER 500-700 64193-0244-02 $0.7800
         
BENEFIX WYETH 250 58394-0003-01 $0.8704
BENEFIX WYETH 500 58394-0002-01 $0.8732
BENEFIX WYETH 1000 58394-0001-01 $0.8718
         
FEIBA-VH BAXTER 400-650 64193-0222-03 $1.1110
FEIBA-VH BAXTER 651-1200 64193-0222-04 $1.1110
FEIBA-VH BAXTER 2500+ 64193-0222-05 $1.1110
         
HELIXATE-FS CLS/BEHRING 250 00053-8130-01 $0.8750
HELIXATE-FS CLS/BEHRING 500 00053-8130-02 $0.8750
HELIXATE-FS CLS/BEHRING 1000 00053-8130-04 $0.8750
         
HEMOFIL-M BAXTER LOW 00944-2935-01 $0.6250
HEMOFIL-M BAXTER MID 00944-2935-02 $0.6250
HEMOFIL-M BAXTER HIGH 00944-2935-03 $0.6250
HEMOFIL-M BAXTER SUPER HIGH 00944-2935-04 $0.6250
         
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CLS/BEHRING 500 00053-7615-05 $0.7650
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CLS/BEHRING 1000 00053-7615-10 $0.7650
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CLS/BEHRING 2000 00053-7615-20 $0.7650
         
KOATE DVI TALECRIS 250 00026-0665-20 $0.5750
KOATE DVI TALECRIS 500 00026-0665-30 $0.5750
KOATE DVI TALECRIS 1000 00026-0665-50 $0.5750
         
KOGENATE-FS BAYER 250 00026-0372-20 $0.8950
KOGENATE-FS BAYER 500 00026-0372-30 $0.8950
KOGENATE-FS BAYER 1000 00026-0372-50 $0.8950
KOGENATE-FS w/ Bioset BAYER 250 00026-0379-20 $0.8850
KOGENATE-FS w/ Bioset BAYER 500 00026-0379-30 $0.8850
KOGENATE-FS w/ Bioset BAYER 1000 00026-0379-50 $0.8850
         
MONARC-M AMERICAN RED CROSS/BAXTER ALL 52769-0460-01 $0.5630
         
MONOCLATE-P CLS/BEHRING 250 00053-7656-01 $0.6150
MONOCLATE-P CLS/BEHRING 500 00053-7656-02 $0.6150
MONOCLATE-P CLS/BEHRING 1000 00053-7656-04 $0.6150
MONOCLATE-P CLS/BEHRING 1500 00053-7656-05 $0.6150
         
MONONINE CLS/BEHRING 250 00053-7668-01 $0.7950
MONONINE CLS/BEHRING 500 00053-7668-02 $0.7950
MONONINE CLS/BEHRING 1000 00053-7668-04 $0.7950
         
NOVOSEVEN 1.2MG VIAL (per mcg) NOVO NORDISK 1.2 mg vial 00169-7060-01 $0.9600
NOVOSEVEN 2.4MG VIAL ( per mcg) NOVO NORDISK 2.4 mg vial 00169-7061-01 $0.9420
NOVOSEVEN 4.8MG VIAL (per mcg) NOVO NORDISK 4.8 mg vial 00169-7062-01 $0.9590
         
PROFILNINE-SD GRIFOLS 450-999 68516-3200-02 $0.5150
PROFILNINE-SD GRIFOLS 1000-1500 68516-3200-03 $0.5150
         
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 $0.9050
REFACTO WYETH 500 58394-0006-02 $0.9050
REFACTO WYETH 1000 58394-0005-02 $0.9050
REFACTO WYETH 2000 58394-0011-02 $0.8550
Notes:

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