AHCCCS Fee-for-Service Rates
Hemophilia Factor Pricing

Effective April 1, 2008 - June 30, 2008

FACTOR NAME MANUFACTURER FACTOR ASSAY RANGE NDC# 2st Quarter Cost
ADVATE BAXTER 200-400 00944-2940-01

$0.9750
ADVATE BAXTER 401-800 00944-2940-02 $0.9750
ADVATE BAXTER 801-1200 00944-2940-03 $0.9750
ADVATE BAXTER 1201-1800 00944-2940-04 $0.9750
ADVATE BAXTER 1801-2400 00944-2940-10 $0.9750
ADVATE BAXTER 200-400 00944-2941-10 $0.9750
ADVATE BAXTER 401-800 00944-2942-10 $0.9750
ADVATE BAXTER 801-1200 00944-2943-10 $0.9750
ADVATE BAXTER 1201-1800 00944-2944-10 $0.9750
ADVATE BAXTER 1801-2400 00944-2945-10 $0.9750
ADVATE BAXTER 2401-3600 00944-2946-10 $0.9750
         
ALPHANATE-SD-HT GRIFOLS 400-624 68516-4600-01 $0.6950
ALPHANATE-SD-HT GRIFOLS 900-1800 68516-4600-02 $0.6950
         
ALPHANATE-AHF/VWF GRIFOLS LOW 68516-4601-01 $0.7950
ALPHANATE-AHF/VWF GRIFOLS MED 68516-4602-01 $0.7950
ALPHANATE-AHF/VWF GRIFOLS HIGH 68516-4603-02 $0.7950
ALPHANATE-AHF/VWF GRIFOLS SUPER HIGH 68516-4604-02 $0.7950
         
ALPHANINE-SD-VF GRIFOLS 500-1500 68516-3600-02 $0.7550
         
BEBULIN BAXTER 500-700 64193-0244-02 $0.8530
         
BENEFIX WYETH 250 58394-0003-01 $0.9284
BENEFIX WYETH 500 58394-0002-01 $0.9293
BENEFIX WYETH 1000 58394-0001-01 $0.9307
BENEFIX-convenience enhanced WYETH 250 58394-0003-06 $0.9284
BENEFIX-convenience enhanced WYETH 500 58394-0002-06 $0.9293
BENEFIX-convenience enhanced WYETH 1000 58394-0001-06 $0.9307
BENEFIX-convenience enhanced WYETH 2000 58394-0008-02 $0.9244
         
FEIBA-VH BAXTER 400-650 64193-0222-03 $1.1300
FEIBA-VH BAXTER 651-1200 64193-0222-04 $1.1300
FEIBA-VH BAXTER 2500+ 64193-0222-05 $1.1300
         
HELIXATE-FS CSL/BEHRING 250 00053-8130-01 $0.8950
HELIXATE-FS CSL/BEHRING 500 00053-8130-02 $0.8950
HELIXATE-FS CSL/BEHRING 1000 00053-8130-04 $0.8950
         
HEMOFIL-M BAXTER LOW 00944-2935-01 $0.6930
HEMOFIL-M BAXTER MID 00944-2935-02 $0.6930
HEMOFIL-M BAXTER HIGH 00944-2935-03 $0.6930
HEMOFIL-M BAXTER SUPER HIGH 00944-2935-04 $0.6930
         
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CSL/BEHRING 500 00053-7615-05 $0.7750
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CSL/BEHRING 1000 00053-7615-10 $0.7750
HUMATE-P (PER RISTOCETIN COFACTOR UNIT) CSL/BEHRING 2000 00053-7615-20 $0.7750
         
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 BAYER 2000 00026-3786-60 $0.8850
KOGENATE-FS w/ Bioset BAYER 250 00026-0379-20 $0.8950
KOGENATE-FS w/ Bioset BAYER 500 00026-0379-30 $0.8950
KOGENATE-FS w/ Bioset BAYER 1000 00026-0379-50 $0.8950
KOGENATE-FS w/ Bioset BAYER 2000 00026-3796-60 $0.8850
         
MONARC-M BAXTER ALL 52769-0460-01 $0.6450
         
MONOCLATE-P CLS/BEHRING 250 00053-7656-01 $0.6250
MONOCLATE-P CLS/BEHRING 500 00053-7656-02 $0.6250
MONOCLATE-P CLS/BEHRING 1000 00053-7656-04 $0.6250
MONOCLATE-P CLS/BEHRING 1500 00053-7656-05 $0.6250
         
MONONINE CLS/BEHRING 500 00053-7668-01 $0.8150
MONONINE CLS/BEHRING 1000 00053-7668-04 $0.8150
         
NOVOSEVEN 1.2MG VIAL
(per mcg)		 NOVO NORDISK 1.2 mg vial 00169-7060-01 $1.0230
NOVOSEVEN 2.4MG VIAL
(per mcg)		 NOVO NORDISK 2.4 mg vial 00169-7061-01 $0.9545
NOVOSEVEN 4.8MG VIAL
(per mcg)		 NOVO NORDISK 4.8 mg vial 00169-7062-01 $1.0242
       

 
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

$0.9430
RECOMBINATE BAXTER 401-800 00944-2938-02

$0.9430
RECOMBINATE BAXTER 801-1240 00944-2938-03

$0.9430
RECOMBINATE-BJII BAXTER 220-400 00944-2831-10 $0.9430
RECOMBINATE-BJII BAXTER 401-800 00944-2832-10 $0.9430
RECOMBINATE-BJII BAXTER 801-1240 00944-2833-10 $0.9430
       

 
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:
1. Alphanate-SD-HT - Last pricing provided for discounted product. (Highlighted in Green)

 

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