AHCCCS Fee-for-Service Rates
Hemophilia Factor Pricing

Effective October 1, 2007 - December 31, 2007

FACTOR NAME MANUFACTURER FACTOR ASSAY RANGE NDC# 4th Quarter Cost
ADVATE BAXTER 200-400 00944-2940-01

$0.9740
ADVATE BAXTER 401-800 00944-2940-02

$0.9740
ADVATE BAXTER 801-1200 00944-2940-03

$0.9740
ADVATE BAXTER 1201-1800 00944-2940-04

$0.9740
ADVATE BAXTER 1801-2400 00944-2940-10

$0.9740
ADVATE BAXTER 200-400 00944-2941-10

$0.9740
ADVATE BAXTER 401-800 00944-2942-10

$0.9740
ADVATE BAXTER 801-1200 00944-2943-10

$0.9740
ADVATE BAXTER 1201-1800 00944-2944-10

$0.9740
ADVATE BAXTER 1801-2400 00944-2945-10

$0.9740
ADVATE BAXTER 2401-3600 00944-2946-10

$0.9740

       

   
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 68516-4603-01 $0.7950
ALPHANATE-AHF/VWF GRIFOLS SUPER HIGH 68516-4604-01 $0.7950
       

   
ALPHANINE-SD-VF GRIFOLS 500-1500 68516-3600-02

$0.7450
       

   
BEBULIN BAXTER 500-700 64193-0244-02

$0.8500
       

   
BENEFIX WYETH 250 58394-0003-01

$0.8704
BENEFIX WYETH 500 58394-0002-01

$0.8745
BENEFIX WYETH 1000 58394-0002-01

$0.8712
BENEFIX-convenience enhanced WYETH 250 58394-0003-06 $0.8704
BENEFIX-convenience enhanced WYETH 500 58394-0002-06 $0.8745
BENEFIX-convenience enhanced WYETH 1000 58394-0001-06 $0.8712
BENEFIX-convenience enhanced WYETH 2000 58394-0008-02 $0.9491
       

   
FEIBA-VH BAXTER 400-650 64193-0222-03

$1.1120
FEIBA-VH BAXTER 651-1200 64193-0222-04

$1.1120
FEIBA-VH BAXTER 2500+ 64193-0222-05 $1.1120
       

   
HELIXATE-FS CLS/BEHRING 250 00053-8130-01

$0.8850
HELIXATE-FS CLS/BEHRING 500 00053-8130-02

$0.8850
HELIXATE-FS CLS/BEHRING 1000 00053-8130-04

$0.8850
       

   
HEMOFIL-M BAXTER LOW 00944-2935-01

$0.6820
HEMOFIL-M BAXTER MID 00944-2935-02

$0.6820
HEMOFIL-M BAXTER HIGH 00944-2935-03

$0.6820
HEMOFIL-M BAXTER SUPER HIGH 00944-2935-04

$0.6820
       

   
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

$0.5350
KOATE DVI TALECRIS 500 00026-0665-30

$0.5350
KOATE DVI TALECRIS 1000 00026-0665-50

$0.5350
       

   
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 0026-3786-60 $0.8650
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 0026-3796-60 $0.8650
       

   
MONARC-M BAXTER ALL 52769-0460-01

$0.6150
       

   
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 500 00053-7668-02

$0.8050
MONONINE CLS/BEHRING 1000 00053-7668-04

$0.8050
       

   
NOVOSEVEN 1.2MG VIAL
(per mcg)		 NOVO NORDISK 1.2 mg vial 00169-7060-01

$1.0114
NOVOSEVEN 2.4MG VIAL
(per mcg)		 NOVO NORDISK 2.4 mg vial 00169-7061-01

$0.9439
NOVOSEVEN 4.8MG VIAL
(per mcg)		 NOVO NORDISK 4.8 mg vial 00169-7062-01

$1.0144
       

   
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

$0.9460
RECOMBINATE BAXTER 401-800 00944-2938-02

$0.9460
RECOMBINATE BAXTER 801-1240 00944-2938-03

$0.9460
       

   
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-AHF/VWF - New product, currently using non-classified HCPC, Grifols has applied for HCPC code

  

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