FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
4th Q 15	
Change Q3
15 to Q4 15	
ADVATE 2mL diluent	BAXALTA	200-400	00944-2921-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	401-800	00944-2922-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-2923-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-2924-02	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	1801-2400	00944-2964-10	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	2401-3600	00944-2965-10	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	3601-4800	00944-2948-10	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	200-400	00944-3051-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	401-800	00944-3052-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-3053-02	J7192	$0.8915	(0.0020)	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-3054-02	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	1801-2400	00944-3045-10	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	2401-3600	00944-3046-10	J7192	$0.8915	(0.0020)	
ADVATE	BAXALTA	3601-4800	00944-3047-10	J7192	$0.8915	(0.0020)	
							
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
250	
68516-4601-01	
J7186	
$0.7175	
0.0000	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
500	
68516-4602-01	
J7186	
$0.7175	
0.0000	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
1000	
68516-4603-02	
J7186	
$0.7175	
0.0000	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
1500	
68516-4604-02	
J7186	
$0.7175	
0.0000	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
2000	
68516-4609-02	
J7186	
$0.7175	
0.0100	
							
ALPHANINE-SD	GRIFOLS	500	68516-3601-02	J7193	$0.7275	0.0000	
ALPHANINE-SD	GRIFOLS	1000	68516-3602-02	J7193	$0.7275	0.0000	
ALPHANINE-SD	GRIFOLS	1500	68516-3603-02	J7193	$0.7375	0.0100	
							
BEBULIN	BAXALTA	500-700	64193-0244-02	J7194	$0.3565	0.0000	
							
BENEFIX -RT	PFIZER/WYETH	250	58394-0633-03	J7195	$1.0501	0.0137	
BENEFIX -RT	PFIZER/WYETH	500	58394-0634-03	J7195	$1.0490	0.0231	
BENEFIX -RT	PFIZER/WYETH	1000	58394-0635-03	J7195	$1.0274	(0.0033)	
BENEFIX -RT	PFIZER/WYETH	2000	58394-0636-03	J7195	$0.8906	0.0120	
BENEFIX -RT	PFIZER/WYETH	3000	58394-0637-03	J7195	$0.9806	0.0124	
							
CEPROTIN	BAXALTA	500	00944-4175-05	J2724	$0.9755	0.0110	
CEPROTIN	BAXALTA	1000	00944-4175-10	J2724	$0.9755	0.0110	
CEPROTIN	BAXALTA	500	00944-4177-05	J2724	$0.9755	0.0110	
CEPROTIN	BAXALTA	1000	00944-4179-10	J2724	$0.9755	0.0110	
							
CORIFACT	CSL BEHRING	1000-1600	63833-0518-02	J7180	$5.1975	0.0400	
							
FEIBA-NF	BAXALTA	400-650	64193-0223-02	J7198	$1.1175	0.0070	
FEIBA-NF	BAXALTA	651-1200	64193-0224-02	J7198	$1.1175	0.0070	
FEIBA-NF	BAXALTA	2000-3000	64193-0225-02	J7198	$1.1175	0.0070	
FEIBA-NF	BAXALTA	400-650	64193-0423-02	J7198	$1.1175	0.0070	
FEIBA-NF	BAXALTA	651-1200	64193-0424-02	J7198	$1.1175	0.0070	
FEIBA-NF	BAXALTA	2000-3000	64193-0425-02	J7198	$1.1175	0.0070	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
4th Q 15	
Change Q3
15 to Q4 15	
							
HELIXATE-FS	CSL BEHRING	250	00053-8131-02	J7192	$0.8475	0.0100	
HELIXATE-FS	CSL BEHRING	500	00053-8132-02	J7192	$0.8475	0.0000	
HELIXATE-FS	CSL BEHRING	1000	00053-8133-02	J7192	$0.8475	0.0000	
HELIXATE-FS	CSL BEHRING	2000	00053-8134-02	J7192	$0.8475	0.0000	
HELIXATE-FS	CSL BEHRING	3000	00053-8135-02	J7192	$0.8475	0.0000	
							
HEMOFIL-M	BAXALTA	220-400	00944-3940-02	J7190	$0.7795	(0.0110)	
HEMOFIL-M	BAXALTA	401-800	00944-3942-02	J7190	$0.7795	(0.0110)	
HEMOFIL-M	BAXALTA	801-1500	00944-3944-02	J7190	$0.7795	(0.0110)	
HEMOFIL-M	BAXALTA	1501-2000	00944-3946-02	J7190	$0.7795	(0.0110)	
							
HUMATE-P (PER VWF:RCOF UNIT)	
CSL BEHRING	
600	
63833-0615-02	
J7187	
$0.7375	
0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	
CSL BEHRING	
1200	
63833-0616-02	
J7187	
$0.7375	
0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	
CSL BEHRING	
2400	
63833-0617-02	
J7187	
$0.7375	
0.0000	
							
KOATE DVI	KEDRION	250	76125-0250-20	J7190	$0.6675	0.0200	
KOATE DVI	KEDRION	500	76125-0667-30	J7190	$0.6675	0.0200	
KOATE DVI	KEDRION	1000	76125-0667-50	J7190	$0.6675	0.0200	
							
KOGENATE-FS rAHF	BAYER	250	00026-3782-20	J7192	$0.8175	0.0000	
KOGENATE-FS rAHF	BAYER	500	00026-3783-30	J7192	$0.8275	0.0100	
KOGENATE-FS rAHF	BAYER	1000	00026-3785-50	J7192	$0.8275	0.0100	
KOGENATE-FS rAHF	BAYER	2000	00026-3786-60	J7192	$0.8275	0.0100	
KOGENATE-FS rAHF	BAYER	3000	00026-3787-70	J7192	$0.8275	0.0100	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
250	
00026-3792-20	
J7192	
$0.7575	
(0.0600)	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
500	
00026-3793-30	
J7192	
$0.8275	
0.0100	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
1000	
00026-3795-50	
J7192	
$0.8275	
0.0100	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
2000	
00026-3796-60	
J7192	
$0.7075	
(0.1100)	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
3000	
00026-3797-70	
J7192	
$0.8075	
0.0000	
KOGENATE-FS vial adapter	BAYER	250	00026-3782-25	J7192	$0.8175	0.0000	
KOGENATE-FS vial adapter	BAYER	500	00026-3783-35	J7192	$0.8275	0.0100	
KOGENATE-FS vial adapter	BAYER	1000	00026-3785-55	J7192	$0.8275	0.0100	
KOGENATE-FS vial adapter	BAYER	2000	00026-3786-65	J7192	$0.8275	0.0100	
KOGENATE-FS vial adapter	BAYER	3000	00026-3787-75	J7192	$0.8275	0.0100	
							
MONOCLATE-P	CSL BEHRING	1000	00053-7633-02	J7190	$0.6775	0.0000	
MONOCLATE-P	CSL BEHRING	1500	00053-7634-02	J7190	$0.6775	0.0000	
							
MONONINE	CSL BEHRING	1000	00053-6233-02	J7193	$0.8775	0.0000	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
4th Q 15	
Change Q3
15 to Q4 15	

NOVOSEVEN RT 1MG (PER MCG)	
NOVO NORDISK	
1mg vial	
00169-7010-01	
J7189	
$0.8985	
(0.2139)	
NOVOSEVEN RT 2MG (PER
MCG)	
NOVO NORDISK	
2mg vial	
00169-7020-01	
J7189	
$0.9108	
(0.1113)	
NOVOSEVEN RT 5MG (PER
MCG)	
NOVO NORDISK	
5mg vial	
00169-7050-01	
J7189	
$0.9344	
(0.1054)	
NOVOSEVEN RT 8 MG MIXPRO
(PER MCG)	
NOVO NORDISK	
8mg vial	
00169-7040-01	
J7189	
$1.2076	
(0.0473)	
NOVOSEVEN RT 1 MG MIXPRO (PER MCG)	
NOVO NORDISK	
1 mg vial	
00169-7201-01	
J7189	
$0.8985	
0.1006	
NOVOSEVEN RT 2 MG MIXPRO (PER MCG)	
NOVO NORDISK	
2 mg vial	
00169-7202-01	
J7189	
$0.9108	
0.0264	
NOVOSEVEN RT 5 MG MIXPRO (PER MCG)	
NOVO NORDISK	
5 mg vial	
00169-7205-01	
J7189	
$0.9344	
0.0467	
NOVOSEVEN RT 8 MG MIXPRO (PER MCG)	
NOVO NORDISK	
8 mg vial	
00169-7208-01	
J7189	
$1.2076	
(0.0047)	
							
PROFILNINE-SD	GRIFOLS	500	68516-3201-01	J7194	$0.1775	(0.0100)	
PROFILNINE-SD	GRIFOLS	1000	68516-3202-02	J7194	$0.1775	(0.0100)	
PROFILNINE-SD	GRIFOLS	1500	68516-3203-02	J7194	$0.1875	0.0000	
							
RECOMBINATE	BAXALTA	220-400	00944-2831-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	401-800	00944-2832-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	801-1240	00944-2833-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	250	00944-2841-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	500	00944-2842-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	1000	00944-2843-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	1500	00944-2844-10	J7192	$0.8945	0.0000	
RECOMBINATE	BAXALTA	2000	00944-2845-10	J7192	$0.8945	0.0000	
							
RIXUBIS	BAXALTA	175-325	00944-3026-02	J7200	$0.9335	0.0020	
RIXUBIS	BAXALTA	350-650	00944-3028-02	J7200	$0.9335	0.0020	
RIXUBIS	BAXALTA	700-1300	00944-3030-02	J7200	$0.9335	0.0020	
RIXUBIS	BAXALTA	1600-2400	00944-3032-02	J7200	$0.9335	0.0020	
RIXUBIS	BAXALTA	2401-3600	00944-3034-02	J7200	$0.9335	0.0020	
							
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	67467-0182-01	J7183	$0.6671	(0.0002)	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	67467-0182-02	J7183	$0.6671	(0.0002)	
							
XYNTHA	PFIZER/WYETH	250	58394-0012-01	J7185	$0.8040	(0.1013)	
XYNTHA	PFIZER/WYETH	500	58394-0013-01	J7185	$0.8771	(0.0261)	
XYNTHA	PFIZER/WYETH	1000	58394-0014-01	J7185	$0.6649	(0.2174)	
XYNTHA	PFIZER/WYETH	2000	58394-0015-01	J7185	$0.7225	(0.1076)	
XYNTHA - Solofuse	PFIZER/WYETH	3000	58394-0016-03	J7185	$0.6669	(0.2055)	
XYNTHA - Solofuse	PFIZER/WYETH	2000	58394-0025-03	J7185	$0.7225	(0.1076)	
XYNTHA - Solofuse	PFIZER/WYETH	1000	58394-0024-03	J7185	$0.6649	(0.2174)	
XYNTHA - Solofuse	PFIZER/WYETH	500	58394-0023-03	J7185	$0.8771	(0.0261)	
XYNTHA - Solofuse	PFIZER/WYETH	250	58394-0022-03	J7185	$0.8040	(0.1013)	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
4th Q 15	
Change Q3
15 to Q4 15	

**Notes:  (all highlighted)
1.