FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st Q 15	
Change Q4
14 to Q1 15	
ADVATE 2mL diluent	BAXTER	200-400	00944-2921-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	401-800	00944-2922-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	801-1200	00944-2923-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	1201-1800	00944-2924-02	J7192	$0.8775	0.0050	
ADVATE	BAXTER	1801-2400	00944-2945-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	1801-2400	00944-2964-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	2401-3600	00944-2946-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	2401-3600	00944-2965-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	3601-4800	00944-2948-10	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	200-400	00944-3051-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	401-800	00944-3052-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	801-1200	00944-3053-02	J7192	$0.8775	0.0050	
ADVATE 2mL diluent	BAXTER	1201-1800	00944-3054-02	J7192	$0.8775	0.0050	
ADVATE	BAXTER	1801-2400	00944-3045-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	2401-3600	00944-3046-10	J7192	$0.8775	0.0050	
ADVATE	BAXTER	3601-4800	00944-3047-10	J7192	$0.8775	0.0050	
							
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
250	
68516-4601-01	
J7186	
$0.7175	
0.0200	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
500	
68516-4602-01	
J7186	
$0.7175	
0.0100	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
1000	
68516-4603-02	
J7186	
$0.7175	
0.0100	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
1500	
68516-4604-02	
J7186	
$0.7075	
0.0100	
ALPHANATE-AHF/VWF (per factor
VIII unit)	
GRIFOLS	
2000	
68516-4609-02	
J7186	
$0.7075	
0.0100	
							
ALPHANINE-SD	GRIFOLS	500	68516-3601-02	J7193	$0.7275	0.0100	
ALPHANINE-SD	GRIFOLS	1000	68516-3602-02	J7193	$0.7275	0.0000	
ALPHANINE-SD	GRIFOLS	1500	68516-3603-02	J7193	$0.7275	0.0000	
							
BEBULIN	BAXTER	500-700	64193-0244-02	J7194	$0.3655	0.0000	
							
BENEFIX -RT	WYETH	250	58394-0633-03	J7195	$1.0209	(0.0056)	
BENEFIX -RT	WYETH	500	58394-0634-03	J7195	$1.0178	(0.0125)	
BENEFIX -RT	WYETH	1000	58394-0635-03	J7195	$1.0385	(0.0003)	
BENEFIX -RT	WYETH	2000	58394-0636-03	J7195	$0.9191	0.0105	
BENEFIX -RT	WYETH	3000	58394-0637-03	J7195	$1.0109	0.0110	
							
CEPROTIN	BAXTER	500	00944-4175-05	J2724	$0.9985	0.0070	
CEPROTIN	BAXTER	1000	00944-4175-10	J2724	$0.9985	0.0070	
							
CORIFACT	CSL/BEHRING	1000-1600	63833-0518-02	J7180	$5.3175	0.0100	
							
FEIBA-NF	BAXTER	400-650	64193-0223-02	J7198	$1.1405	0.0020	
FEIBA-NF	BAXTER	651-1200	64193-0224-02	J7198	$1.1405	0.0020	
FEIBA-NF	BAXTER	2000-3000	64193-0225-02	J7198	$1.1405	0.0020	
FEIBA-NF	BAXTER	400-650	64193-0423-02	J7198	$1.1405	0.0020	
FEIBA-NF	BAXTER	651-1200	64193-0424-02	J7198	$1.1405	0.0020	
FEIBA-NF	BAXTER	2000-3000	64193-0425-02	J7198	$1.1405	0.0020	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st Q 15	
Change Q4
14 to Q1 15	
							
HELIXATE-FS	CSL/BEHRING	250	00053-8131-02	J7192	$0.8275	0.0000	
HELIXATE-FS	CSL/BEHRING	500	00053-8132-02	J7192	$0.8375	0.0000	
HELIXATE-FS	CSL/BEHRING	1000	00053-8133-02	J7192	$0.8375	0.0000	
HELIXATE-FS	CSL/BEHRING	2000	00053-8134-02	J7192	$0.8375	0.0000	
HELIXATE-FS	CSL/BEHRING	3000	00053-8135-02	J7192	$0.8375	0.0000	
							
HEMOFIL-M	BAXTER	220-400	00944-2930-01	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	401-800	00944-2931-01	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	801-1500	00944-2932-01	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	1501-2000	00944-2933-01	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	220-400	00944-3940-02	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	401-800	00944-3942-02	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	801-1500	00944-3944-02	J7190	$0.7635	0.0150	
HEMOFIL-M	BAXTER	1501-2000	00944-3946-02	J7190	$0.7635	0.0150	
							
HUMATE-P (PER VWF:RCOF UNIT)	
CSL/BEHRING	
600	
63833-0615-02	
J7187	
$0.7075	
0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	
CSL/BEHRING	
1200	
63833-0616-02	
J7187	
$0.7075	
0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	
CSL/BEHRING	
2400	
63833-0617-02	
J7187	
$0.7075	
0.0000	
							
KOATE DVI	KEDRION	250	76125-0250-20	J7190	$0.6275	0.0000	
KOATE DVI	KEDRION	500	76125-0667-30	J7190	$0.6275	0.0000	
KOATE DVI	KEDRION	1000	76125-0667-50	J7190	$0.6275	0.0000	
							
KOGENATE-FS rAHF	BAYER	250	00026-3782-20	J7192	$0.8175	0.0000	
KOGENATE-FS rAHF	BAYER	500	00026-3783-30	J7192	$0.8175	0.0000	
KOGENATE-FS rAHF	BAYER	1000	00026-3785-50	J7192	$0.8175	0.0000	
KOGENATE-FS rAHF	BAYER	2000	00026-3786-60	J7192	$0.8175	0.0000	
KOGENATE-FS rAHF	BAYER	3000	00026-3787-70	J7192	$0.8175	0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
250	
00026-3792-20	
J7192	
$0.7775	
(0.0200)	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
500	
00026-3793-30	
J7192	
$0.8175	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
1000	
00026-3795-50	
J7192	
$0.8175	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
2000	
00026-3796-60	
J7192	
$0.8175	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
3000	
00026-3797-70	
J7192	
$0.8075	
(0.0100)	
KOGENATE-FS vial adapter	BAYER	250	00026-3782-25	J7192	$0.8175	0.0000	
KOGENATE-FS vial adapter	BAYER	500	00026-3783-35	J7192	$0.8175	0.0000	
KOGENATE-FS vial adapter	BAYER	1000	00026-3785-55	J7192	$0.8175	0.0000	
KOGENATE-FS vial adapter	BAYER	2000	00026-3786-65	J7192	$0.8175	0.0000	
KOGENATE-FS vial adapter	BAYER	3000	00026-3787-75	J7192	$0.8175	0.0000	
							
MONOCLATE-P	CSL/BEHRING	1000	00053-7633-02	J7190	$0.6575	0.0300	
MONOCLATE-P	CSL/BEHRING	1500	00053-7634-02	J7190	$0.6575	0.0300	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st Q 15	
Change Q4
14 to Q1 15	
MONONINE	CSL/BEHRING	1000	00053-6233-02	J7193	$0.8375	0.0300	

NOVOSEVEN RT 1 MG (PER MCG)	
NOVO NORDISK	
1 mg vial	
00169-7010-01	
J7189	
$1.0121	
0.0071	

NOVOSEVEN RT 2 MG (PER MCG)	
NOVO NORDISK	
2 mg vial	
00169-7020-01	
J7189	
$0.9956	
0.0056	

NOVOSEVEN RT 5 MG (PER MCG)	
NOVO NORDISK	
5 mg vial	
00169-7050-01	
J7189	
$0.9914	
0.0036	

NOVOSEVEN RT 8 MG (PER MCG)	
NOVO NORDISK	
8 mg vial	
00169-7040-01	
J7189	
$1.2624	
(0.0008)	

NOVOSEVEN RT 1 MG (PER MCG)	
NOVO NORDISK	
1 mg vial	
00169-7201-01	
J7189	
$1.0121	
0.0071	

NOVOSEVEN RT 2 MG (PER MCG)	
NOVO NORDISK	
2 mg vial	
00169-7202-01	
J7189	
$0.9956	
0.0056	

NOVOSEVEN RT 5 MG (PER MCG)	
NOVO NORDISK	
5 mg vial	
00169-7205-01	
J7189	
$0.9914	
0.0036	

NOVOSEVEN RT 8 MG (PER MCG)	
NOVO NORDISK	
8 mg vial	
00169-7208-01	
J7189	
$1.2624	
(0.0008)	
							
PROFILNINE-SD	GRIFOLS	500	68516-3201-01	J7194	$0.1875	(0.0100)	
PROFILNINE-SD	GRIFOLS	1000	68516-3202-02	J7194	$0.1875	0.0000	
PROFILNINE-SD	GRIFOLS	1500	68516-3203-02	J7194	$0.1875	0.0000	
							
RECOMBINATE	BAXTER	220-400	00944-2831-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	401-800	00944-2832-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	801-1240	00944-2833-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	250	00944-2841-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	500	00944-2842-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	1000	00944-2843-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	1500	00944-2844-10	J7192	$0.8675	0.0010	
RECOMBINATE	BAXTER	2000	00944-2845-10	J7192	$0.8675	0.0010	
							
RIXUBIS	BAXTER	175-325	00944-3026-02	J7199	$0.9435	0.0170	
RIXUBIS	BAXTER	350-650	00944-3028-02	J7199	$0.9435	0.0170	
RIXUBIS	BAXTER	700-1300	00944-3030-02	J7199	$0.9435	0.0170	
RIXUBIS	BAXTER	1600-2400	00944-3032-02	J7199	$0.9435	0.0170	
RIXUBIS	BAXTER	2401-3600	00944-3034-02	J7199	$0.9435	0.0170	
							
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	67467-0182-01	J7184	$0.6795	0.0082	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	67467-0182-02	J7184	$0.6795	0.0082	
							
XYNTHA	WYETH	250	58394-0012-01	J7185	$0.8862	0.0126	
XYNTHA	WYETH	500	58394-0013-01	J7185	$0.8908	0.0136	
XYNTHA	WYETH	1000	58394-0014-01	J7185	$0.8849	(0.0105)	
XYNTHA	WYETH	2000	58394-0015-01	J7185	$0.8533	0.0085	
XYNTHA - Solofuse	WYETH	3000	58394-0016-03	J7185	$0.8835	0.0059	
XYNTHA - Solofuse	WYETH	2000	58394-0025-03	J7185	$0.8533	0.0085	
XYNTHA - Solofuse	WYETH	1000	58394-0024-03	J7185	$0.8849	(0.0105)	
XYNTHA - Solofuse	WYETH	500	58394-0023-03	J7185	$0.8908	0.0136	
XYNTHA - Solofuse	WYETH	250	58394-0022-03	J7185	$0.8862	0.0126	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st 0 15	
Change 04
14to 0115	

**Notes: (all highlighted)
1.