FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st Q 16	
Change Q4 15 to Q1 16	
ADVATE 2mL diluent	BAXALTA	200-400	00944-2921-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	401-800	00944-2922-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-2923-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-2924-02	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	1801-2400	00944-2964-10	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	2401-3600	00944-2965-10	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	3601-4800	00944-2948-10	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	200-400	00944-3051-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	401-800	00944-3052-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-3053-02	J7192	$0.9035	0.0120	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-3054-02	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	1801-2400	00944-3045-10	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	2401-3600	00944-3046-10	J7192	$0.9035	0.0120	
ADVATE	BAXALTA	3601-4800	00944-3047-10	J7192	$0.9035	0.0120	
							
ALPHANATE-AHF/VWF (per factor VIII unit)	
GRIFOLS	
250	
68516-4601-01	
J7186	
$0.7075	
(0.0100)	
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	
0.0000	
							
ALPHANINE-SD	GRIFOLS	500	68516-3601-02	J7193	$0.7475	0.0200	
ALPHANINE-SD	GRIFOLS	1000	68516-3602-02	J7193	$0.7475	0.0200	
ALPHANINE-SD	GRIFOLS	1500	68516-3603-02	J7193	$0.7475	0.0200	
							
BEBULIN	BAXALTA	500-700	64193-0445-02	J7194	$0.3605	0.0040	
							
BENEFIX -RT	PFIZER/WYETH	250	58394-0633-03	J7195	$1.0577	0.0076	
BENEFIX -RT	PFIZER/WYETH	500	58394-0634-03	J7195	$1.0617	0.0127	
BENEFIX -RT	PFIZER/WYETH	1000	58394-0635-03	J7195	$1.0596	0.0322	
BENEFIX -RT	PFIZER/WYETH	2000	58394-0636-03	J7195	$0.9002	0.0096	
BENEFIX -RT	PFIZER/WYETH	3000	58394-0637-03	J7195	$0.9945	0.0139	
							
CEPROTIN	BAXALTA	500	00944-4175-05	J2724	$0.9885	0.0130	
CEPROTIN	BAXALTA	1000	00944-4175-10	J2724	$0.9885	0.0130	
CEPROTIN	BAXALTA	500	00944-4177-05	J2724	$0.9885	0.0130	
CEPROTIN	BAXALTA	1000	00944-4179-10	J2724	$0.9885	0.0130	
							
CORIFACT	CSL BEHRING	1000-1600	63833-0518-02	J7180	$5.2075	0.0100	
							
FEIBA-NF	BAXALTA	400-650	64193-0223-02	J7198	$1.1205	0.0030	
FEIBA-NF	BAXALTA	651-1200	64193-0224-02	J7198	$1.1205	0.0030	
FEIBA-NF	BAXALTA	2000-3000	64193-0225-02	J7198	$1.1205	0.0030	
FEIBA-NF	BAXALTA	400-650	64193-0423-02	J7198	$1.1205	0.0030	
FEIBA-NF	BAXALTA	651-1200	64193-0424-02	J7198	$1.1205	0.0030	
FEIBA-NF	BAXALTA	2000-3000	64193-0425-02	J7198	$1.1205	0.0030	

FACTOR NAME	

MANUFACTURER	
FACTOR ASSAY RANGE	

NDC#	
HCPCS CODE	
AHCCCS
1st Q 16	
Change Q4 15 to Q1 16	
							
HELIXATE-FS	CSL BEHRING	250	00053-8131-02	J7192	$0.8475	0.0000	
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	$0.7785	(0.0010)	
HEMOFIL-M	BAXALTA	401-800	00944-3942-02	J7190	$0.7785	(0.0010)	
HEMOFIL-M	BAXALTA	801-1500	00944-3944-02	J7190	$0.7785	(0.0010)	
HEMOFIL-M	BAXALTA	1501-2000	00944-3946-02	J7190	$0.7785	(0.0010)	
							
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	0.0000	
KOATE DVI	KEDRION	500	76125-0667-30	J7190	$0.6675	0.0000	
KOATE DVI	KEDRION	1000	76125-0667-50	J7190	$0.6675	0.0000	
							
KOGENATE-FS rAHF	BAYER	250	00026-3782-20	J7192	$0.8275	0.0100	
KOGENATE-FS rAHF	BAYER	500	00026-3783-30	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	1000	00026-3785-50	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	2000	00026-3786-60	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	3000	00026-3787-70	J7192	$0.8275	0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
250	
00026-3792-20	
J7192	
$0.7575	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
500	
00026-3793-30	
J7192	
$0.8275	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
1000	
00026-3795-50	
J7192	
$0.8275	
0.0000	

KOGENATE-FS rAHF w/ Bioset	
BAYER	
2000	
00026-3796-60	
J7192	
$0.7275	
0.0000	

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	$0.8275	0.0100	
KOGENATE-FS vial adapter	BAYER	500	00026-3783-35	J7192	$0.8275	0.0000	
KOGENATE-FS vial adapter	BAYER	1000	00026-3785-55	J7192	$0.8275	0.0000	
KOGENATE-FS vial adapter	BAYER	2000	00026-3786-65	J7192	$0.8275	0.0000	
KOGENATE-FS vial adapter	BAYER	3000	00026-3787-75	J7192	$0.8275	0.0000	
							
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
1st Q 16	
Change Q4 15 to Q1 16	
NOVOSEVEN RT 1MG (PER MCG)	
NOVO NORDISK	
1mg vial	
00169-7010-01	
J7189	
$0.9714	
(0.2139)	
NOVOSEVEN RT 2MG (PER
MCG)	
NOVO NORDISK	
2mg vial	
00169-7020-01	
J7189	
$0.9609	
(0.1113)	
NOVOSEVEN RT 5MG (PER
MCG)	
NOVO NORDISK	
5mg vial	
00169-7050-01	
J7189	
$0.9628	
(0.1054)	
NOVOSEVEN RT 8 MG MIXPRO
(PER MCG)	
NOVO NORDISK	
8mg vial	
00169-7040-01	
J7189			
NOVOSEVEN RT 1 MG MIXPRO (PER MCG)	
NOVO NORDISK	
1 mg vial	
00169-7201-01	
J7189	
$0.9714	
0.0729	
NOVOSEVEN RT 2 MG MIXPRO (PER MCG)	
NOVO NORDISK	
2 mg vial	
00169-7202-01	
J7189	
$0.9609	
0.0501	
NOVOSEVEN RT 5 MG MIXPRO (PER MCG)	
NOVO NORDISK	
5 mg vial	
00169-7205-01	
J7189	
$0.9628	
0.0284	
NOVOSEVEN RT 8 MG MIXPRO (PER MCG)	
NOVO NORDISK	
8 mg vial	
00169-7208-01	
J7189			
							
PROFILNINE-SD	GRIFOLS	500	68516-3201-01	J7194	$0.1775	0.0000	
PROFILNINE-SD	GRIFOLS	1000	68516-3202-02	J7194	$0.1775	0.0000	
PROFILNINE-SD	GRIFOLS	1500	68516-3203-02	J7194	$0.1775	(0.0100)	
							
RECOMBINATE	BAXALTA	220-400	00944-2831-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	401-800	00944-2832-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	801-1240	00944-2833-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	250	00944-2841-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	500	00944-2842-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	1000	00944-2843-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	1500	00944-2844-10	J7192	$0.9025	0.0080	
RECOMBINATE	BAXALTA	2000	00944-2845-10	J7192	$0.9025	0.0080	
							
RIXUBIS	BAXALTA	175-325	00944-3026-02	J7200	$0.9315	(0.0020)	
RIXUBIS	BAXALTA	350-650	00944-3028-02	J7200	$0.9315	(0.0020)	
RIXUBIS	BAXALTA	700-1300	00944-3030-02	J7200	$0.9315	(0.0020)	
RIXUBIS	BAXALTA	1600-2400	00944-3032-02	J7200	$0.9315	(0.0020)	
RIXUBIS	BAXALTA	2401-3600	00944-3034-02	J7200	$0.9315	(0.0020)	
							
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	67467-0182-01	J7183	$0.6787	0.0116	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	67467-0182-02	J7183	$0.6787	0.0116	
							
XYNTHA	PFIZER/WYETH	250	58394-0012-01	J7185	$0.8946	0.0906	
XYNTHA	PFIZER/WYETH	500	58394-0013-01	J7185	$0.9499	0.0728	
XYNTHA	PFIZER/WYETH	1000	58394-0014-01	J7185	$0.9020	0.2371	
XYNTHA	PFIZER/WYETH	2000	58394-0015-01	J7185	$0.8530	0.1305	
XYNTHA - Solofuse	PFIZER/WYETH	3000	58394-0016-03	J7185	$0.8684	0.2015	
XYNTHA - Solofuse	PFIZER/WYETH	2000	58394-0025-03	J7185	$0.8530	0.1305	
XYNTHA - Solofuse	PFIZER/WYETH	1000	58394-0024-03	J7185	$0.9020	0.2371	
XYNTHA - Solofuse	PFIZER/WYETH	500	58394-0023-03	J7185	$0.9499	0.0728	
XYNTHA - Solofuse	PFIZER/WYETH	250	58394-0022-03	J7185	$0.8946	0.0906	

**Notes: (all highlighted)
Bebulin- Revised to reflect correct NDC number
Novoseven RT- 8mg vial no longer available under this pricing schedule