FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
1st Q 17	
Change Q4 16 to Q1 17	
ADVATE 2mL diluent	BAXALTA	200-400	00944-3051-02	J7192	$0.9075	0.0000	
ADVATE 2mL diluent	BAXALTA	401-800	00944-3052-02	J7192	$0.9075	0.0000	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-3053-02	J7192	$0.9075	0.0000	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-3054-02	J7192	$0.9075	0.0000	
ADVATE	BAXALTA	1801-2400	00944-3045-10	J7192	$0.9075	0.0000	
ADVATE	BAXALTA	2401-3600	00944-3046-10	J7192	$0.9075	0.0000	
ADVATE	BAXALTA	3601-4800	00944-3047-10	J7192	$0.9075	0.0000	
							
ALPHANATE-AHF/VWF (per factor VIII unit)	GRIFOLS	250	68516-4601-01	J7186	$0.7275	0.0000	
ALPHANATE-AHF/VWF (per factor VIII unit)	GRIFOLS	500	68516-4602-01	J7186	$0.7275	(0.0100)	
ALPHANATE-AHF/VWF (per factor VIII unit)	GRIFOLS	1000	68516-4603-02	J7186	$0.7275	0.0000	
ALPHANATE-AHF/VWF (per factor VIII unit)	GRIFOLS	1500	68516-4604-02	J7186	$0.7175	(0.0100)	
ALPHANATE-AHF/VWF (per factor VIII unit)	GRIFOLS	2000	68516-4609-02	J7186	$0.7275	0.0100	
							
ALPHANINE-SD	GRIFOLS	500	68516-3601-02	J7193	$0.7675	0.0100	
ALPHANINE-SD	GRIFOLS	1000	68516-3602-02	J7193	$0.7575	0.0000	
ALPHANINE-SD	GRIFOLS	1500	68516-3603-02	J7193	$0.7575	0.0000	
							
BEBULIN	BAXALTA	500-700	64193-0445-02	J7194	$0.3675	0.0000	
							
BENEFIX -RT	PFIZER/WYETH	250	58394-0633-03	J7195	$1.0506	0.0242	
BENEFIX -RT	PFIZER/WYETH	500	58394-0634-03	J7195	$1.0560	0.0259	
BENEFIX -RT	PFIZER/WYETH	1000	58394-0635-03	J7195	$1.0728	0.0321	
BENEFIX -RT	PFIZER/WYETH	2000	58394-0636-03	J7195	$0.8955	0.0284	
BENEFIX -RT	PFIZER/WYETH	3000	58394-0637-03	J7195	$0.9739	0.0197	
							
CEPROTIN	BAXALTA	500	00944-4177-05	J2724	$0.9975	0.0100	
CEPROTIN	BAXALTA	1000	00944-4179-10	J2724	$0.9975	0.0100	
							
CORIFACT	CSL BEHRING	1000-1600	63833-0518-02	J7180	$5.2175	0.0700	
							
FEIBA - NF	BAXALTA	400-650	64193-0223-02	J7198	$1.1375	0.0200	
FEIBA - NF	BAXALTA	651-1200	64193-0224-02	J7198	$1.1375	0.0200	
FEIBA - NF	BAXALTA	2000-3000	64193-0225-02	J7198	$1.1375	0.0200	
FEIBA - NF	BAXALTA	400-650	64193-0423-02	J7198	$1.1375	0.0200	
FEIBA - NF	BAXALTA	651-1200	64193-0424-02	J7198	$1.1375	0.0200	
FEIBA - NF	BAXALTA	2000-3000	64193-0425-02	J7198	$1.1375	0.0200	
							
HELIXATE-FS	CSL BEHRING	250	00053-8131-02	J7192	$0.8575	0.0000	
HELIXATE-FS	CSL BEHRING	500	00053-8132-02	J7192	$0.8575	0.0000	
HELIXATE-FS	CSL BEHRING	1000	00053-8133-02	J7192	$0.8675	0.0000	
HELIXATE-FS	CSL BEHRING	2000	00053-8134-02	J7192	$0.8575	0.0000	
HELIXATE-FS	CSL BEHRING	3000	00053-8135-02	J7192	$0.8575	(0.0100)	

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
1st Q 17	
Change Q4 16 to Q1 17	
HEMOFIL-M	BAXALTA	220-400	00944-3940-02	J7190	$0.7875	0.0000	
HEMOFIL-M	BAXALTA	401-800	00944-3942-02	J7190	$0.7875	0.0000	
HEMOFIL-M	BAXALTA	801-1500	00944-3944-02	J7190	$0.7875	0.0000	
HEMOFIL-M	BAXALTA	1501-2000	00944-3946-02	J7190	$0.7875	0.0000	
							
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	600	63833-0615-02	J7187	$0.7675	0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	1200	63833-0616-02	J7187	$0.7675	0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	2400	63833-0617-02	J7187	$0.7575	(0.0100)	
							
KOATE DVI	KEDRION	250	76125-0250-20	J7190	$0.6575	0.0100	
KOATE DVI	KEDRION	500	76125-0667-30	J7190	$0.6575	0.0100	
KOATE DVI	KEDRION	1000	76125-0667-50	J7190	$0.6575	0.0100	
KOATE DVI	KEDRION	1000	76125-0672-50	J7190	$0.6575		
							
KOGENATE-FS rAHF	BAYER	250	00026-3782-20	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	500	00026-3783-30	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	1000	00026-3785-50	J7192	$0.8375	0.0000	
KOGENATE-FS rAHF	BAYER	2000	00026-3786-60	J7192	$0.8275	0.0000	
KOGENATE-FS rAHF	BAYER	3000	00026-3787-70	J7192	$0.8175	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	
$0.8475	
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	
$0.7175	
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	$0.8375	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	$0.8375	0.0100	
KOGENATE-FS vial adapter	BAYER	2000	00026-3786-65	J7192	$0.8375	0.0100	
KOGENATE-FS vial adapter	BAYER	3000	00026-3787-75	J7192	$0.8375	0.0100	
							
MONOCLATE-P	CSL BEHRING	1000	00053-7633-02	J7190	$0.7075	0.0000	
MONOCLATE-P	CSL BEHRING	1500	00053-7634-02	J7190	$0.7075	0.0000	
							
MONONINE	CSL BEHRING	1000	00053-6233-02	J7193	$0.9075	0.0000	
							
NOVOSEVEN RT 1 MG MIXPRO (PER MCG)	NOVO NORDISK	1 mg vial	00169-7201-01	J7189	$0.9947	0.0106	
NOVOSEVEN RT 2 MG MIXPRO (PER MCG)	NOVO NORDISK	2 mg vial	00169-7202-01	J7189	$0.9840	0.0129	
NOVOSEVEN RT 5 MG MIXPRO (PER MCG)	NOVO NORDISK	5 mg vial	00169-7205-01	J7189	$0.9827	0.0132	

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
1st Q 17	
Change Q4 16 to Q1 17	
							
PROFILNINE-SD	GRIFOLS	500	68516-3201-01	J7194	$0.1675	0.0100	
PROFILNINE-SD	GRIFOLS	1000	68516-3202-02	J7194	$0.1675	0.0000	
PROFILNINE-SD	GRIFOLS	1500	68516-3203-02	J7194	$0.1675	0.0000	
							
RECOMBINATE	BAXALTA	250	00944-2841-10	J7192	$0.9075	0.0000	
RECOMBINATE	BAXALTA	500	00944-2842-10	J7192	$0.9075	0.0000	
RECOMBINATE	BAXALTA	1000	00944-2843-10	J7192	$0.9075	0.0000	
RECOMBINATE	BAXALTA	1500	00944-2844-10	J7192	$0.9075	0.0000	
RECOMBINATE	BAXALTA	2000	00944-2845-10	J7192	$0.9075	0.0000	
							
RIXUBIS	BAXALTA	175-325	00944-3026-02	J7200	$0.9275	0.0000	
RIXUBIS	BAXALTA	350-650	00944-3028-02	J7200	$0.9275	0.0000	
RIXUBIS	BAXALTA	700-1300	00944-3030-02	J7200	$0.9275	0.0000	
RIXUBIS	BAXALTA	1600-2400	00944-3032-02	J7200	$0.9275	0.0000	
RIXUBIS	BAXALTA	2401-3600	00944-3034-02	J7200	$0.9275	0.0000	
							
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	67467-0182-01	J7183	$0.6817	0.0006	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	67467-0182-02	J7183	$0.6817	0.0006	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	68982-0182-01	J7183	$0.6817	0.0006	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	68982-0182-02	J7183	$0.6817	0.0006	
							
XYNTHA	PFIZER/WYETH	250	58394-0012-01	J7185	$0.9013	(0.0119)	
XYNTHA	PFIZER/WYETH	500	58394-0013-01	J7185	$0.9155	0.0115	
XYNTHA	PFIZER/WYETH	1000	58394-0014-01	J7185	$0.9062	(0.0154)	
XYNTHA	PFIZER/WYETH	2000	58394-0015-01	J7185	$0.8579	0.0058	
XYNTHA - Solofuse	PFIZER/WYETH	3000	58394-0016-03	J7185	$0.8927	0.0196	
XYNTHA - Solofuse	PFIZER/WYETH	2000	58394-0025-03	J7185	$0.8579	0.0058	
XYNTHA - Solofuse	PFIZER/WYETH	1000	58394-0024-03	J7185	$0.9062	(0.0154)	
XYNTHA - Solofuse	PFIZER/WYETH	500	58394-0023-03	J7185	$0.9155	0.0115	
XYNTHA - Solofuse	PFIZER/WYETH	250	58394-0022-03	J7185	$0.9013	(0.0119)	
							
**Notes: (all highlighted)
Koate-DVI -- Second NDC number available with a 1,000 unit range vial
Kogenate FS -- highlighted vials (NDC) have been discontinued - pricing listed is the last price provided (2nd QTR 2016)