FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
2nd Q 18	
Change Q1 18 to Q2 18	
ADVATE 2mL diluent	BAXALTA	200-400	00944-3051-02	J7192	$0.9875	0.0000	
ADVATE 2mL diluent	BAXALTA	401-800	00944-3052-02	J7192	$0.9875	0.0000	
ADVATE 2mL diluent	BAXALTA	801-1200	00944-3053-02	J7192	$0.9875	0.0000	
ADVATE 2mL diluent	BAXALTA	1201-1800	00944-3054-02	J7192	$0.9875	0.0000	
ADVATE	BAXALTA	1801-2400	00944-3045-10	J7192	$0.9875	0.0000	
ADVATE	BAXALTA	2401-3600	00944-3046-10	J7192	$0.9875	0.0000	
ADVATE	BAXALTA	3601-4800	00944-3047-10	J7192	$0.9875	0.0000	
							
ADYNOVATE	BAXALTA/SHIRE	200-399	00944-4622-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	400-600	00944-4623-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	601-900	00944-4626-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	901-1250	00944-4624-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	1251-1800	00944-4627-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	1801-2500	00944-4625-01	J7207	$1.3775	0.0000	
ADYNOVATE	BAXALTA/SHIRE	2501-3600	00944-4628-01	J7207	$1.3775	0.0000	
							
AFSTYLA	CSL Behring	250	69911-0474-02	J7199	$1.0575	0.0000	
AFSTYLA	CSL Behring	500	69911-0475-02	J7199	$1.0275	(0.0100)	
AFSTYLA	CSL Behring	1000	69911-0476-02	J7199	$1.0475	0.0000	
AFSTYLA	CSL Behring	2000	69911-0477-02	J7199	$1.0075	(0.0200)	
AFSTYLA	CSL Behring	3000	69911-0478-02	J7199	$1.0575	(0.0100)	
AFSTYLA	CSL Behring	1500	69911-0480-02	J7199	$0.9675	(0.0900)	
AFSTYLA	CSL Behring	2500	69911-0481-02	J7199	$0.9775	(0.0800)	
							
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
250	
68516-4601-01	
J7186	
$0.7275	
0.0200	
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
500	
68516-4602-01	
J7186	
$0.7275	
0.0000	
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
1000	
68516-4603-02	
J7186	
$0.7275	
0.0100	
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	
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
250	
68516-4611-01	
J7186	
$0.7275		
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
500	
68516-4612-01	
J7186	
$0.7275		
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
1000	
68516-4613-02	
J7186	
$0.7275		
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
1500	
68516-4614-02	
J7186	
$0.7175		
ALPHANATE-AHF/VWF (per
factor VIII unit)	
GRIFOLS	
2000	
68516-4615-02	
J7186	
$0.7175		

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
2nd Q 18	
Change Q1 18 to Q2 18	
ALPHANINE-SD	GRIFOLS	500	68516-3601-02	J7193	$0.7575	(1.0000)	
ALPHANINE-SD	GRIFOLS	1000	68516-3602-02	J7193	$0.7575	(1.0000)	
ALPHANINE-SD	GRIFOLS	1500	68516-3603-02	J7193	$0.7575	(1.0000)	
ALPHANINE-SD	GRIFOLS	500	68516-3607-02	J7193	$0.7575		
ALPHANINE-SD	GRIFOLS	1000	68516-3608-02	J7193	$0.7575		
ALPHANINE-SD	GRIFOLS	1500	68516-3609-02	J7193	$0.7575		
							
ALPROLIX	BIOGEN	250	64406-0966-01	J7201	$2.2875	0.0200	
ALPROLIX	BIOGEN	500	64406-0911-01	J7201	$2.2375	0.0100	
ALPROLIX	BIOGEN	1000	64406-0922-01	J7201	$2.2275	0.0200	
ALPROLIX	BIOGEN	2000	64406-0933-01	J7201	$2.2375	0.0200	
ALPROLIX	BIOGEN	3000	64406-0944-01	J7201	$2.2275	0.0200	
ALPROLIX	BIOGEN	4000	64406-0977-01	J7201	$2.3475	0.0300	
							
BEBULIN	BAXALTA	500-700	64193-0445-02	J7194	$0.3775	0.0100	
							
BENEFIX -RT	PFIZER/WYETH	250	58394-0633-03	J7195	$1.1006	0.0137	
BENEFIX -RT	PFIZER/WYETH	500	58394-0634-03	J7195	$1.0756	(0.0124)	
BENEFIX -RT	PFIZER/WYETH	1000	58394-0635-03	J7195	$1.1031	0.0066	
BENEFIX -RT	PFIZER/WYETH	2000	58394-0636-03	J7195	$0.9188	0.0077	
BENEFIX -RT	PFIZER/WYETH	3000	58394-0637-03	J7195	$1.0251	0.0241	
							
CEPROTIN	BAXALTA	500	00944-4177-05	J2724	$1.0275	0.0000	
CEPROTIN	BAXALTA	1000	00944-4179-10	J2724	$1.0275	0.0000	
							
COAGADEX	BPL	250	64208-7752-01	J7175	$5.2475	0.0500	
COAGADEX	BPL	500	64208-7753-01	J7175	$5.2475	0.0500	
							
CORIFACT	CSL BEHRING	1000-1600	63833-0518-02	J7180	$5.3675	0.0500	
							
ELOCTATE	BIOGEN	250	64406-0801-01	J7205	$1.5375	0.0100	
ELOCTATE	BIOGEN	500	64406-0802-01	J7205	$1.4975	0.0100	
ELOCTATE	BIOGEN	750	64406-0803-01	J7205	$1.5175	0.0100	
ELOCTATE	BIOGEN	1000	64406-0804-01	J7205	$1.4875	0.0100	
ELOCTATE	BIOGEN	1500	64406-0805-01	J7205	$1.4975	0.0000	
ELOCTATE	BIOGEN	2000	64406-0806-01	J7205	$1.5175	0.0100	
ELOCTATE	BIOGEN	3000	64406-0807-01	J7205	$1.5075	0.0100	
ELOCTATE	BIOGEN	4000	64406-0808-01	J7205	$1.5575	0.0300	
ELOCTATE	BIOGEN	5000	64406-0809-01	J7205	$1.5475	0.0300	
ELOCTATE	BIOGEN	6000	64406-0810-01	J7205	$1.5575	0.0000	
							
FEIBA	BAXALTA/SHIRE	500	64193-0426-02	J7198	$1.1575	0.0200	
FEIBA	BAXALTA/SHIRE	400-650	64193-0423-02	J7198	$1.1575	0.0200	
FEIBA	BAXALTA/SHIRE	651-1200	64193-0424-02	J7198	$1.1575	0.0200	
FEIBA	BAXALTA/SHIRE	2000-3000	64193-0425-02	J7198	$1.1575	0.0200	

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
2nd Q 18	
Change Q1 18 to Q2 18	
HELIXATE-FS	CSL BEHRING	250	00053-8131-02	J7192	$0.8675	0.0000	
HELIXATE-FS	CSL BEHRING	500	00053-8132-02	J7192	$0.8675	0.0000	
HELIXATE-FS	CSL BEHRING	1000	00053-8133-02	J7192	$0.8675	0.0000	
HELIXATE-FS	CSL BEHRING	2000	00053-8134-02	J7192	$0.8675	0.0000	
HELIXATE-FS	CSL BEHRING	3000	00053-8135-02	J7192	$0.8675	0.0000	
							
HEMOFIL-M	BAXALTA	220-400	00944-3940-02	J7190	$0.8475	(0.0300)	
HEMOFIL-M	BAXALTA	401-800	00944-3942-02	J7190	$0.8475	(0.0300)	
HEMOFIL-M	BAXALTA	801-1500	00944-3944-02	J7190	$0.8475	(0.0300)	
HEMOFIL-M	BAXALTA	1501-2000	00944-3946-02	J7190	$0.8475	(0.0300)	
							
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	600	63833-0615-02	J7187	$0.8075	0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	1200	63833-0616-02	J7187	$0.8075	0.0000	
HUMATE-P (PER VWF:RCOF UNIT)	CSL BEHRING	2400	63833-0617-02	J7187	$0.8075	0.0100	
							
IDELVION	CSL BEHRING	250	69911-0864-02	J7202	$3.2475	0.0000	
IDELVION	CSL BEHRING	500	69911-0865-02	J7202	$3.2875	0.0700	
IDELVION	CSL BEHRING	1000	69911-0866-02	J7202	$3.2575	0.0800	
IDELVION	CSL BEHRING	2000	69911-0867-02	J7202	$3.2775	0.0600	
							
IXINITY	APTEVO	250	70504-0287-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	500	70504-0282-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	1000	70504-0283-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	1500	70504-0284-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	2000	70504-0288-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	3000	70504-0289-05	J7194	$1.0875	0.0300	
IXINITY	APTEVO	1000 x 2 kit	70504-0285-06	J7194	$1.0875	0.0300	
IXINITY	APTEVO	1500 x 2 kit	70504-0286-06	J7194	$1.0875	0.0300	
							
KOATE DVI	KEDRION	250	76125-0256-20	J7190	$0.7175	(0.0300)	
KOATE DVI	KEDRION	500	76125-0668-30	J7190	$0.7175	(0.0300)	
KOATE DVI	KEDRION	1000	76125-0676-50	J7190	$0.7175	(0.0300)	
							
KOGENATE-FS vial adapter	BAYER	250	00026-3782-25	J7192	$0.8275	0.0700	
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	$0.8275	0.0000	
KOGENATE-FS vial adapter	BAYER	3000	00026-3787-75	J7192	$0.8275	(0.0100)	
							
KOVALTRY	BAYER	250	00026-3821-25	J7192	$0.9175	0.0000	
KOVALTRY	BAYER	500	00026-3822-25	J7192	$0.9075	0.0000	
KOVALTRY	BAYER	1000	00026-3824-25	J7192	$0.9175	0.0000	
KOVALTRY	BAYER	2000	00026-3826-50	J7192	$0.9175	0.0000	
KOVALTRY	BAYER	3000	00026-3828-50	J7192	$0.9275	0.0000	
							
MONOCLATE-P	CSL BEHRING	1000	00053-7633-02	J7190	$0.6975	(0.0100)	
MONOCLATE-P	CSL BEHRING	1500	00053-7634-02	J7190	$0.7075	0.0000	

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
2nd Q 18	
Change Q1 18 to Q2 18	
							
MONONINE	CSL BEHRING	1000	00053-6233-02	J7193	$0.9575	0.0000	
							
NOVOEIGHT	NOVO NORDISK	250	00169-7825-01	J7182	$0.9975	0.0000	
NOVOEIGHT	NOVO NORDISK	500	00169-7850-01	J7182	$0.9975	0.0000	
NOVOEIGHT	NOVO NORDISK	1000	00169-7810-01	J7182	$0.9975	0.0000	
NOVOEIGHT	NOVO NORDISK	1500	00169-7815-01	J7182	$0.9975	0.0000	
NOVOEIGHT	NOVO NORDISK	2000	00169-7820-01	J7182	$0.9975	0.0000	
NOVOEIGHT	NOVO NORDISK	3000	00169-7830-01	J7182	$0.9975	0.0000	
							
NOVOSEVEN RT 1 MG MIXPRO (PER MCG)	NOVO NORDISK	1 mg vial	00169-7201-01	J7189	$1.0032	(0.0023)	
NOVOSEVEN RT 2 MG MIXPRO (PER MCG)	NOVO NORDISK	2 mg vial	00169-7202-01	J7189	$0.9902	(0.0006)	
NOVOSEVEN RT 5 MG MIXPRO (PER MCG)	NOVO NORDISK	5 mg vial	00169-7205-01	J7189	$0.9880	(0.0016)	
							
NUWIQ	OCTAPHARMA	250	68982-0139-01	J7209	$0.9975	(0.0100)	
NUWIQ	OCTAPHARMA	500	68982-0141-01	J7209	$0.9975	(0.0100)	
NUWIQ	OCTAPHARMA	1000	68982-0143-01	J7209	$0.9975	(0.0100)	
NUWIQ	OCTAPHARMA	2000	68982-0145-01	J7209	$0.9975	(0.0100)	
NUWIQ	OCTAPHARMA	2500	68982-0147-01	J7209	$0.9975	(0.2828)	
NUWIQ	OCTAPHARMA	3000	68982-0149-01	J7209	$0.9975	(0.2908)	
NUWIQ	OCTAPHARMA	4000	68982-0151-01	J7209	$0.9975	(0.2841)	
							
PROFILNINE-SD	GRIFOLS	500	68516-3201-01	J7194	$0.1475	0.0000	
PROFILNINE-SD	GRIFOLS	1000	68516-3202-02	J7194	$0.1475	0.0000	
PROFILNINE-SD	GRIFOLS	1500	68516-3203-02	J7194	$0.1475	0.0000	
PROFILNINE-SD	GRIFOLS	500	68516-3207-01	J7194	$0.1475		
PROFILNINE-SD	GRIFOLS	1000	68516-3208-02	J7194	$0.1475		
PROFILNINE-SD	GRIFOLS	1500	68516-3209-02	J7194	$0.1475		
							
RECOMBINATE	BAXALTA	250	00944-2841-10	J7192	$0.9975	0.0000	
RECOMBINATE	BAXALTA	500	00944-2842-10	J7192	$0.9975	0.0000	
RECOMBINATE	BAXALTA	1000	00944-2843-10	J7192	$0.9975	0.0000	
RECOMBINATE	BAXALTA	1500	00944-2844-10	J7192	$0.9975	0.0000	
RECOMBINATE	BAXALTA	2000	00944-2845-10	J7192	$0.9975	0.0000	
							
RIXUBIS	BAXALTA	175-325	00944-3026-02	J7200	$0.9775	0.0200	
RIXUBIS	BAXALTA	350-650	00944-3028-02	J7200	$0.9775	0.0200	
RIXUBIS	BAXALTA	700-1300	00944-3030-02	J7200	$0.9775	0.0200	
RIXUBIS	BAXALTA	1600-2400	00944-3032-02	J7200	$0.9775	0.0200	
RIXUBIS	BAXALTA	2401-3600	00944-3034-02	J7200	$0.9775	0.0200	
							
TRETTEN	NOVO NORDISK	2000-3125	00169-7013-01	J7181	$11.0875	0.1100	
							
VONVENDI	BAXALTA/SHIRE	450-850	00944-7551-02	J7179	$1.7475	0.0100	
VONVENDI	BAXALTA/SHIRE	900-1700	00944-7553-02	J7179	$1.7475	0.0100	

FACTOR NAME	
MANUFACTURER	FACTOR ASSAY RANGE	
NDC#	
HCPCS CODE	
AHCCCS
2nd Q 18	
Change Q1 18 to Q2 18	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	67467-0182-01	J7183	$0.6987	0.0026	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	67467-0182-02	J7183	$0.6987	0.0026	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	500	68982-0182-01	J7183	$0.6987	0.0026	
WILATE (PER VWF:RCOF UNIT)	OCTAPHARMA	1000	68982-0182-02	J7183	$0.6987	0.0026	
							
XYNTHA	PFIZER/WYETH	250	58394-0012-01	J7185	$0.9507	0.0366	
XYNTHA	PFIZER/WYETH	500	58394-0013-01	J7185	$0.9519	0.0368	
XYNTHA	PFIZER/WYETH	1000	58394-0014-01	J7185	$0.9243	0.0194	
XYNTHA	PFIZER/WYETH	2000	58394-0015-01	J7185	$0.8826	0.0235	
XYNTHA - Solofuse	PFIZER/WYETH	3000	58394-0016-03	J7185	$0.9103	0.0088	
XYNTHA - Solofuse	PFIZER/WYETH	2000	58394-0025-03	J7185	$0.8826	0.0235	
XYNTHA - Solofuse	PFIZER/WYETH	1000	58394-0024-03	J7185	$0.9243	0.0194	
XYNTHA - Solofuse	PFIZER/WYETH	500	58394-0023-03	J7185	$0.9519	0.0368	
XYNTHA - Solofuse	PFIZER/WYETH	250	58394-0022-03	J7185	$0.9507	0.0366	
							
**Notes: (all highlighted)
1. New NDC numbers for Grifols products Alphante, Alphanine SD, and Profilnine SD. To be distributed once current NDC numbers are depleted from inventory
2.