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Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
00193144001 BAYER HEALTHCARE BREEZE 2 METER<br />
00193145001 BAYER HEALTHCARE BREEZE 2 METER<br />
00193146550 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP<br />
00193146621 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP<br />
00193148901 BAYER HEALTHCARE BREEZE 2 SOLUTION<br />
00193149001 BAYER HEALTHCARE BREEZE 2 SOLUTION<br />
00193149101 BAYER HEALTHCARE BREEZE 2 SOLUTION<br />
00193237021 BAYER HEALTHCARE GLUCOFILM TEST STRIPS<br />
00193237150 BAYER HEALTHCARE GLUCOFILM TEST STRIPS<br />
00193237225 BAYER HEALTHCARE GLUCOFILM TEST STRIPS<br />
00193237321 BAYER HEALTHCARE GLUCOSTIX REAGENT STRIPS<br />
00193237525 BAYER HEALTHCARE GLUCOSTIX REAGENT STRIPS<br />
00193288821 BAYER HEALTHCARE DEXTROSTIX REAGENT STRIPS<br />
00193364402 BAYER HEALTHCARE GLUCOMETER DEX CONTROL SOLN<br />
00193364502 BAYER HEALTHCARE GLUCOMETER DEX CONTROL SOLN<br />
00193392602 BAYER HEALTHCARE GLUCOMETER ELITE CNTRL SOLN<br />
00193392702 BAYER HEALTHCARE GLUCOMETER ELITE CNTRL SOLN<br />
00193545002 BAYER HEALTHCARE GLUCOFILM CONTROL - LOW<br />
00193545102 BAYER HEALTHCARE GLUCOFILM CONTROL - NORMAL<br />
00193545202 BAYER HEALTHCARE GLUCOFILM CONTROL - HIGH<br />
00193596531 BAYER HEALTHCARE FINGERSTIX LANCETS<br />
00193597610 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE<br />
00193597901 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE<br />
00193597901 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE<br />
00193618101 BAYER HEALTHCARE DIDGET METER<br />
00193654621 BAYER HEALTHCARE MICROLET LANCETS<br />
00193656801 BAYER HEALTHCARE SINGLE-LET LANCETS<br />
00193658621 BAYER HEALTHCARE MICROLET LANCETS<br />
00193660601 BAYER HEALTHCARE MICROLET 2 LANCING DEVICE<br />
00193660601 BAYER HEALTHCARE MICROLET 2 LANCING DEVICE<br />
00193707025 BAYER HEALTHCARE CONTOUR TEST STRIPS<br />
00193708050 BAYER HEALTHCARE CONTOUR TEST STRIPS<br />
00193709021 BAYER HEALTHCARE CONTOUR TEST STRIPS<br />
00193710901 BAYER HEALTHCARE CONTOUR SOLUTION<br />
00193711001 BAYER HEALTHCARE CONTOUR SOLUTION<br />
00193711101 BAYER HEALTHCARE CONTOUR SOLUTION<br />
00193715101 BAYER HEALTHCARE CONTOUR METER<br />
00193718301 BAYER HEALTHCARE CONTOUR METER<br />
00193718401 BAYER HEALTHCARE CONTOUR METER<br />
00193718901 BAYER HEALTHCARE CONTOUR METER<br />
00193719101 BAYER HEALTHCARE CONTOUR METER<br />
00193739301 BAYER HEALTHCARE CONTOUR USB METER<br />
00536991501 WATSON PHARMA, INC. INSULIN SYRINGE U100 1 ML<br />
00536991601 WATSON PHARMA, INC. INSULIN SYRINGE U100 0.5 ML<br />
00904437525 MAJOR PHARMACEUTICALS E-Z JECT LANCETS<br />
00904437560 MAJOR PHARMACEUTICALS MAJOR COMFORT LANCETS<br />
08080852801 TYCO HEALTHCARE GROUP LP MONOJECT KENDALL DIV. 0.5 ML SYRN 28GX1/2"<br />
08189001666 CAN-AM CARE CORPORATION LANCETS<br />
08189750220 CAN-AM CARE CORPORATION RELION LANCET<br />
08189750510 CAN-AM CARE CORPORATION COMFORT LANCETS<br />
08189850310 CAN-AM CARE CORPORATION RELION THIN LANCET<br />
08189850320 CAN-AM CARE CORPORATION RELION THIN LANCET<br />
Page 1 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08189850920 CAN-AM CARE CORPORATION SUPER THIN LANCETS<br />
08214015720 OWEN MUMFORD US THIN LANCET<br />
08214015721 OWEN MUMFORD US CAREONE THIN LANCET<br />
08214015724 OWEN MUMFORD US AURORA THIN LANCETS<br />
08214018718 OWEN MUMFORD US KN LANCETS<br />
08214020718 OWEN MUMFORD US KN THIN LANCETS<br />
08214020740 OWEN MUMFORD US TODAY'S HLTH ULTRA THIN LANCET<br />
08214025714 OWEN MUMFORD US ULTRA THIN LANCETS<br />
08214025720 OWEN MUMFORD US ULTRA THIN 28 G LANCET<br />
08214025735 OWEN MUMFORD US ULTRA THIN 28G LANCETS<br />
08214025740 OWEN MUMFORD US TODAY'S HLTH ULTRA THIN LANCET<br />
08214026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08214026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08214026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08214026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08214027001 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV<br />
08214027020 OWEN MUMFORD US ADVANCED LANCING DEVICE<br />
08214027020 OWEN MUMFORD US ADVANCED LANCING DEVICE<br />
08214027101 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV<br />
08214030720 OWEN MUMFORD US ULTRA THIN LANCET<br />
08214035720 OWEN MUMFORD US ULTRA THIN LANCET<br />
08214035721 OWEN MUMFORD US CAREONE ULTRA THIN LANCET<br />
08214035726 OWEN MUMFORD US LIVE BETTER ULTRA THIN LANCET<br />
08214035729 OWEN MUMFORD US PUB LANCETS<br />
08214040001 OWEN MUMFORD US UNILET LANCET<br />
08214041401 OWEN MUMFORD US UNILET GP LANCET<br />
08214041801 OWEN MUMFORD US UNILET GP LANCET<br />
08214043514 OWEN MUMFORD US ALTERNATE SITE LANCETS<br />
08214043520 OWEN MUMFORD US ALTERNATE SITE 26 G LANCET<br />
08214044001 OWEN MUMFORD US UNILET LANCET SUPERLITE<br />
08214044501 OWEN MUMFORD US UNILET LANCET SUPERLITE<br />
08214045001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08214045501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08214046001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08214046501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08214046520 OWEN MUMFORD US SUPER THIN 30 G LANCET<br />
08214048715 OWEN MUMFORD US ADVANCED TRAVEL LANCETS 28G<br />
08214051001 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
08214051501 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
08214053001 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
08214053501 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
08214057601 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV<br />
08214060001 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE<br />
08214060001 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE<br />
08214061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
08214061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
08214065711 OWEN MUMFORD US COMFORT LANCETS<br />
08214065714 OWEN MUMFORD US SUPER THIN LANCETS<br />
08214065720 OWEN MUMFORD US SUPER THIN LANCET<br />
08214065724 OWEN MUMFORD US AURORA SUPER THIN LANCET<br />
08214065726 OWEN MUMFORD US LIVE BETTER SUPER THIN LANCET<br />
08214065735 OWEN MUMFORD US SUPER THIN 30G LANCETS<br />
Page 2 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08214065740 OWEN MUMFORD US TODAY'S HLTH SUPER THIN LANCET<br />
08214070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08214070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08214070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08214070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08214070720 OWEN MUMFORD US LANCING DEVICE<br />
08214070721 OWEN MUMFORD US CAREONE LANCING DEVICE<br />
08214070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING<br />
08214070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING<br />
08214070729 OWEN MUMFORD US PUB ADVANCED LANCING DEVICE<br />
08214070729 OWEN MUMFORD US PUB ADVANCED LANCING DEVICE<br />
08214070734 OWEN MUMFORD US LANCING DEVICE<br />
08214070740 OWEN MUMFORD US TODAY'S HEALTH LANCING DEVICE<br />
08214071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214074201 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE<br />
08214074201 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE<br />
08214075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08214076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
08214076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
08214090001 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE<br />
08214092001 OWEN MUMFORD US UNILET GP LANCET<br />
08214092501 OWEN MUMFORD US UNILET GP LANCET<br />
08214100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214104201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214104201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214106201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214106201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08214465714 OWEN MUMFORD US SUPER THIN LANCETS<br />
08214515714 OWEN MUMFORD US DR LANCET<br />
08214535714 OWEN MUMFORD US DR ULTRA THIN LANCET<br />
08214535716 OWEN MUMFORD US PC SUPER THIN 30G LANCETS<br />
08222072016 ULTIMED INC ULTICARE THIN 28G LANCETS<br />
08222072191 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE<br />
08222072191 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE<br />
08222072399 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE<br />
08222072399 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE<br />
08222072597 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE<br />
08222072597 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE<br />
08222073150 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
08222073198 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
08222073198 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
08222073358 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
08222073396 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
08222073396 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
08222073556 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
08222073594 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
08222073594 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
Page 3 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08222074195 ULTIMED INC ULTIGUARD 31GX1 ML SYRINGE<br />
08222074393 ULTIMED INC ULTIGUARD 31GX0.3 ML SYRINGE<br />
08222074591 ULTIMED INC ULTIGUARD 31GX0.5 ML SYRINGE<br />
08222082183 ULTIMED INC ULTICARE INS SYR 1 ML 28GX1/2"<br />
08222082589 ULTIMED INC ULTICARE SYRIN 0.5 ML 28GX1/2"<br />
08222092199 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"<br />
08222092397 ULTIMED INC ULTICARE SYRIN 0.3 ML 29GX1/2"<br />
08222092595 ULTIMED INC ULTICARE U100 0.5 ML 29GX1/2"<br />
08222093158 ULTIMED INC ULTICARE INSULIN SYR U100 1 ML<br />
08222093196 ULTIMED INC ULTCARE INS SYR 1 ML 30GX5/16"<br />
08222093356 ULTIMED INC ULTICARE INSUL SYR U100 0.3 ML<br />
08222093394 ULTIMED INC ULTICARE U100 0.3 ML 30GX5/16"<br />
08222093554 ULTIMED INC ULTICARE INSUL SYR U100 0.5 ML<br />
08222093592 ULTIMED INC ULTICARE SYR 0.5 ML 30GX5/16"<br />
08222094193 ULTIMED INC ULTCARE INS SYR 1 ML 31GX5/16"<br />
08222094391 ULTIMED INC ULTICARE SYR 0.3 ML 31GX5/16"<br />
08222094599 ULTIMED INC ULTICARE SYR 0.5 ML 31GX5/16"<br />
08238049001 AMIRA MEDICAL AT-LAST BLOOD GLUCOSE SYSTM<br />
08238053904 AMIRA MEDICAL AT-LAST LANCETS<br />
08238054702 AMIRA MEDICAL AT-LAST TEST STRIPS<br />
08238115301 AMIRA MEDICAL AT LAST CONTROL SOLUTION<br />
08238117104 AMIRA MEDICAL AT-LAST TEST STRIPS<br />
08271033100 MED.PLASTIC DEV LANCETS THIN<br />
08271035100 MED.PLASTIC DEV LANCETS THIN<br />
08271036100 MED.PLASTIC DEV LANCETS ULTRA THIN<br />
08271036200 MED.PLASTIC DEV LANCETS ULTRA THIN<br />
08271138100 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS<br />
08271138200 MED.PLASTIC DEV MEDLANCE PLUS UNIVERSAL LANCET<br />
08271138400 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS<br />
08271310100 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE<br />
08271310200 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE<br />
08271310300 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE<br />
08271352300 MED.PLASTIC DEV INSUMED SYR 0.3 ML 31GX5/16"<br />
08278110011 MED.PLASTIC DEV GLUCOSOURCE LANCING DEVICE<br />
08278220011 MED.PLASTIC DEV GLUCOSOURCE LANCETS<br />
08287126001 EXEL INT'L INC. EXEL INSUL SYR 0.5 ML 28GX1/2"<br />
08287126002 EXEL INT'L INC. EXEL INSULIN SYRN 27G-1/2 ML<br />
08287126014 EXEL INT'L INC. EXEL U100 0.3 ML 30GX5/16"<br />
08287126015 EXEL INT'L INC. EXEL U100 0.5 ML 30GX5/16"<br />
08287126016 EXEL INT'L INC. EXEL U100 1 ML 30GX5/16"<br />
08287126018 EXEL INT'L INC. EXEL U100 0.3 ML 29GX1/2"<br />
08287126020 EXEL INT'L INC. EXEL INSULIN SYRINGE 27G-1 ML<br />
08287126022 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2<br />
08287126026 EXEL INT'L INC. EXEL U100 0.5 ML 28GX1/2"<br />
08287126027 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2<br />
08287126028 EXEL INT'L INC. EXEL U100 0.5 ML 29GX1/2"<br />
08287126029 EXEL INT'L INC. EXEL U100 INS SYR 1 ML 29GX1/2<br />
08290305934 BD BECTON DICKINSON BD SAFTGLD INS SYR 0.5 ML 30G<br />
08290305935 BD BECTON DICKINSON BD SAFTGLD INS SYR 0.3 ML 29G<br />
08290305937 BD BECTON DICKINSON BD SAFTGLD INS 0.3 ML 31GX5/16<br />
08290309300 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"<br />
08290309301 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 29GX1/2"<br />
Page 4 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08290309305 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"<br />
08290309306 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 29GX1/2"<br />
08290309309 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290309310 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX1/2"<br />
08290309311 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"<br />
08290322057 BD BECTON DICKINSON BD LANCETS 33G<br />
08290322065 BD BECTON DICKINSON BD LANCETS 33G<br />
08290325657 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX5/8"<br />
08290325772 BD BECTON DICKINSON BD LANCETS 30G<br />
08290325773 BD BECTON DICKINSON BD LANCETS 30G<br />
08290325775 BD BECTON DICKINSON BD LANCET DEVICE<br />
08290328278 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"<br />
08290328279 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2"<br />
08290328280 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"<br />
08290328281 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290328282 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"<br />
08290328283 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"<br />
08290328289 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"<br />
08290328290 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16"<br />
08290328291 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"<br />
08290328410 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290328411 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"<br />
08290328412 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX5/8"<br />
08290328418 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"<br />
08290328430 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"<br />
08290328431 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"<br />
08290328438 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"<br />
08290328440 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"<br />
08290328465 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"<br />
08290328466 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2"<br />
08290328468 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16"<br />
08290329411 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"<br />
08290329412 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX5/8"<br />
08290329420 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290329424 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290329430 BD BECTON DICKINSON BD INSULIN U100-3/10 ML SYR<br />
08290329461 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"<br />
08290329464 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"<br />
08290329465 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"<br />
08290329466 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 29GX1/2"<br />
08290329622 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX1"<br />
08290329651 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX5/8"<br />
08290329652 BD BECTON DICKINSON BD INSULIN SYR 1 ML 26GX1/2"<br />
08290366592 BD BECTON DICKINSON BD LANCETS MICROTAINER 30G<br />
08290366593 BD BECTON DICKINSON BD LANCETS MICROTAINER 21G<br />
08290366594 BD BECTON DICKINSON BD LANCETS MICROTAINER<br />
08290593001 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"<br />
08290841002 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"<br />
08290841101 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"<br />
08290841801 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"<br />
08290843002 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"<br />
08290843101 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"<br />
Page 5 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08290843801 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"<br />
08290844001 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"<br />
08290846502 BD BECTON DICKINSON B-D INSULIN U100 SYRINGE<br />
08290846601 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2"<br />
08290846801 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16"<br />
08317015001 ARKRAY USA HAEMOLANCE, RETRACTABLE<br />
08317035050 ARKRAY USA HAEMOLANCE, RETRACTABLE<br />
08317330000 ARKRAY USA QUICKTEK TEST STRIPS<br />
08317330001 ARKRAY USA QUICKTEK METER<br />
08317330501 ARKRAY USA QUICKTEK CONTROL SOLUTION<br />
08317331100 ARKRAY USA QUICKTEK KIT<br />
08317335050 ARKRAY USA QUICKTEK TEST STRIPS<br />
08317410000 ARKRAY USA ADVANCE MICRO-DRAW TEST STRIPS<br />
08317410012 ARKRAY USA HYPOLANCE AST LANCING KIT<br />
08317410012 ARKRAY USA HYPOLANCE AST LANCING KIT<br />
08317410501 ARKRAY USA ADVANCE MICRO-DRAW CONTRL SOLN<br />
08317415050 ARKRAY USA ADVANCE MICRO-DRAW TEST STRIPS<br />
08317420001 ARKRAY USA ADVANCE INTUITION METER<br />
08317420005 ARKRAY USA ADVANCE NORMAL CONTROL SOLN<br />
08317420050 ARKRAY USA ADVANCE TEST STRIPS<br />
08317421100 ARKRAY USA ADVANCE INTUITION METER<br />
08317460001 ARKRAY USA ASSURE PRO METER<br />
08317460006 ARKRAY USA ASSURE PRO CONTROL SOLUTION<br />
08317460006 ARKRAY USA ASSURE PRO CONTROL SOLUTION<br />
08317460050 ARKRAY USA ASSURE PRO TEST STRIPS<br />
08317460100 ARKRAY USA ASSURE PRO TEST STRIPS<br />
08317500001 ARKRAY USA ASSURE PLATINUM GLUCOSE METER<br />
08317500005 ARKRAY USA ASSURE DOSE CONTROL SOLUTION<br />
08317500006 ARKRAY USA ASSURE DOSE CONTROL SOLUTION<br />
08317500006 ARKRAY USA ASSURE DOSE CONTROL SOLUTION<br />
08317500050 ARKRAY USA ASSURE PLATINUM TEST STRIPS<br />
08317500100 ARKRAY USA ASSURE PLATINUM TEST STRIPS<br />
08317550602 ARKRAY USA ASSURE 3 CONTROL SOLUTION<br />
08317550602 ARKRAY USA ASSURE 3 CONTROL SOLUTION<br />
08317551000 ARKRAY USA ASSURE 3 TEST STRIPS<br />
08317555050 ARKRAY USA ASSURE 3 TEST STRIPS<br />
08317560001 ARKRAY USA ASSURE 4 BLOOD GLUCOSE METER<br />
08317560006 ARKRAY USA ASSURE 4 CONTROL SOLUTION<br />
08317560050 ARKRAY USA ASSURE 4 TEST STRIPS<br />
08317560100 ARKRAY USA ASSURE 4 TEST STRIPS<br />
08317630005 ARKRAY USA POCKETCHEM EZ CONTROL SOLUTION<br />
08317630050 ARKRAY USA POCKETCHEM EZ TEST STRIPS<br />
08317631101 ARKRAY USA POCKETCHEM EZ METER KIT<br />
08317660001 ARKRAY USA SELECT-LITE LANCING DEVICE<br />
08317660015 ARKRAY USA MULTI-LANCET DEVICE<br />
08317710001 ARKRAY USA RELION MICRO SYSTEM<br />
08317710050 ARKRAY USA RELION MICRO TEST STRIPS<br />
08317712002 ARKRAY USA RELION CONFIRM SYSTEM KIT<br />
08317712003 ARKRAY USA RELION CONFIRM SYSTEM KIT<br />
08317712020 ARKRAY USA RELION CONFIRM-MICRO TEST STRP<br />
08317712100 ARKRAY USA RELION CONFIRM-MICRO TEST STRP<br />
08317720001 ARKRAY USA GLUCOCARD 01 BLOOD GLUCOSE MTR<br />
Page 6 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08317720005 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION<br />
08317720050 ARKRAY USA GLUCOCARD 01 SENSOR TEST STRIP<br />
08317721100 ARKRAY USA GLUCOCARD 01 METER KIT<br />
08317731100 ARKRAY USA GLUCOCARD 01-MINI METER KIT<br />
08317740006 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION<br />
08317740006 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION<br />
08317740050 ARKRAY USA GLUCOCARD 01 SENSOR TEST STRIP<br />
08317741100 ARKRAY USA GLUCOCARD 01 METER KIT<br />
08317750005 ARKRAY USA GLUCOCARD X-METER CONTROL SOLN<br />
08317750050 ARKRAY USA GLUCOCARD X-SENSOR TEST STRIPS<br />
08317751100 ARKRAY USA GLUCOCARD X-METER SYSTEM KIT<br />
08317752050 ARKRAY USA GLUCOCARD X-SENSOR TEST STRIPS<br />
08317760050 ARKRAY USA GLUCOCARD VITAL SENSOR STRIP<br />
08317761101 ARKRAY USA GLUCOCARD VITAL METER KIT<br />
08317761102 ARKRAY USA GLUCOCARD VITAL METER KIT<br />
08317761103 ARKRAY USA GLUCOCARD VITAL METER KIT<br />
08317762050 ARKRAY USA GLUCOCARD VITAL SENSOR STRIP<br />
08317880125 ARKRAY USA TECHLITE BLOOD LANCET<br />
08317880128 ARKRAY USA TECHLITE BLOOD LANCET<br />
08317880225 ARKRAY USA TECHLITE BLOOD LANCET<br />
08317880228 ARKRAY USA TECHLITE BLOOD LANCET<br />
08317880300 ARKRAY USA TECHLITE AST LANCETS<br />
08317950000 ARKRAY USA HAEMOLANCE LANCET<br />
08317955000 ARKRAY USA HAEMOLANCE LANCET<br />
08317980125 ARKRAY USA ASSURE LANCE LANCET<br />
08317980128 ARKRAY USA ASSURE LANCE MICRO FLOW LANCET<br />
08317980225 ARKRAY USA ASSURE LANCE LANCET<br />
08317980228 ARKRAY USA ASSURE LANCE MICRO FLOW LANCET<br />
08317990200 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990250 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990400 ARKRAY USA HAEMOLANCE PLUS LANCET<br />
08317990600 ARKRAY USA HAEMOLANCE PLUS LANCET<br />
08317990700 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990750 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990800 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990900 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08317990950 ARKRAY USA HAEMOLANCE PLUS LANCETS<br />
08321000123 PRODIGY DIABETE LANCETS<br />
08321000170 PRODIGY DIABETE SAFETY LANCETS<br />
08321081028 PRODIGY DIABETE LANCETS<br />
08321081030 PRODIGY DIABETE LANCETS 30G<br />
08321081038 PRODIGY DIABETE LANCETS 28G<br />
08321081128 PRODIGY DIABETE LANCETS<br />
08321083225 PRODIGY DIABETE LANCING DEVICE<br />
08321240110 PRODIGY DIABETE LANCETS<br />
08321240128 PRODIGY DIABETE LANCETS 28G<br />
08321240130 PRODIGY DIABETE SAFETY LANCETS<br />
08321240160 PRODIGY DIABETE SAFETY LANCETS<br />
08321240228 PRODIGY DIABETE LANCETS 28G<br />
08326200001 BOCA MEDICAL SAFETY LANCET 2MM<br />
08326261001 BOCA MEDICAL ULTILET CLASSIC 26G LANCETS<br />
08326280001 BOCA MEDICAL ULTILET LANCETS<br />
Page 7 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08326280002 BOCA MEDICAL ULTILET LANCETS<br />
08326281001 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS<br />
08326281002 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS<br />
08326281101 BOCA MEDICAL PUBLIX 28G LANCET<br />
08326281102 BOCA MEDICAL PUBLIX 28G LANCET<br />
08326284001 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS<br />
08326284101 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS<br />
08326290110 BOCA MEDICAL INSULIN SYRINGE 1 ML<br />
08326290130 BOCA MEDICAL INSULIN SYRINGE 0.3 ML<br />
08326290150 BOCA MEDICAL INSULIN SYRINGE 0.5 ML<br />
08326290310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML<br />
08326290330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML<br />
08326290350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML<br />
08326300001 BOCA MEDICAL ULTILET 30G LANCETS<br />
08326300110 BOCA MEDICAL INSULIN SYRINGE 1 ML<br />
08326300130 BOCA MEDICAL INSULIN SYRINGE 0.3 ML<br />
08326300150 BOCA MEDICAL INSULIN SYRINGE 0.5 ML<br />
08326300210 BOCA MEDICAL INSULIN SYRINGE 1 ML<br />
08326300230 BOCA MEDICAL INSULIN SYRINGE 0.3 ML<br />
08326300310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML<br />
08326300330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML<br />
08326300350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML<br />
08326301001 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS<br />
08326302001 BOCA MEDICAL ULTILET BASIC 30G LANCETS<br />
08326304001 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS<br />
08326304101 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS<br />
08326310310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML<br />
08326310330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML<br />
08326310350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML<br />
08326412801 BOCA MEDICAL ULTILET 28G LANCETS<br />
08327048609 MEDLINE INDUS. EVENCARE MONITORING SYSTEM<br />
08327048629 MEDLINE INDUS. EVENCARE GLUCOSE TST STRIPS<br />
08327048692 MEDLINE INDUS. EVENCARE CONTROL SOLUTION<br />
08327048692 MEDLINE INDUS. EVENCARE CONTROL SOLUTION<br />
08327052029 MEDLINE INDUS. EVENCARE TEST STRIPS<br />
08367010102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC<br />
08367010202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 1CC<br />
08367011102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 1CC<br />
08367011202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC<br />
08367012202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC<br />
08367013202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC<br />
08367033202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.3CC<br />
08367050102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.5CC<br />
08367050202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 0.5CC<br />
08367051102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1/2CC<br />
08367051202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.5CC<br />
08367052202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 0.5CC<br />
08367053202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INS SYR 0.5CC<br />
08396705014 CAN-AM CARE RA HEALTH CARE LANCING DEVICE<br />
08396705014 CAN-AM CARE RA HEALTH CARE LANCING DEVICE<br />
08396800100 CAN-AM CARE ULTRA COMFORT 0.5 ML 28GX1/2"<br />
08396800200 CAN-AM CARE ULTRA COMFORT 1 ML 28GX1/2"<br />
Page 8 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08396800300 CAN-AM CARE ULTRA COMFORT 0.3 ML 29GX1/2"<br />
08396800400 CAN-AM CARE ULTRA COMFORT 0.5 ML 29GX1/2"<br />
08396800500 CAN-AM CARE ULTRA COMFORT 1 ML 29GX1/2"<br />
08396800600 CAN-AM CARE ULTRA COMFORT 0.3 ML 30GX5/16"<br />
08396800700 CAN-AM CARE ULTRA COMFORT 0.5 ML 30GX5/16"<br />
08396800800 CAN-AM CARE ULTRA COMFORT 1 ML 30GX5/16"<br />
08396800900 CAN-AM CARE ULTRA COMFORT 0.3 ML 31GX5/16"<br />
08396801000 CAN-AM CARE ULTRA COMFORT 0.5 ML 31GX5/16"<br />
08396801100 CAN-AM CARE ULTRA COMFORT 1 ML 31GX5/16"<br />
08396900400 CAN-AM CARE CLICKFINE UNIVERSAL 31G X 1/4"<br />
08396900500 CAN-AM CARE CLICKFINE UNIVERSAL 31GX5/16"<br />
08463000301 US DIAGNOSTICS EASYGLUCO MONITORING SYSTEM<br />
08463010301 US DIAGNOSTICS EASYGLUCO METER<br />
08463020350 US DIAGNOSTICS EASYGLUCO TEST STRIPS<br />
08463020401 US DIAGNOSTICS EASYGLUCO TEST STRIPS<br />
08463120350 US DIAGNOSTICS EASY GLUCO G2 TEST STRIP<br />
08463120401 US DIAGNOSTICS EASY GLUCO G2 TEST STRIP<br />
08463220350 US DIAGNOSTICS CONTROL G3 TEST STRIP<br />
08463220401 US DIAGNOSTICS CONTROL G3 TEST STRIP<br />
08463310301 US DIAGNOSTICS CONTROL MONITORING SYSTEM<br />
08463320350 US DIAGNOSTICS CONTROL TEST STRIPS<br />
08463320401 US DIAGNOSTICS CONTROL TEST STRIPS<br />
08463382001 US DIAGNOSTICS LANCING DEVICE<br />
08463400300 US DIAGNOSTICS G-4 MONITORING STARTER KIT<br />
08463400301 US DIAGNOSTICS G-4 MONITORING SYSTEM<br />
08463400501 US DIAGNOSTICS MAXIMA CONTROL SOLUTION<br />
08463410300 US DIAGNOSTICS G-4 BLOOD GLUCOSE METER<br />
08463410301 US DIAGNOSTICS G-4 BLOOD GLUCOSE METER<br />
08463410501 US DIAGNOSTICS MAXIMA CONTROL SOLUTION<br />
08463420300 US DIAGNOSTICS G-4 TEST STRIPS<br />
08463420301 US DIAGNOSTICS MAXIMA CONTROL SOLUTION<br />
08463420350 US DIAGNOSTICS MAXIMA TEST STRIP<br />
08463430301 US DIAGNOSTICS MAXIMA CONTROL SOLUTION<br />
08463500301 US DIAGNOSTICS INFINITY STARTER KIT<br />
08463500401 US DIAGNOSTICS INFINITY STARTER KIT<br />
08463500501 US DIAGNOSTICS INFINITY CONTROL SOLN NORMAL<br />
08463510301 US DIAGNOSTICS INFINITY METER KIT<br />
08463510501 US DIAGNOSTICS INFINITY CONTROL SOLN HIGH<br />
08463520350 US DIAGNOSTICS INFINITY TEST STRIPS<br />
08463520501 US DIAGNOSTICS INFINITY CONTROL SOLN LOW<br />
08463600301 US DIAGNOSTICS ACURA STARTER KIT<br />
08463600501 US DIAGNOSTICS ACURA CONTROL SOLUTION NORMAL<br />
08463610301 US DIAGNOSTICS ACURA METER KIT<br />
08463610501 US DIAGNOSTICS ACURA CONTROL SOLUTION HIGH<br />
08463620350 US DIAGNOSTICS ACURA TEST STRIPS<br />
08463620501 US DIAGNOSTICS ACURA CONTROL SOLUTION LOW<br />
08463700301 US DIAGNOSTICS ACURA PLUS STARTER KIT<br />
08463701228 US DIAGNOSTICS LANCETS 28G<br />
08463702930 US DIAGNOSTICS LANCETS 30G<br />
08463710300 US DIAGNOSTICS ACURA PLUS METER KIT<br />
08463710301 US DIAGNOSTICS ACURA PLUS METER KIT<br />
08463720350 US DIAGNOSTICS G-4 TEST STRIPS<br />
Page 9 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08463803028 US DIAGNOSTICS SAFETY LANCETS<br />
08463820350 US DIAGNOSTICS INFINITY TEST STRIPS<br />
08470026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08470026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08470026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08470026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
08470027001 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470027001 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470027101 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470027101 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470027401 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470027401 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE<br />
08470040001 OWEN MUMFORD US UNILET LANCET<br />
08470041401 OWEN MUMFORD US UNILET GP LANCET<br />
08470041801 OWEN MUMFORD US UNILET GP LANCET<br />
08470043001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08470043501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08470044001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08470044501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08470045001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08470045501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
08470046001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08470046501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
08470051001 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
08470051501 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
08470053001 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
08470053501 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
08470057601 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV<br />
08470060001 OWEN MUMFORD US UNISTIK 2.4MM DEVICES<br />
08470060001 OWEN MUMFORD US UNISTIK 2.4MM DEVICES<br />
08470061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
08470061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
08470070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470070401 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470070401 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
08470071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470071401 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470071401 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470074001 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC<br />
08470074001 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC<br />
08470074201 OWEN MUMFORD US UNISTIK 2 1.8 MM LANCING DEVIC<br />
08470074201 OWEN MUMFORD US UNISTIK 2 1.8 MM LANCING DEVIC<br />
08470074701 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC<br />
08470074701 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC<br />
08470075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
08470075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
Page 10 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08470076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
08470076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
08470090001 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE<br />
08470092001 OWEN MUMFORD US UNILET GP LANCET<br />
08470092501 OWEN MUMFORD US UNILET GP LANCET<br />
08470100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08470100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08470100401 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08470100401 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
08470100701 OWEN MUMFORD US UNISTIK 3 NORMAL LANCET<br />
08470100801 OWEN MUMFORD US UNISTIK CZT NORMAL LANCET<br />
08470101201 OWEN MUMFORD US UNISTIK 3 EXTRA LANCET<br />
08470101401 OWEN MUMFORD US UNISTIK 3 EXTRA LANCET<br />
08470101801 OWEN MUMFORD US UNISTIK 3 SAFETY LANCET 21G<br />
08470104201 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC<br />
08470104201 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC<br />
08470104401 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC<br />
08470104401 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC<br />
08470104701 OWEN MUMFORD US UNISTIK 3 COMFORT LANCET<br />
08470104801 OWEN MUMFORD US UNISTIK CZT COMFORT LANCET<br />
08470106201 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV<br />
08470106201 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV<br />
08470106401 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV<br />
08470106401 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV<br />
08474010278 ULTIMED INC ULTRACOMFORT 29GX0.5 ML SYR<br />
08474010278 ULTIMED INC ULTRACOMFORT 29GX0.5 ML SYR<br />
08474010378 ULTIMED INC ULTRACOMFORT 29GX1 ML SYRINGE<br />
08474010378 ULTIMED INC ULTRACOMFORT 29GX1 ML SYRINGE<br />
08474010478 ULTIMED INC ULTRACOMFORT 30GX0.5 ML SYR<br />
08474010478 ULTIMED INC ULTRACOMFORT 30GX0.5 ML SYR<br />
08474010578 ULTIMED INC ULTRACOMFORT 30GX1 ML SYRINGE<br />
08474010578 ULTIMED INC ULTRACOMFORT 30GX1 ML SYRINGE<br />
08474010678 ULTIMED INC ULTRACOMFORT 31GX0.5 ML SYR<br />
08474010678 ULTIMED INC ULTRACOMFORT 31GX0.5 ML SYR<br />
08474010778 ULTIMED INC ULTRACOMFORT 31GX1 ML SYRINGE<br />
08474010778 ULTIMED INC ULTRACOMFORT 31GX1 ML SYRINGE<br />
08474010878 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML<br />
08474010978 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML<br />
08474011078 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML<br />
08474011178 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML<br />
08474011278 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML<br />
08474011378 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML<br />
08474592590 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML<br />
08474593191 ULTIMED INC ORSINI INSUL SYR U100 1 ML<br />
08474593597 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML<br />
08474721901 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"<br />
08474721901 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"<br />
08474723901 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"<br />
08474723901 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"<br />
08474725901 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"<br />
08474725901 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"<br />
08474731901 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"<br />
Page 11 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08474731901 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"<br />
08474733901 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"<br />
08474733901 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"<br />
08474735901 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"<br />
08474735901 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"<br />
08474925900 ULTIMED INC SCHNUCKS SYR 0.5 ML 29GX1/2"<br />
08474935900 ULTIMED INC SCHNUCKS SYR 0.5 ML 30GX5/16"<br />
08480492050 HYPOGUARD EASY PRO PLUS TEST STRIPS<br />
08480492101 HYPOGUARD EASY PRO PLUS SYSTEM KIT<br />
08484050300 DIAGNOSTIC DEVI<br />
PRODIGY POCKET GLUCOSE METER<br />
08484050301 DIAGNOSTIC DEVI<br />
PRODIGY POCKET GLUCOSE METER<br />
08484050302 DIAGNOSTIC DEVI<br />
PRODIGY POCKET GLUCOSE METER<br />
08484050303 DIAGNOSTIC DEVI<br />
PRODIGY POCKET GLUCOSE METER<br />
08484050304 DIAGNOSTIC DEVI<br />
PRODIGY POCKET GLUCOSE METER<br />
08484050360 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484050361 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484050362 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484050363 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484050364 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484051880 DIAGNOSTIC DEVI<br />
PRODIGY AUTOCODE METER KIT<br />
08484051885 DIAGNOSTIC DEVI<br />
PRODIGY AUTOCODE METER KIT<br />
08484051890 DIAGNOSTIC DEVI<br />
PRODIGY AUTOCODE METER KIT<br />
08484052300 DIAGNOSTIC DEVI<br />
PRODIGY GLUCOSE TEST STRIP<br />
08484052400 DIAGNOSTIC DEVI<br />
PRODIGY GLUCOSE TEST STRIP<br />
08484052800 DIAGNOSTIC DEVI<br />
PRODIGY NO CODING TEST STRIPS<br />
08484052835 DIAGNOSTIC DEVI<br />
PRODIGY GLUCOSE TEST STRIP<br />
08484052870 DIAGNOSTIC DEVI<br />
PRODIGY AUTOCODE TEST STRIPS<br />
08484052970 DIAGNOSTIC DEVI<br />
PRODIGY VOICE GLU TEST STRIP<br />
08484053310 DIAGNOSTIC DEVI<br />
PRODIGY CONTROL SOLUTION LOW<br />
08484053350 DIAGNOSTIC DEVI<br />
PRODIGY CONTROL SOLUTION<br />
08484056100 DIAGNOSTIC DEVI<br />
PRODIGY PREFERRED METER<br />
08484056150 DIAGNOSTIC DEVI<br />
PRODIGY PREFERRED METER KIT<br />
08484070120 DIAGNOSTIC DEVI<br />
PRODIGY AUTOCODE METER KIT<br />
08484070800 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484070801 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484070802 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484070803 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484070804 DIAGNOSTIC DEVI<br />
PRODIGY POCKET METER KIT<br />
08484072500 DIAGNOSTIC DEVI<br />
PRODIGY NO CODING TEST STRIPS<br />
08484081028 DIAGNOSTIC DEVI<br />
PRODIGY TWIST TOP 28G LANCET<br />
08484082026 DIAGNOSTIC DEVI<br />
PRODIGY SAFETY LANCETS<br />
08484082316 DIAGNOSTIC DEVI<br />
PRODIGY PRESSURE ACTIVE LANCET<br />
08484082321 DIAGNOSTIC DEVI<br />
PRODIGY PRESSURE ACTIVE LANCET<br />
08484082341 DIAGNOSTIC DEVI<br />
PRODIGY PRESSURE ACTIVE LANCET<br />
08484083225 DIAGNOSTIC DEVI<br />
PRODIGY LANCING DEVICE<br />
08484990250 DIAGNOSTIC DEVI<br />
PRODIGY NO CODING TEST STRIPS<br />
08484990310 DIAGNOSTIC DEVI<br />
PRODIGY CONTROL SOLUTION LOW<br />
08484990328 DIAGNOSTIC DEVI<br />
PRODIGY TWIST TOP 28G LANCET<br />
08484990338 DIAGNOSTIC DEVI<br />
PRODIGY PRESSURE ACTIVE LANCET<br />
08484990355 DIAGNOSTIC DEVI<br />
PRODIGY LANCING DEVICE<br />
08484990430 DIAGNOSTIC DEVI<br />
PRODIGY INS SYR 1ML 28GX1/2"<br />
08484990432 DIAGNOSTIC DEVI<br />
PRODIGY INS SYR 1ML 28GX1/2"<br />
Page 12 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08484990435 DIAGNOSTIC DEVI<br />
PRODIGY SYRNG 0.5 ML 31GX5/16"<br />
08484990437 DIAGNOSTIC DEVI<br />
PRODIGY SYRNG 0.5 ML 31GX5/16"<br />
08484990438 DIAGNOSTIC DEVI<br />
PRODIGY SYRNGE 0.3ML 31GX5/16"<br />
08484990480 DIAGNOSTIC DEVI<br />
PRODIGY SYRNG 1 ML 29GX1/2"<br />
08489715510 INPHARMA INC. ACTI-LANCE LITE 28G LANCETS<br />
08489715610 INPHARMA INC. ACTI-LANCE 23G LANCETS<br />
08489715710 INPHARMA INC. ACTI-LANCE SPECIAL 17G LANCETS<br />
08489716130 INPHARMA INC. DROPLET 30G LANCETS<br />
08496281501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496281511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496285501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496285511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496291501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496291511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496295501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496295511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496301601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496301611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496303601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML<br />
08496303611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML<br />
08496305601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496305611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496311601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496311611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496313601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML<br />
08496313611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML<br />
08496315601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496315611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML<br />
08496791501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08496801501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML<br />
08517015722 OWEN MUMFORD US 1ST CHOICE THIN LANCETS<br />
08517025736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET<br />
08517030722 OWEN MUMFORD US 1ST CHOICE ULTRA THIN LANCETS<br />
08517035722 OWEN MUMFORD US 1ST CHOICE ULTRA THIN LANCETS<br />
08517065722 OWEN MUMFORD US 1ST CHOICE SUPER THIN LANCETS<br />
08517065736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET<br />
08521000131 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 1 ML<br />
08521000231 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 0.5 ML<br />
08521000331 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 0.3 ML<br />
08521080001 FIFTY50 PHARMAC<br />
FIFTY50 LANCING DEVICE<br />
08521081030 FIFTY50 PHARMAC<br />
FIFTY50 SAFETY SEAL LANCETS<br />
08521081032 FIFTY50 PHARMAC<br />
FIFTY50 SAFETY SEAL LANCETS<br />
08522000001 HMD MEDICAL, LL<br />
ECLIPSE BLOOD GLUCOSE MONITOR<br />
08522000002 HMD MEDICAL, LL<br />
ECLIPSE TEST STRIPS<br />
08522000003 HMD MEDICAL, LL<br />
ECLIPSE CONTROL SOLN NORMAL<br />
08522000004 HMD MEDICAL, LL<br />
ECLIPSE CONTROL SOLUTION LOW<br />
08522000005 HMD MEDICAL, LL<br />
ECLIPSE CONTROL SOLUTION HIGH<br />
08522000010 HMD MEDICAL, LL<br />
ENVISION MONITORING SYSTEM<br />
08522000011 HMD MEDICAL, LL<br />
ENVISION TEST STRIPS<br />
08522000012 HMD MEDICAL, LL<br />
ENVISION CONTROL SOLN NORMAL<br />
08522000013 HMD MEDICAL, LL<br />
ENVISION CONTROL SOLN HIGH<br />
08522000014 HMD MEDICAL, LL<br />
ENVISION CONTROL SOLN LOW<br />
Page 13 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08522000016 HMD MEDICAL, LL<br />
EVOLUTION BLOOD GLUCOSE METER<br />
08522000017 HMD MEDICAL, LL<br />
EVOLUTION TEST STRIPS<br />
08522000018 HMD MEDICAL, LL<br />
EVOLUTION CONTROL SOLN NORMAL<br />
08522000022 HMD MEDICAL, LL<br />
ELEMENT BLOOD GLUCOSE METER KT<br />
08522000023 HMD MEDICAL, LL<br />
ELEMENT TEST STRIPS<br />
08522000024 HMD MEDICAL, LL<br />
ELEMENT CONTROL SOLN NORMAL<br />
08522000025 HMD MEDICAL, LL<br />
ELEMENT CONTROL SOLUTION LOW<br />
08522000026 HMD MEDICAL, LL<br />
ELEMENT CONTROL SOLUTION HIGH<br />
08522000043 HMD MEDICAL, LL<br />
SMARTDIABETES XPRES TEST STRIP<br />
08522000046 HMD MEDICAL, LL<br />
SMARTDIABETES XPRES GLUC SYST<br />
08522000050 HMD MEDICAL, LL<br />
VANTAGE LANCING DEVICE<br />
08522000052 HMD MEDICAL, LL<br />
SMARTDIABETES VANTAGE LANCETS<br />
08522031908 HMD MEDICAL, LL GLUCOLAB CONTROL SOLUTION HIGH<br />
08522031912 HMD MEDICAL, LL GLUCOLAB CONTROL SOLUTION LOW<br />
08522031914 HMD MEDICAL, LL GLUCOLAB CONTROL SOLN NORMAL<br />
08522131100 HMD MEDICAL, LL GLUCOLAB METER KIT<br />
08522201950 HMD MEDICAL, LL GLUCOLAB TEST STRIPS<br />
08524000103 PROGRESSIVE HEA<br />
SMARTEST TEST STRIPS<br />
08524000201 PROGRESSIVE HEA<br />
SMARTEST CONTROL SOLUTION<br />
08524000403 PROGRESSIVE HEA<br />
SMARTEST LANCET<br />
08524001201 PROGRESSIVE HEA<br />
SMARTEST EJECT METER<br />
08524001301 PROGRESSIVE HEA<br />
SMARTEST PROTEGE METER<br />
08524001401 PROGRESSIVE HEA<br />
SMARTEST SMART CODE METER<br />
08524001702 PROGRESSIVE HEA<br />
SMARTEST PRONTO GLUCOSE METER<br />
08524001802 PROGRESSIVE HEA<br />
SMARTEST PERSONA GLUCOSE METER<br />
08524002201 PROGRESSIVE HEA<br />
SMARTEST EJECT METER<br />
08524002301 PROGRESSIVE HEA<br />
SMARTEST PROTEGE METER<br />
08524002401 PROGRESSIVE HEA<br />
SMARTEST SMART CODE METER<br />
08524002702 PROGRESSIVE HEA<br />
SMARTEST PRONTO STARTER KIT<br />
08524002802 PROGRESSIVE HEA<br />
SMARTEST PERSONA STARTER KIT<br />
08525010001 CARDIOCOM MULTI<br />
GLUCOCOM BLOOD GLUCOSE KIT<br />
08525010150 CARDIOCOM MULTI<br />
GLUCOCOM GLUCOSE TEST STRIP<br />
08525010300 CARDIOCOM MULTI<br />
GLUCOCOM LANCETS 28G<br />
08525010601 CARDIOCOM MULTI<br />
GLUCOCOM BLOOD GLUCOSE METER<br />
08525011001 CARDIOCOM MULTI<br />
GLUCOCOM CONTROL SOLUTION<br />
08525011101 CARDIOCOM MULTI<br />
GLUCOCOM CONTROL SOLUTION<br />
08525011200 CARDIOCOM MULTI<br />
GLUCOCOM LANCETS 30G<br />
08525011300 CARDIOCOM MULTI<br />
GLUCOCOM LANCETS 33G<br />
08525011501 CARDIOCOM MULTI<br />
GLUCOCOM VALUE KIT<br />
08539000101 INVICTUS SCIENT RIGHTEST GM300 SYSTEM KIT<br />
08539000501 INVICTUS SCIENT RIGHTEST GS300 TEST STRIPS<br />
08539001201 INVICTUS SCIENT RIGHTEST CONTROL SOLUTION HIGH<br />
08539001301 INVICTUS SCIENT RIGHTEST CONTROL SOLN NORMAL<br />
08539002001 INVICTUS SCIENT RIGHTEST GD500 LANCING DEVICE<br />
08539010001 INVICTUS SCIENT RIGHTEST GM100 SYSTEM KIT<br />
08539055003 INVICTUS SCIENT RIGHTEST GM550 SYSTEM KIT<br />
08539060000 INVICTUS SCIENT RIGHTEST GL300 LANCETS<br />
08539105002 INVICTUS SCIENT RIGHTEST GS100 TEST STRIPS<br />
08539505003 INVICTUS SCIENT RIGHTEST GS550 TEST STRIPS<br />
08548043416 NOVA BIOMEDICAL<br />
NOVA MAX GLUCOSE TEST STRIP<br />
08548043421 NOVA BIOMEDICAL<br />
NOVA SUREFLEX LANCETS<br />
08548043423 NOVA BIOMEDICAL<br />
NOVA MAX GLUCOSE TEST STRIP<br />
Page 14 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08548043433 NOVA BIOMEDICAL<br />
NOVA SUREFLEX LANCING DEVICE<br />
08548043435 NOVA BIOMEDICAL<br />
NOVA MAX BLOOD GLUCOSE METER<br />
08548043436 NOVA BIOMEDICAL<br />
NOVA MAX BLOOD GLUCOSE METER<br />
08548043437 NOVA BIOMEDICAL<br />
NOVA MAX GLUCOSE TEST STRIP<br />
08548043446 NOVA BIOMEDICAL<br />
NOVA MAX GLUCOSE CONTROL SOLN<br />
08548043447 NOVA BIOMEDICAL<br />
NOVA SUREFLEX LANCING DEVICE<br />
08548043447 NOVA BIOMEDICAL<br />
NOVA SUREFLEX LANCING DEVICE<br />
08548043523 NOVA BIOMEDICAL<br />
NOVA MAX GLUCOSE TEST STRIP<br />
08548045824 NOVA BIOMEDICAL<br />
NOVA MAX BLOOD GLUCOSE METER<br />
08548048738 NOVA BIOMEDICAL<br />
NOVA SUREFLEX THIN LANCETS<br />
08554131701 AGAMATRIX, INC. KEYNOTE BLOOD GLUCOSE SYSTEM<br />
08554132801 AGAMATRIX, INC. KEYNOTE GLUCOSE TEST STRIPS<br />
08554133301 AGAMATRIX, INC. WAVESENSE CONTROL SOLN NORMAL<br />
08554197101 AGAMATRIX, INC. WAVESENSE ULTRA THIN LANCETS<br />
08554226502 AGAMATRIX, INC. KEYNOTE GLUCOSE TEST STRIPS<br />
08554229701 AGAMATRIX, INC. WAVESENSE JAZZ SYSTEM KIT<br />
08554232001 AGAMATRIX, INC. WAVESENSE JAZZ TEST STRIPS<br />
08554264901 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT<br />
08554318802 AGAMATRIX, INC. WAVESENSE JAZZ TEST STRIPS<br />
08554332901 AGAMATRIX, INC. WAVESENSE PRESTO TEST STRIPS<br />
08554333702 AGAMATRIX, INC. WAVESENSE PRESTO TEST STRIPS<br />
08554338401 AGAMATRIX, INC. KEYNOTE PRO BLOOD GLUCOSE SYST<br />
08554362901 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT<br />
08554386401 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT<br />
08554402401 AGAMATRIX, INC. WAVESENSE AMP SYSTEM KIT<br />
08554403601 AGAMATRIX, INC. WAVESENSE AMP TEST STRIPS<br />
08554408801 AGAMATRIX, INC. PRESTO PRO BLOOD GLUCOSE METER<br />
08554424001 AGAMATRIX, INC. BLOOD GLUCOSE TEST STRIPS<br />
08554442601 AGAMATRIX, INC. LIBERTY TEST STRIPS<br />
08554444201 AGAMATRIX, INC. LIBERTY BLOOD GLUCOSE METER<br />
08554453801 AGAMATRIX, INC. LIBERTY CONTROL SOLN NORMAL<br />
08554454601 AGAMATRIX, INC. LIBERTY CONTROL SOLUTION HIGH<br />
08565015915 STERILANCE MEDI TWIST LANCETS<br />
08565016915 STERILANCE MEDI TWIST LANCETS<br />
08565017915 STERILANCE MEDI TWIST LANCETS<br />
08565044415 STERILANCE MEDI LANCETS 26G X 1.8MM<br />
08565045415 STERILANCE MEDI LANCETS 28G X 1.8MM<br />
08565054015 STERILANCE MEDI LANCETS 26G<br />
08565134415 STERILANCE MEDI LANCETS 26G X 1.8MM<br />
08565135415 STERILANCE MEDI LANCETS 28G X 1.8MM<br />
08580301001 BIO-MED USA INC INSULIN SYRINGE 1 ML 30GX1/2"<br />
08580311101 BIO-MED USA INC INSULIN SYRINGE 1 ML 30GX5/16"<br />
08580500201 BIO-MED USA INC INSULIN SYRIN 0.5 ML 30GX5/16"<br />
08580500501 BIO-MED USA INC INSULIN SYRIN 0.5 ML 30GX1/2"<br />
08593211002 VERTEX DIATNOST ULTRATRAK TEST STRIP<br />
08593211102 VERTEX DIATNOST ULTRATRAK PRO GLUCOSE MTR SYS<br />
08593211202 VERTEX DIATNOST ULTRATRAK CONTROL SOL NORMAL<br />
08593211302 VERTEX DIATNOST ULTRATRAK CONTROL SOLUTION<br />
08593211302 VERTEX DIATNOST ULTRATRAK CONTROL SOLUTION<br />
08593211402 VERTEX DIATNOST ULTRALANCE LANCETS 26G<br />
08593211502 VERTEX DIATNOST ULTRALANCE LANCETS 28G<br />
08593211602 VERTEX DIATNOST ULTRATRAK BLOOD GLUCOSE METER<br />
Page 15 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08593211702 VERTEX DIATNOST ULTRATRAK PRO METER KIT<br />
08593211802 VERTEX DIATNOST ULTRATRAK ULTIMATE GLUCOSE MTR<br />
08593212002 VERTEX DIATNOST ULTRATRAK ULTIMATE TEST STRIPS<br />
08593212102 VERTEX DIATNOST ULTRATRAK ULTIMATE CNTRL SOLN<br />
08593212102 VERTEX DIATNOST ULTRATRAK ULTIMATE CNTRL SOLN<br />
08595013001 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML<br />
08595013010 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML<br />
08595022901 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
08595022910 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
08595023001 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
08595023010 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
08595032801 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
08595032810 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
08595032901 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
08595032910 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
08611501001 BIOSENSE MEDICA SOLO V2 METER SYSTEM KIT<br />
08611503050 BIOSENSE MEDICA SOLO V2 TEST STRIPS<br />
08611504000 BIOSENSE MEDICA SOLO V2 30G LANCETS<br />
08611505001 BIOSENSE MEDICA SOLO V2 LANCING DEVICE<br />
08611505001 BIOSENSE MEDICA SOLO V2 LANCING DEVICE<br />
08611506001 BIOSENSE MEDICA SOLO V2 CONTROL SOLUTION HIGH<br />
08611506101 BIOSENSE MEDICA SOLO V2 CONTROL SOLUTION LOW<br />
08617155104 I-SENS, INC. CARESENS N TEST STRIPS<br />
08617155264 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
08617164104 I-SENS, INC. CARESENS N TEST STRIPS<br />
08617164265 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
08617164301 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
08617187104 I-SENS, INC. CARESENS N TEST STRIPS<br />
08617187301 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
08617192104 I-SENS, INC. SMART CARESENS N TEST STRIPS<br />
08617192303 I-SENS, INC. SMART CARESENS N GLUCOSE SYSTM<br />
08626000101 GENESIS HEALTH GDRIVE BLOOD GLUCOSE SYSTEM<br />
08626333350 GENESIS HEALTH BLOOD GLUCOSE TEST STRIP<br />
08627073001 DEXCOM, INC. SEVEN PLUS REPLACMNT TRNSMTTER<br />
08627073101 DEXCOM, INC. SEVEN PLUS REPLACEMNT RECEIVER<br />
08627073201 DEXCOM, INC. SEVEN PLUS SYSTEM STARTER KIT<br />
08627073201 DEXCOM, INC. SEVEN PLUS SYSTEM STARTER KIT<br />
08633900001 HTL-STREFE, S.A. DROPLET LANCING DEVICE<br />
08881500014 LEADER MONOJECT INSUL SYR U100 0.5 ML<br />
08881501210 LEADER MONOJECT 1 ML SYRN 28GX1/2"<br />
08881501384 LEADER MONOJECT INSUL SYR U100 1 ML<br />
08881501822 LEADER MONOJECT INSUL SYR U100 1 ML<br />
08881501970 LEADER MONOJECT INSUL SYR U100 1 ML<br />
08881511110 LEADER MONOJECT INSULIN SYR U-100<br />
08881511136 LEADER MONOJECT INSULIN SYR U-100<br />
08881511144 LEADER MONOJECT INSULIN SYRN 3/10 ML<br />
08881511310 LEADER MONOJECT INSULIN SYR 1 ML<br />
08881511336 LEADER MONOJECT INSULIN SYR 0.5 ML<br />
08881511344 LEADER MONOJECT INSULIN SYR 0.3 ML<br />
08881566015 LEADER MONOJECT SAFETY SYRINGE<br />
08881566023 LEADER MONOJECT SAFETY SYRINGE<br />
08881600004 LEADER MONOJECT INSUL SYR U100 0.5 ML<br />
Page 16 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08881600145 LEADER MONOJECT INSUL SYR U100<br />
08881600350 LEADER MONOJECT INSUL SYR U100<br />
08881600700 LEADER MONOJECT INSULIN SYR 0.5 ML<br />
08881600800 LEADER MONOJECT INSULIN SYR 0.3 ML<br />
08881600904 LEADER ULTRA COMFORT 0.5 ML 28GX1/2"<br />
08881601101 LEADER MONOJECT 1 ML SYRN 28GX1/2"<br />
08881601358 LEADER MONOJECT INSUL SYR U100 1 ML<br />
08881601600 LEADER MONOJECT INSULIN SYR 1 ML<br />
08881602018 LEADER MONOLET LANCETS<br />
08881602034 LEADER MONOLET LANCETS<br />
08881602075 LEADER MONOLET LANCETS<br />
08881602117 LEADER MONOJECTOR LANCET DEVICE<br />
08881602125 LEADER MONOJECT BLOOD LANCET STERL<br />
08881602141 LEADER MONOLET LANCETS<br />
08881602190 LEADER MONOLET LANCETS<br />
08881602208 LEADER MONOLET THIN LANCETS<br />
08881602216 LEADER MONOLET THIN LANCETS<br />
08881609004 LEADER ULTRA COMFORT 0.5 ML SYRINGE<br />
08881609101 LEADER ULTRA COMFORT 1 ML SYRINGE<br />
08881609131 LEADER MONOJECT SYRINGE 1 ML<br />
08881609145 LEADER ULTRA COMFORT 0.3 ML 29GX1/2"<br />
08881609231 LEADER MONOJECT SYRINGE 0.5 ML<br />
08881609331 LEADER MONOJECT SYRINGE 0.3 ML<br />
08881609350 LEADER ULTRA COMFORT 0.5 ML 29GX1/2"<br />
08881609358 LEADER ULTRA COMFORT 1 ML 29GX1/2"<br />
08881609600 LEADER ULTRA COMFORT 1 ML 30GX5/16"<br />
08881609700 LEADER ULTRA COMFORT 0.5 ML SYRINGE<br />
08881609800 LEADER ULTRA COMFORT 0.3 ML SYRINGE<br />
08881700408 LEADER INSULIN SYR 1/2 ML BULK PACK<br />
08881701406 LEADER INSULIN SYRINGE 1 ML-HARD PK<br />
08881892910 LEADER MAGELLAN INSULIN SYRINGE 1 ML<br />
08881892930 LEADER MAGELLAN INSULIN SYR 0.3 ML<br />
08881892950 LEADER MAGELLAN INSULIN SYR 0.5 ML<br />
08881893010 LEADER MAGELLAN INSULIN SYRINGE 1 ML<br />
08881893030 LEADER MAGELLAN INSUL SYRINGE 0.3 ML<br />
08881893050 LEADER MAGELLAN INSUL SYRINGE 0.5 ML<br />
08970100160 TERUMO TERUMO INS SYRINGE U100-1/3 ML<br />
08970100161 TERUMO TERUMO INS SYRINGE U100-1/2 ML<br />
08970100827 TERUMO TERUMO INS SYRINGE U100-1 ML<br />
08970100861 TERUMO THINPRO INS SYRIN U100-0.3 ML<br />
08970100863 TERUMO THINPRO INS SYRIN U100-1 ML<br />
08970100864 TERUMO THINPRO INS SYRIN U100-0.5 ML<br />
08970100869 TERUMO THINPRO INS SYRIN U100-0.5 ML<br />
08970100870 TERUMO THINPRO INS SYRIN U100-1 ML<br />
08970100871 TERUMO THINPRO INS SYRIN U100-0.3 ML<br />
08970100872 TERUMO THINPRO INS SYRIN U100-0.5 ML<br />
08970100873 TERUMO THINPRO INS SYRIN U100-1 ML<br />
08970100874 TERUMO THINPRO INS SYRIN U100-0.3 ML<br />
08970100875 TERUMO THINPRO INS SYRIN U100-0.5 ML<br />
08970100876 TERUMO THINPRO INS SYRIN U100-1 ML<br />
08970200521 TERUMO TERUMO INS SYRNG U100-1/2 ML<br />
08970200531 TERUMO TERUMO INS SYRNG U100-1/2 ML<br />
Page 17 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
08970200541 TERUMO TERUMO INS SYRNG U100-1/2 ML<br />
08970201021 TERUMO TERUMO INS SYRINGE U100-1 ML<br />
08970201031 TERUMO TERUMO INS SYRINGE U100-1 ML<br />
08970201041 TERUMO TERUMO INS SYRINGE U100-1 ML<br />
08970203031 TERUMO TERUMO INS SYR 0.3 ML 29GX1/2"<br />
10939007033 MCKESSON DRUG<br />
SM LANCETS<br />
10939007133 MCKESSON DRUG<br />
SM THIN LANCETS<br />
10939007233 MCKESSON DRUG<br />
SM SUPER THIN LANCETS<br />
10939007333 MCKESSON DRUG<br />
SM LANCETS<br />
10939007433 MCKESSON DRUG<br />
SM COLORED LANCETS<br />
10939007533 MCKESSON DRUG<br />
SM THIN LANCETS<br />
10939007633 MCKESSON DRUG<br />
SM INSULIN SYR 0.5 ML 28GX1/2"<br />
10939007733 MCKESSON DRUG<br />
SM INS SYRINGE 1 ML 28GX1/2"<br />
10939007833 MCKESSON DRUG<br />
SM INSULIN SYR 0.3 ML 29GX1/2"<br />
10939007933 MCKESSON DRUG<br />
SM INS SYR 0.5 ML 29GX1/2"<br />
10939008033 MCKESSON DRUG<br />
SM INS SYR 1 ML 29GX1/2"<br />
10939008133 MCKESSON DRUG<br />
SM INS SYRING 0.3 ML 30GX5/16"<br />
10939008233 MCKESSON DRUG<br />
SM INS SYR 0.5 ML 30GX5/16"<br />
10939008333 MCKESSON DRUG<br />
SM INS SYRINGE 1 ML 30GX5/16"<br />
10939033122 MCKESSON DRUG<br />
LANCETS<br />
10939033222 MCKESSON DRUG<br />
LANCETS<br />
10939056211 MCKESSON DRUG<br />
BLOOD GLUCOSE TEST STRIPS<br />
10939056311 MCKESSON DRUG<br />
SM LANCETS<br />
10939062722 MCKESSON DRUG<br />
SM INS SYRING 0.3 ML 30GX5/16"<br />
10939062822 MCKESSON DRUG<br />
SM INS SYRINGE 1 ML 30GX5/16"<br />
10939062922 MCKESSON DRUG<br />
SM INS SYR 0.5 ML 30GX5/16"<br />
10939082522 MCKESSON DRUG<br />
V-R GLUCOSE TEST STRIP<br />
10939084533 MCKESSON DRUG<br />
SM INSUL SYR 0.3 ML 31GX5/16"<br />
10939084633 MCKESSON DRUG<br />
SM INSUL SYR 0.5 ML 31GX5/16"<br />
10939084733 MCKESSON DRUG<br />
SM INSULIN SYR 1 ML 31GX5/16"<br />
10939090611 MCKESSON DRUG<br />
SM INSULIN SYR 0.5 ML 28GX1/2"<br />
10939090711 MCKESSON DRUG<br />
SM INS SYRINGE 1 ML 28GX1/2"<br />
10939090811 MCKESSON DRUG<br />
SM INSULIN SYR 0.3 ML 29GX1/2"<br />
10939090911 MCKESSON DRUG<br />
SM INS SYR 0.5 ML 29GX1/2"<br />
10939091011 MCKESSON DRUG<br />
SM INS SYR 1 ML 29GX1/2"<br />
10939091111 MCKESSON DRUG<br />
SM THIN LANCETS<br />
10939091211 MCKESSON DRUG<br />
SM COLORED LANCETS<br />
11110035224 KROGER KROGER INS SYRINGE 3/10ML<br />
11110035232 KROGER KROGER INS SYRINGE 0.5ML<br />
11822023660 RITE AID CORP. RA EZJECT LANCETS<br />
11822023670 RITE AID CORP. RA EZJECT LANCETS<br />
11822037140 RITE AID CORP. RA TRUETEST GLUCOSE TEST STRIP<br />
11822321570 RITE AID CORP. RA INS SYR 0.5 ML 29GX1/2"<br />
11822321580 RITE AID CORP. RA INS SYR 1 ML 29GX1/2"<br />
11822367950 RITE AID CORP. RA TRUE2GO BLOOD GLUCOSE SYSTM<br />
11822371430 RITE AID CORP. RA TRUETEST GLUCOSE TEST STRIP<br />
11822576430 RITE AID CORP. RA INS SYR 0.5 ML 30GX5/16"<br />
11822576440 RITE AID CORP. RA INS SYRINGE 1 ML 30GX5/16"<br />
11822801460 RITE AID CORP. RA BLOOD GLUCOSE MONITOR<br />
11822989400 RITE AID CORP. RA LANCET-THIN<br />
11917001487 WALGREEN CO. INSULIN 1 ML SYRINGE<br />
11917001489 WALGREEN CO. INSULIN 1/2 ML SYRINGE<br />
Page 18 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
11917001492 WALGREEN CO. INSULIN 3/10 ML SYRINGE<br />
11917001648 WALGREEN CO. SUPER THIN LANCETS<br />
11917001668 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS<br />
11917002527 WALGREEN CO. INSULIN 3/10 ML SYRINGE<br />
11917002528 WALGREEN CO. INSULIN 1/2 ML SYRINGE<br />
11917002529 WALGREEN CO. INSULIN 1 ML SYRINGE<br />
11917002536 WALGREEN CO. INSULIN SYRIN 0.5 ML 31GX5/16"<br />
11917003182 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS<br />
11917003277 WALGREEN CO. LANCING DEVICE<br />
11917004813 WALGREEN CO. INSULIN SYRINGE 1 ML 31GX5/16"<br />
11917004814 WALGREEN CO. INSULIN SYRIN 0.5 ML 31GX5/16"<br />
11917004815 WALGREEN CO. INSULIN SYRIN 0.3 ML 31GX5/16"<br />
11917005059 WALGREEN CO. TRUETRACK SMART SYSTEM<br />
11917005075 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS<br />
11917005076 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS<br />
11917006105 WALGREEN CO. WALGREENS THIN LANCETS<br />
11917006109 WALGREEN CO. WALGREENS LANCETS<br />
11917006110 WALGREEN CO. WALGREENS THIN LANCETS<br />
11917006111 WALGREEN CO. WALGREENS ULTRA THIN LANCETS<br />
11917009921 WALGREEN CO. TRUETRACK BLOOD GLUCOSE SYSTEM<br />
11917009960 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS<br />
11917009961 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS<br />
11917010002 WALGREEN CO. TRUE2GO BLOOD GLUCOSE SYSTEM<br />
11917010003 WALGREEN CO. TRUERESULT BLOOD GLUCOSE SYSTM<br />
11917010488 WALGREEN CO. TRUETRACK GLUCOSE TEST STRIPS<br />
11917011158 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS<br />
11917011815 WALGREEN CO. WALGREENS SUPER THIN LANCET<br />
11917011816 WALGREEN CO. WALGREENS SUPER THIN LANCETS<br />
11917011817 WALGREEN CO. WALGREENS MICRO THIN LANCET<br />
13703010210 RETRACTABLE TEC<br />
VANISHPOINT U-100 29X1/2 SYR<br />
13703010211 RETRACTABLE TEC<br />
VANISHPOINT U-100 29X1/2 SYR<br />
13703010212 RETRACTABLE TEC<br />
VANISHPOINT U-100 29X1/2 SYR<br />
13774020200 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML<br />
13774020202 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML<br />
13774020210 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
13774020212 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
13774020218 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
13774020220 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML<br />
13774020226 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
13774020228 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
13774020234 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
13774020236 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML<br />
15127001145 SELECT BRAND DISTRIBUTORS SB INSULN SYR 0.5 ML 30GX5/16"<br />
15127040101 SELECT BRAND DISTRIBUTORS SB INS SYR 1 ML 29GX1/2"<br />
15127040105 SELECT BRAND DISTRIBUTORS SB INS SYR 0.5 ML 29GX1/2"<br />
15127040201 SELECT BRAND DISTRIBUTORS SB INS SYRINGE 1 ML 30GX5/16"<br />
15127040205 SELECT BRAND DISTRIBUTORS SB INS SYR 0.5 ML 30GX5/16"<br />
15127040301 SELECT BRAND DISTRIBUTORS SB INSULIN SYR 1 ML 31GX5/16"<br />
15127040305 SELECT BRAND DISTRIBUTORS SB INSULN SYR 0.5 ML 30GX5/16"<br />
15127099010 SELECT BRAND DISTRIBUTORS SB LANCETS THIN<br />
15127099020 SELECT BRAND DISTRIBUTORS SB LANCETS THIN<br />
15127099110 SELECT BRAND DISTRIBUTORS SB LANCETS ULTRA THIN<br />
Page 19 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
15127099120 SELECT BRAND DISTRIBUTORS SB LANCETS ULTRA THIN<br />
15482033005 HYPOGUARD QUICKTEK CONTROL SOLUTION<br />
15482033050 HYPOGUARD QUICKTEK TEST STRIPS<br />
15482033100 HYPOGUARD QUICKTEK TEST STRIPS<br />
15482033110 HYPOGUARD QUICKTEK KIT<br />
15482041005 HYPOGUARD ADVANCE MICRO-DRAW CONTRL SOLN<br />
15482041012 HYPOGUARD HYPOLANCE AST LANCING KIT<br />
15482041012 HYPOGUARD HYPOLANCE AST LANCING KIT<br />
15482041050 HYPOGUARD ADVANCE MICRO-DRAW TEST STRIPS<br />
15482041100 HYPOGUARD ADVANCE MICRO-DRAW TEST STRIPS<br />
15482042000 HYPOGUARD ADVANCE INTUITION METER<br />
15482042005 HYPOGUARD ADVANCE NORMAL CONTROL SOLN<br />
15482042050 HYPOGUARD ADVANCE TEST STRIPS<br />
15482042110 HYPOGUARD ADVANCE INTUITION METER<br />
15482046001 HYPOGUARD ASSURE PRO METER<br />
15482046050 HYPOGUARD ASSURE PRO TEST STRIPS<br />
15482046060 HYPOGUARD ASSURE PRO CONTROL SOLUTION<br />
15482046060 HYPOGUARD ASSURE PRO CONTROL SOLUTION<br />
15482046100 HYPOGUARD ASSURE PRO TEST STRIPS<br />
15482050001 HYPOGUARD ASSURE PLATINUM GLUCOSE METER<br />
15482050005 HYPOGUARD ASSURE DOSE CONTROL SOLUTION<br />
15482050006 HYPOGUARD ASSURE DOSE CONTROL SOLUTION<br />
15482050006 HYPOGUARD ASSURE DOSE CONTROL SOLUTION<br />
15482050050 HYPOGUARD ASSURE PLATINUM TEST STRIPS<br />
15482050100 HYPOGUARD ASSURE PLATINUM TEST STRIPS<br />
15482055006 HYPOGUARD ASSURE 3 CONTROL SOLUTION<br />
15482055006 HYPOGUARD ASSURE 3 CONTROL SOLUTION<br />
15482055050 HYPOGUARD ASSURE 3 TEST STRIPS<br />
15482055100 HYPOGUARD ASSURE 3 TEST STRIPS<br />
15482056001 HYPOGUARD ASSURE 4 BLOOD GLUCOSE METER<br />
15482056006 HYPOGUARD ASSURE 4 CONTROL SOLUTION<br />
15482056050 HYPOGUARD ASSURE 4 TEST STRIPS<br />
15482056100 HYPOGUARD ASSURE 4 TEST STRIPS<br />
15482063005 HYPOGUARD POCKETCHEM EZ CONTROL SOLUTION<br />
15482063050 HYPOGUARD POCKETCHEM EZ TEST STRIPS<br />
15482063110 HYPOGUARD POCKETCHEM EZ METER KIT<br />
15482066015 HYPOGUARD MULTI-LANCET DEVICE<br />
15482066600 HYPOGUARD SELECT-LITE LANCING DEVICE<br />
15482072001 HYPOGUARD GLUCOCARD 01 BLOOD GLUCOSE MTR<br />
15482072005 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION<br />
15482072050 HYPOGUARD GLUCOCARD 01 SENSOR TEST STRIP<br />
15482072110 HYPOGUARD GLUCOCARD 01 METER KIT<br />
15482073110 HYPOGUARD GLUCOCARD 01-MINI METER KIT<br />
15482074006 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION<br />
15482074006 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION<br />
15482074050 HYPOGUARD GLUCOCARD 01 SENSOR TEST STRIP<br />
15482074110 HYPOGUARD GLUCOCARD 01 METER KIT<br />
15482075005 HYPOGUARD GLUCOCARD X-METER CONTROL SOLN<br />
15482075050 HYPOGUARD GLUCOCARD X-SENSOR TEST STRIPS<br />
15482075110 HYPOGUARD GLUCOCARD X-METER SYSTEM KIT<br />
15482075205 HYPOGUARD GLUCOCARD X-SENSOR TEST STRIPS<br />
15482076050 HYPOGUARD GLUCOCARD VITAL SENSOR STRIP<br />
Page 20 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
15482076110 HYPOGUARD GLUCOCARD VITAL METER KIT<br />
15482076112 HYPOGUARD GLUCOCARD VITAL METER KIT<br />
15482076113 HYPOGUARD GLUCOCARD VITAL METER KIT<br />
15482076205 HYPOGUARD GLUCOCARD VITAL SENSOR STRIP<br />
15482088012 HYPOGUARD TECHLITE BLOOD LANCET<br />
15482088018 HYPOGUARD TECHLITE BLOOD LANCET<br />
15482088022 HYPOGUARD TECHLITE BLOOD LANCET<br />
15482088028 HYPOGUARD TECHLITE BLOOD LANCET<br />
15482088030 HYPOGUARD TECHLITE AST LANCETS<br />
15482098018 HYPOGUARD ASSURE LANCE MICRO FLOW LANCET<br />
15482098028 HYPOGUARD ASSURE LANCE MICRO FLOW LANCET<br />
15482099030 HYPOGUARD HAEMOLANCE, RETRACTABLE<br />
15482099035 HYPOGUARD HAEMOLANCE, RETRACTABLE<br />
15482099050 HYPOGUARD HAEMOLANCE LANCET<br />
15482099055 HYPOGUARD HAEMOLANCE LANCET<br />
15482099070 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099075 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099080 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099090 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099095 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099200 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099250 HYPOGUARD HAEMOLANCE PLUS LANCETS<br />
15482099400 HYPOGUARD HAEMOLANCE PLUS LANCET<br />
15482099600 HYPOGUARD HAEMOLANCE PLUS LANCET<br />
15482990305 HYPOGUARD HAEMOLANCE, RETRACTABLE<br />
15482990350 HYPOGUARD HAEMOLANCE, RETRACTABLE<br />
20221026014 EXEL INT'L INC. EXEL U100 0.3 ML 30GX5/16"<br />
20221026015 EXEL INT'L INC. EXEL U100 0.5 ML 30GX5/16"<br />
20221026016 EXEL INT'L INC. EXEL U100 1 ML 30GX5/16"<br />
20221026018 EXEL INT'L INC. EXEL U100 0.3 ML 29GX1/2"<br />
20221026026 EXEL INT'L INC. EXEL U100 0.5 ML 28GX1/2"<br />
20221026027 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2<br />
20221026028 EXEL INT'L INC. EXEL U100 0.5 ML 29GX1/2"<br />
20221026029 EXEL INT'L INC. EXEL U100 INS SYR 1 ML 29GX1/2<br />
21292000263 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM<br />
21292000265 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM<br />
21292000291 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS<br />
21292000294 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS<br />
25294000624 NIPRO DIAGNOSTIC AUTO-LANCET MINI LANCING DEV<br />
25294094300 NIPRO DIAGNOSTIC EZ-LETS II LANCETS #EZ-300<br />
28465000331 MED.PLASTIC DEV VITALET 23 GAUGE LANCET<br />
28465000351 MED.PLASTIC DEV VITALET 23 GAUGE LANCET<br />
28465000361 MED.PLASTIC DEV VITALET THIN 26GAUGE LANCET<br />
28465000362 MED.PLASTIC DEV VITALET THIN 26GAUGE LANCET<br />
28465001212 MED.PLASTIC DEV VITALET PRO LANCETS<br />
28465001222 MED.PLASTIC DEV VITALET PRO LANCETS<br />
28465001340 MED.PLASTIC DEV VITALET PRO PLUS LANCETS<br />
28465001350 MED.PLASTIC DEV VITALET PRO PLUS LANCETS<br />
28465001381 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS<br />
28465001382 MED.PLASTIC DEV MEDLANCE PLUS UNIVERSAL LANCET<br />
32671000020 MEDICORE LITE TOUCH LANCING DEVICE<br />
32671000500 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR<br />
Page 21 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
32671000501 MEDICORE LITE TOUCH INSULIN 1 ML SYR<br />
32671000502 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR<br />
32671000503 MEDICORE LITE TOUCH INSULIN 1 ML SYR<br />
32671000504 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR<br />
32671000505 MEDICORE LITE TOUCH INSULIN 1 ML SYR<br />
32671000506 MEDICORE LITE TOUCH INSULIN 0.3 ML SYR<br />
32671000507 MEDICORE LITE TOUCH INSULIN 0.3 ML SYR<br />
32671000508 MEDICORE LITE TOUCH INSULIN SYR 0.3 ML<br />
32671000509 MEDICORE LITE TOUCH INSULIN SYR 0.5 ML<br />
32671000514 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR<br />
32671000520 MEDICORE LITE TOUCH INSULIN SYR 1 ML<br />
32671020044 MEDICORE AURORA HEALTH LANCET DEVICE<br />
32671020100 MEDICORE MEDI-LANCE LANCETS<br />
32671020133 MEDICORE LITE TOUCH LANCETS<br />
32671020144 MEDICORE AURORA HEALTHCARE LANCETS<br />
32671020200 MEDICORE MEDI-LANCE LANCETS<br />
32671020233 MEDICORE LITE TOUCH LANCETS<br />
32671020244 MEDICORE AURORA HEALTHCARE LANCETS<br />
35515095934 CHAIN DRUG QC ADVANCED LANCING DEVICE<br />
35515095934 CHAIN DRUG QC ADVANCED LANCING DEVICE<br />
35515095935 CHAIN DRUG QC SUPER THIN LANCET<br />
35515095936 CHAIN DRUG QC ULTRA THIN LANCET<br />
37205608104 LEADER INSULIN 1 ML SYRINGE<br />
37205608204 LEADER INSULIN 1/2 ML SYRINGE<br />
37205608304 LEADER INSULIN 3/10 ML SYRINGE<br />
37654049726 SACKS MEDICAL REFUAH PLUS MONITORING SYSTEM<br />
37654049727 SACKS MEDICAL REFUAH PLUS TEST STRIPS<br />
37654049728 SACKS MEDICAL REFUAH PLUS CONTROL SOLUTION<br />
37867099246 CAN-AM/ACCESS MONOJECT SYRINGE 0.3 ML<br />
37867099247 CAN-AM/ACCESS MONOJECT SYRINGE 0.5 ML<br />
37867099248 CAN-AM/ACCESS MONOJECT SYRINGE 1 ML<br />
38396000010 CAN-AM/ACCESS W&F COLORED LANCETS<br />
38396000425 CAN-AM/ACCESS VALUE PLUS LANCING DEVICE<br />
38396000506 CAN-AM/ACCESS KINRAY SYRING 0.3 ML 31GX5/16"<br />
38396000606 CAN-AM/ACCESS KINRAY SYRING 0.5 ML 31GX5/16"<br />
38396000706 CAN-AM/ACCESS KINRAY INS SYR 1 ML 31GX5/16"<br />
38396001078 CAN-AM/ACCESS W&F COLORED LANCETS<br />
38396016201 CAN-AM/ACCESS W&F COLORED LANCETS<br />
38396030100 CAN-AM/ACCESS E-ZJECT THIN LANCETS<br />
38396030108 CAN-AM/ACCESS LEADER THIN LANCETS<br />
38396030112 CAN-AM/ACCESS MS THIN LANCETS<br />
38396030113 CAN-AM/ACCESS FIRST CHOICE THIN LANCETS<br />
38396030114 CAN-AM/ACCESS RA E-ZJECT LANCETS<br />
38396030118 CAN-AM/ACCESS KROGER THIN LANCETS<br />
38396030120 CAN-AM/ACCESS MEIJER THIN GAUGE LANCETS<br />
38396030137 CAN-AM/ACCESS TOPCARE UNIVERSAL1 THIN LANCET<br />
38396030140 CAN-AM/ACCESS EQL LANCETS THIN<br />
38396030157 CAN-AM/ACCESS DRUG MART THIN LANCETS<br />
38396030200 CAN-AM/ACCESS E-ZJECT THIN LANCETS<br />
38396030208 CAN-AM/ACCESS LEADER THIN LANCETS<br />
38396030213 CAN-AM/ACCESS FIRST CHOICE THIN LANCETS<br />
38396030218 CAN-AM/ACCESS KROGER THIN LANCETS<br />
Page 22 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
38396030220 CAN-AM/ACCESS MEIJER THIN GAUGE LANCETS<br />
38396030240 CAN-AM/ACCESS EQL LANCETS THIN<br />
38396030300 CAN-AM/ACCESS E-Z JECT LANCETS<br />
38396030312 CAN-AM/ACCESS MS LANCETS<br />
38396030316 CAN-AM/ACCESS H&H THINLET LANCETS<br />
38396030318 CAN-AM/ACCESS KROGER SUPER THIN LANCETS<br />
38396030320 CAN-AM/ACCESS MEIJER LANCETS<br />
38396030400 CAN-AM/ACCESS E-Z JECT LANCETS<br />
38396030412 CAN-AM/ACCESS MS LANCETS<br />
38396030416 CAN-AM/ACCESS H&H THINLET LANCETS<br />
38396030418 CAN-AM/ACCESS KROGER LANCETS<br />
38396030420 CAN-AM/ACCESS MEIJER LANCETS<br />
38396030500 CAN-AM/ACCESS E-Z JECT COLORED LANCETS<br />
38396030508 CAN-AM/ACCESS LEADER SUPER THIN LANCETS<br />
38396030512 CAN-AM/ACCESS MS SUPER THIN LANCETS<br />
38396030513 CAN-AM/ACCESS FIRST CHOICE COLORED LANCET<br />
38396030514 CAN-AM/ACCESS RA E-ZJECT LANCETS<br />
38396030520 CAN-AM/ACCESS MEIJER LANCETS<br />
38396030537 CAN-AM/ACCESS TOPCARE UNIVERSAL1 THIN LANCET<br />
38396030540 CAN-AM/ACCESS EQL SUPER THIN LANCETS<br />
38396030557 CAN-AM/ACCESS DRUG MART ULTRA THIN LANCETS<br />
38396030600 CAN-AM/ACCESS E-Z JECT COLORED LANCETS<br />
38396030608 CAN-AM/ACCESS LEADER COLORED LANCETS<br />
38396030613 CAN-AM/ACCESS FIRST CHOICE COLORED LANCET<br />
38396030640 CAN-AM/ACCESS EQL SUPER THIN LANCETS<br />
38396030740 CAN-AM/ACCESS EQL COLOR LANCETS<br />
38396030800 CAN-AM/ACCESS E-Z JECT SUPER THIN LANCETS<br />
38396030900 CAN-AM/ACCESS E-ZJECT COLORED LANCETS<br />
38396031114 CAN-AM/ACCESS RA E-ZJECT LANCETS<br />
38396031132 CAN-AM/ACCESS WALGREENS SUPER THIN LANCETS<br />
38396031156 CAN-AM/ACCESS PREFERRED PLUS LANCETS<br />
38396031214 CAN-AM/ACCESS RA E-ZJECT LANCETS<br />
38396031225 CAN-AM/ACCESS VALUE PLUS THIN LANCETS<br />
38396031402 CAN-AM/ACCESS RELION ULTRA THIN PLUS LANCETS<br />
38396031506 CAN-AM/ACCESS PREFERRED PLUS THIN LANCETS<br />
38396031600 CAN-AM/ACCESS E-Z JECT MICRO THIN LANCETS<br />
38396031614 CAN-AM/ACCESS RA E-ZJECT MICRO-THIN LANCET<br />
38396031618 CAN-AM/ACCESS UNIVERSAL 1 LANCETS<br />
38396031620 CAN-AM/ACCESS UNIVERSAL 1 33 GAUGE LANCETS<br />
38396031632 CAN-AM/ACCESS WALGREENS MICRO THIN LANCET<br />
38396031664 CAN-AM/ACCESS GNP MICRO THIN 33G LANCETS<br />
38396031702 CAN-AM/ACCESS RELION ULTRA THIN PLUS LANCET<br />
38396031739 CAN-AM/ACCESS SM MICRO THIN LANCETS<br />
38396031775 CAN-AM/ACCESS CVS MICRO THIN LANCETS<br />
38396032225 CAN-AM/ACCESS VALUE PLUS THIN LANCETS<br />
38396032300 CAN-AM/ACCESS VALUE DRUG LANCETS 21G<br />
38396032325 CAN-AM/ACCESS VALUE PLUS SUPER THIN LANCETS<br />
38396032870 CAN-AM/ACCESS LONGS LANCETS 21G<br />
38396032970 CAN-AM/ACCESS LONGS THIN LANCETS 26G<br />
38396033070 CAN-AM/ACCESS LONGS THIN LANCETS 30G<br />
38396033277 CAN-AM/ACCESS FP LANCETS THIN<br />
38396033577 CAN-AM/ACCESS FP LANCETS THIN<br />
Page 23 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
38396034264 CAN-AM/ACCESS GNP LANCETS<br />
38396034364 CAN-AM/ACCESS GNP LANCETS<br />
38396034464 CAN-AM/ACCESS GNP THIN LANCETS<br />
38396034564 CAN-AM/ACCESS GNP THIN LANCETS<br />
38396035506 CAN-AM/ACCESS PREFERRED PLUS COLORED LANCETS<br />
38396036606 CAN-AM/ACCESS PREFERRED PLUS COLORED LANCETS<br />
38396040102 CAN-AM/ACCESS RELION SYRING 0.3 ML 31GX5/16"<br />
38396040105 CAN-AM/ACCESS QC INSULIN SYRINGE 1 ML<br />
38396040108 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 28GX1/2"<br />
38396040202 CAN-AM/ACCESS RELION SYRING 0.5 ML 31GX5/16"<br />
38396040205 CAN-AM/ACCESS QC INSULIN SYRINGE 0.5 ML<br />
38396040208 CAN-AM/ACCESS LEADER INS SYR 1 ML 28GX1/2"<br />
38396040212 CAN-AM/ACCESS MS INSULIN SYR 0.3 ML 29GX1/2"<br />
38396040218 CAN-AM/ACCESS KROGER INS SYRINGE 3/10 ML<br />
38396040302 CAN-AM/ACCESS RELION INS SYR 1 ML 31GX5/16"<br />
38396040305 CAN-AM/ACCESS QC INSULIN SYRINGE 0.3 ML<br />
38396040308 CAN-AM/ACCESS LEADER INS SYR 0.3 ML 29GX1/2"<br />
38396040318 CAN-AM/ACCESS KROGER INS SYR 0.5 ML 29GX1/2"<br />
38396040325 CAN-AM/ACCESS KMART VALU PLUS SYR 1/2 ML<br />
38396040405 CAN-AM/ACCESS QC INSULIN SYR 1 ML 31GX5/16"<br />
38396040408 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 29GX1/2"<br />
38396040412 CAN-AM/ACCESS MS INS SYR 0.5 ML 29GX1/2"<br />
38396040425 CAN-AM/ACCESS VALUEPLUS SYR 0.3 ML 29GX1/2"<br />
38396040501 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML<br />
38396040502 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.3 ML<br />
38396040503 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML<br />
38396040504 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML<br />
38396040505 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML<br />
38396040506 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML<br />
38396040507 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML<br />
38396040508 CAN-AM/ACCESS LEADER INS SYR 1 ML 29GX1/2"<br />
38396040512 CAN-AM/ACCESS MS INS SYR 1 ML 29GX1/2"<br />
38396040518 CAN-AM/ACCESS KROGER INS SYR 1 ML 29GX1/2"<br />
38396040525 CAN-AM/ACCESS KMART VALU PLUS SYRINGE 1 ML<br />
38396040605 CAN-AM/ACCESS QC INSUL SYR 0.5 ML 31GX5/16"<br />
38396040608 CAN-AM/ACCESS LEADER INSULIN SYRINGE 0.3 ML<br />
38396040612 CAN-AM/ACCESS MS INSULIN SYRINGE 0.3 ML<br />
38396040618 CAN-AM/ACCESS KROGER INSULIN SYRINGE 1 ML<br />
38396040625 CAN-AM/ACCESS KMART VALU PLUS SYRINGE 1 ML<br />
38396040708 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 30GX1/2"<br />
38396040712 CAN-AM/ACCESS MS INSUL SYR 0.5 ML 30GX1/2"<br />
38396040718 CAN-AM/ACCESS KROGER SYR 0.5 ML 30GX5/16"<br />
38396040725 CAN-AM/ACCESS KMART VALU PLUS SYR 1/2 ML<br />
38396040801 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 0.5 ML<br />
38396040802 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 0.3 ML<br />
38396040803 CAN-AM/ACCESS PREFERRED PLUS 0.5 ML 29GX1/2"<br />
38396040804 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 1 ML<br />
38396040805 CAN-AM/ACCESS PREF PLUS SYRING 1 ML 29GX1/2"<br />
38396040806 CAN-AM/ACCESS PREFPLS INS SYR 1 ML 30GX5/16"<br />
38396040807 CAN-AM/ACCESS PREF PLUS SYR 0.5 ML 30GX5/16"<br />
38396040808 CAN-AM/ACCESS PREFERRED PLUS 0.3 ML 30GX5/16<br />
38396040812 CAN-AM/ACCESS MS INS SYRINGE 1 ML 30GX1/2"<br />
Page 24 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
38396040818 CAN-AM/ACCESS KROGER INS SYR 0.3 ML 30GX5/16<br />
38396040825 CAN-AM/ACCESS KMART VALU PLUS SYR 3/10 ML<br />
38396040918 CAN-AM/ACCESS KROGER SYRING 0.3 ML 31GX5/16"<br />
38396040970 CAN-AM/ACCESS INSULIN SYRIN 0.3 ML 31GX5/16"<br />
38396041018 CAN-AM/ACCESS KROGER SYRING 0.5 ML 31GX5/16"<br />
38396041070 CAN-AM/ACCESS INSULIN SYRIN 0.5 ML 31GX5/16"<br />
38396041102 CAN-AM/ACCESS RELION INSULIN SYR 0.3 ML<br />
38396041118 CAN-AM/ACCESS KROGER INS SYR 1 ML 31GX5/16"<br />
38396041131 CAN-AM/ACCESS WDMEDIC SYRING 0.3 ML 29GX1/2"<br />
38396041137 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041140 CAN-AM/ACCESS EQL INSULIN 0.3 ML SYRINGE<br />
38396041157 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396041202 CAN-AM/ACCESS RELION INSULIN SYR 0.5 ML<br />
38396041231 CAN-AM/ACCESS WD MEDIC SYR 0.5 ML 29GX1/2"<br />
38396041237 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041240 CAN-AM/ACCESS EQL INSULIN 0.5 ML SYRINGE<br />
38396041302 CAN-AM/ACCESS RELION INS SYR 1 ML 29GX1/2"<br />
38396041331 CAN-AM/ACCESS WD MEDIC SYR 1 ML 29GX1/2"<br />
38396041337 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041340 CAN-AM/ACCESS EQL INS SYR 1 ML 29GX1/2"<br />
38396041357 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396041431 CAN-AM/ACCESS WD MEDIC SYR 0.3 ML 30GX5/16"<br />
38396041437 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041440 CAN-AM/ACCESS EQL INSULIN 0.3 ML SYRINGE<br />
38396041457 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396041531 CAN-AM/ACCESS WD MEDIC SYR 0.5 ML 30GX5/16"<br />
38396041537 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041540 CAN-AM/ACCESS EQL INSULIN 0.5 ML SYRINGE<br />
38396041557 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396041631 CAN-AM/ACCESS WDMEDIC INS SYR 1 ML 30GX5/16"<br />
38396041637 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041640 CAN-AM/ACCESS EQL INSULIN 1 ML SYRINGE<br />
38396041657 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396041808 CAN-AM/ACCESS LEADER INS SYR 1 ML 30GX5/16"<br />
38396041908 CAN-AM/ACCESS LEADER SYRING 0.3 ML 31GX5/16"<br />
38396041937 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396041940 CAN-AM/ACCESS EQL INSUL SYR 0.3 ML 31GX5/16"<br />
38396041957 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396042003 CAN-AM/ACCESS VH INS SYR 0.5 ML 29GX1/2"<br />
38396042005 CAN-AM/ACCESS VH INS SYR 1 ML 29GX1/2"<br />
38396042008 CAN-AM/ACCESS LEADER SYRING 0.5 ML 31GX5/16"<br />
38396042037 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396042040 CAN-AM/ACCESS EQL INSUL SYR 0.5 ML 31GX5/16"<br />
38396042057 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR<br />
38396042108 CAN-AM/ACCESS LEADER INS SYR 1 ML 31GX5/16"<br />
38396042137 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE<br />
38396042140 CAN-AM/ACCESS EQL INSULIN SYR 1 ML 31GX5/16"<br />
38396042912 CAN-AM/ACCESS MS INSUL SYR 0.3 ML 31GX5/16"<br />
38396043012 CAN-AM/ACCESS MS INSUL SYR 0.5 ML 31GX5/16"<br />
38396043112 CAN-AM/ACCESS MS INSULIN SYR 1 ML 31GX5/16"<br />
38396043277 CAN-AM/ACCESS FP INSULIN 1 ML SYRINGE<br />
38396043377 CAN-AM/ACCESS FP INSULIN 1 ML SYRINGE<br />
Page 25 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
38396043477 CAN-AM/ACCESS FP INSULIN 0.5 ML SYRINGE<br />
38396044164 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR<br />
38396044264 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE<br />
38396044364 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR<br />
38396044455 CAN-AM/ACCESS RENEW ADVANCED MICRO-LANCETS<br />
38396044464 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE<br />
38396044564 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR<br />
38396044664 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR<br />
38396044764 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE<br />
38396044864 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR<br />
38396044902 CAN-AM/ACCESS RELION THIN LANCETS<br />
38396044964 CAN-AM/ACCESS GNP INSUL SYR 0.3 ML 31GX5/16"<br />
38396045002 CAN-AM/ACCESS RELION LANCETS<br />
38396045064 CAN-AM/ACCESS GNP INSUL SYR 0.5 ML 31GX5/16"<br />
38396045102 CAN-AM/ACCESS RELION THIN LANCETS<br />
38396045164 CAN-AM/ACCESS GNP INSULIN SYR 1 ML 31GX5/16"<br />
38396045202 CAN-AM/ACCESS RELION THIN LANCETS<br />
38396045302 CAN-AM/ACCESS RELION ULTRA THIN COL LANCET<br />
38396045339 CAN-AM/ACCESS SM INSUL SYR 0.3 ML 31GX5/16"<br />
38396045402 CAN-AM/ACCESS RELION ULTRA THIN LANCET<br />
38396045532 CAN-AM/ACCESS WALGREENS SUPER THIN LANCET<br />
38396046339 CAN-AM/ACCESS SM INSUL SYR 0.5 ML 31GX5/16"<br />
38396047339 CAN-AM/ACCESS SM INSULIN SYR 1 ML 31GX5/16"<br />
38396050101 CAN-AM/ACCESS RELION LANCING DEVICE<br />
38396050132 CAN-AM/ACCESS WALGREENS LANCETS<br />
38396050175 CAN-AM/ACCESS CVS THIN LANCETS<br />
38396050178 CAN-AM/ACCESS W&F 30G LANCETS<br />
38396050232 CAN-AM/ACCESS WALGREENS THIN LANCETS<br />
38396050275 CAN-AM/ACCESS CVS LANCETS<br />
38396050332 CAN-AM/ACCESS WALGREENS THIN LANCETS<br />
38396050375 CAN-AM/ACCESS CVS THIN LANCETS<br />
38396050432 CAN-AM/ACCESS WALGREENS ULTRA THIN LANCETS<br />
38396051075 CAN-AM/ACCESS CVS LANCING DEVICE<br />
38396051075 CAN-AM/ACCESS CVS LANCING DEVICE<br />
38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM<br />
38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM<br />
38396052175 CAN-AM/ACCESS CVS ULTRA THIN LANCETS<br />
38396052275 CAN-AM/ACCESS CVS ULTRA THIN LANCETS<br />
38396054764 CAN-AM/ACCESS GNP SUPER THIN LANCETS<br />
38396060118 CAN-AM/ACCESS KROGER LANCING DEVICE<br />
38396070339 CAN-AM/ACCESS SM LANCETS<br />
38396071339 CAN-AM/ACCESS SM THIN LANCETS<br />
38396072339 CAN-AM/ACCESS SM SUPER THIN LANCETS<br />
38396073339 CAN-AM/ACCESS SM LANCETS<br />
38396074339 CAN-AM/ACCESS SM COLORED LANCETS<br />
38396075339 CAN-AM/ACCESS SM THIN LANCETS<br />
38396076339 CAN-AM/ACCESS SM INSULIN SYR 0.5 ML 28GX1/2"<br />
38396077339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 28GX1/2"<br />
38396078339 CAN-AM/ACCESS SM INSULIN SYR 0.3 ML 29GX1/2"<br />
38396079339 CAN-AM/ACCESS SM INS SYR 0.5 ML 29GX1/2"<br />
38396080339 CAN-AM/ACCESS SM INS SYR 1 ML 29GX1/2"<br />
38396081339 CAN-AM/ACCESS SM INS SYRING 0.3 ML 30GX5/16"<br />
Page 26 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
38396082339 CAN-AM/ACCESS SM INS SYR 0.5 ML 30GX5/16"<br />
38396083339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 30GX5/16"<br />
38396090002 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS<br />
38396090178 CAN-AM/ACCESS W&F THIN LANCETS<br />
38396090180 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS<br />
38396091825 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS<br />
38396091925 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS<br />
38415001630 SPECIALTY MED INSULIN SYRINGE 1 ML 30GX5/16"<br />
38415001631 SPECIALTY MED INSULIN SYRINGE 1 ML 31GX5/16"<br />
38415003529 SPECIALTY MED INSULIN SYRIN 0.3 ML 29GX1/2"<br />
38415003531 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16"<br />
38415003630 SPECIALTY MED INSULIN SYR 0.3 ML 30GX5/16"<br />
38415003631 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16"<br />
38415005129 SPECIALTY MED INSULIN SYRIN 1 ML 29GX1/2"<br />
38415005529 SPECIALTY MED INSULIN SYRING 0.5 ML 29GX1/2"<br />
38415005630 SPECIALTY MED INSULIN SYRIN 0.5 ML 30GX5/16"<br />
38415005631 SPECIALTY MED INSULIN SYRIN 0.5 ML 31GX5/16"<br />
38415010001 SPECIALTY MED SAFETY-LET LANCETS<br />
38415010028 SPECIALTY MED LANCETS<br />
38415010029 SPECIALTY MED ASSURE ULTRA THIN LANCETS<br />
38415010030 SPECIALTY MED LANCETS<br />
38415020801 SPECIALTY MED AQUA LANCE LANCING DEVICE<br />
38415030028 SPECIALTY MED LANCETS<br />
38415030030 SPECIALTY MED LANCETS<br />
38415040028 SPECIALTY MED LANCETS<br />
38415042302 SPECIALTY MED SURECHEK TEST STRIPS<br />
38415042308 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN<br />
38415042401 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER<br />
38415042402 SPECIALTY MED SURE EDGE TEST STRIPS<br />
38415042440 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415042460 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415042480 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415051001 SPECIALTY MED LANCING DEVICE<br />
38415051002 SPECIALTY MED ALTERNATE SITE LANCING DEVICE<br />
38415051208 SPECIALTY MED AQUA LANCE LANCING DEVICE<br />
38415060023 SPECIALTY MED LANCETS<br />
38415060025 SPECIALTY MED LANCETS<br />
38415423010 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR<br />
38415423120 SPECIALTY MED SURECHEK TEST STRIPS<br />
38415423240 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR<br />
38415423830 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN<br />
38415424010 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER<br />
38415424110 SPECIALTY MED SURE EDGE TEST STRIPS<br />
38415424410 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415424620 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415424830 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN<br />
38415425110 SPECIALTY MED VOCAL POINT TEST STRIP<br />
38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE<br />
38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE<br />
40986001668 CHAIN DRUG CONS<br />
PV ULTRA THIN LANCETS<br />
40986001669 CHAIN DRUG CONS<br />
PV ULTRA THIN LANCETS<br />
40986001670 CHAIN DRUG CONS<br />
PV LANCING DEVICE<br />
Page 27 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
40986001676 CHAIN DRUG CONS<br />
PV TRUETRACK SMART SYSTEM<br />
40986001677 CHAIN DRUG CONS<br />
PV TRUETRACK SMART SYS STRIPS<br />
40986001678 CHAIN DRUG CONS<br />
PV TRUETRACK SMART SYS STRIPS<br />
40986002136 CHAIN DRUG CONS<br />
PV INSULIN SYRINGE 0.5 ML<br />
40986002137 CHAIN DRUG CONS<br />
PV INSULIN SYRINGE 1 ML<br />
40986002138 CHAIN DRUG CONS<br />
PV INSULIN SYRINGE 0.5 ML<br />
40986002139 CHAIN DRUG CONS<br />
PV INS SYRIN 1 ML 29GX1/2"<br />
40986002140 CHAIN DRUG CONS<br />
PV INSULIN SYRINGE 0.5 ML<br />
40986002141 CHAIN DRUG CONS<br />
PV INSULIN SYRINGE 1 ML<br />
40986002142 CHAIN DRUG CONS<br />
PV INSUL SYR 0.3 ML 31GX5/16"<br />
40986002143 CHAIN DRUG CONS<br />
PV INSUL SYR 0.5 ML 31GX5/16"<br />
40986002144 CHAIN DRUG CONS<br />
PV INSULIN SYR 1 ML 31GX5/16"<br />
41163026310 EQUALINE VITAMI EQL INS SYR 0.3 ML 29GX1/2"<br />
41163026311 EQUALINE VITAMI EQL INS SYR 0.5 ML 29GX1/2"<br />
41163026312 EQUALINE VITAMI EQL INSULIN SYR 1 ML 29GX1/2"<br />
41163026313 EQUALINE VITAMI EQL INS SYR 0.3 ML 30GX5/16"<br />
41163026314 EQUALINE VITAMI EQL INS SYR 0.5 ML 30GX5/16"<br />
41163026315 EQUALINE VITAMI EQL INSULIN SYR 1 ML 30GX5/16"<br />
41163040141 EQUALINE VITAMI INSULIN SYRINGE 1 ML 31GX5/16"<br />
41163040241 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 31GX5/16"<br />
41163040341 EQUALINE VITAMI EQL INSUL SYR 0.3 ML 31GX5/16"<br />
41163042682 EQUALINE VITAMI EQL INSUL SYR 0.5 ML 31GX5/16"<br />
41163042683 EQUALINE VITAMI EQL INSULIN SYR 1 ML 31GX5/16"<br />
41163042684 EQUALINE VITAMI EQL INSUL SYR 0.3 ML 31GX5/16"<br />
41163263109 EQUALINE VITAMI INSULIN SYRIN 0.3 ML 29GX1/2"<br />
41163402203 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 29GX1/2"<br />
41163402205 EQUALINE VITAMI INSULIN SYRINGE 1 ML 29GX1/2"<br />
41163402206 EQUALINE VITAMI INSULIN SYRINGE 1 ML 30GX5/16"<br />
41163402207 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 30GX5/16"<br />
41163402208 EQUALINE VITAMI INSULIN SYRIN 0.3 ML 30GX5/16"<br />
41250036930 MEIJER INC. MEIJER SUPER THIN LANCETS<br />
41250088304 MEIJER INC. MEIJER LANCETS<br />
41250088305 MEIJER INC. MEIJER THIN GAUGE LANCETS<br />
41250088306 MEIJER INC. MEIJER THIN GAUGE LANCETS<br />
41280021545 MEIJER INC. OSCO LANCETS<br />
41280021546 MEIJER INC. OSCO LANCETS<br />
41280021547 MEIJER INC. OSCO LANCETS<br />
41318071768 ULTIMED INC SCHNUCKS SYR 0.5 ML 29GX1/2"<br />
41318071769 ULTIMED INC SCHNUCKS SYR 0.5 ML 30GX5/16"<br />
41405129301 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML<br />
41405129310 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML<br />
41405129350 ULTIMED INC GLUCOPRO U100 INSULIN 1 ML SYR<br />
41405130301 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML<br />
41405130310 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML<br />
41405130350 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML<br />
41405130801 ULTIMED INC GLUCOPRO SYRINGE U100 1 ML<br />
41405130810 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML<br />
41405130850 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML<br />
41405131810 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML<br />
41405131850 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML<br />
41405329301 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405329310 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
Page 28 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
41405329350 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405330301 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405330310 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405330350 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405330810 ULTIMED INC GLUCOPRO INSUL SYR U100 0.3 ML<br />
41405330850 ULTIMED INC GLUCOPRO INSULIN SYR 0.3 ML<br />
41405331801 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405331810 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML<br />
41405529301 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML<br />
41405529310 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML<br />
41405529350 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML<br />
41405530301 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41405530310 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41405530350 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41405530801 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML<br />
41405530810 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML<br />
41405530850 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML<br />
41405531801 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41405531810 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41405531850 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML<br />
41415001578 PUBLIX SUPERMKT PUB INS SYRIN 0.3 ML 30GX1/2"<br />
41415001678 PUBLIX SUPERMKT PUB INSUL SYR 0.3 ML 31GX5/16"<br />
41415001778 PUBLIX SUPERMKT PUB INSUL SYR 0.5 ML 30GX1/2"<br />
41415001878 PUBLIX SUPERMKT PUB INSUL SYR 0.5 ML 31GX5/16"<br />
41415001978 PUBLIX SUPERMKT PUB INS SYRINGE 1 ML 30GX1/2"<br />
41415002078 PUBLIX SUPERMKT PUB INSULIN SYR 1 ML 31GX5/16"<br />
41415003178 PUBLIX SUPERMKT PUB ADVANCED LANCING DEVICE<br />
41415003178 PUBLIX SUPERMKT PUB ADVANCED LANCING DEVICE<br />
41415003278 PUBLIX SUPERMKT PUB LANCETS<br />
41520031420 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"<br />
41520031420 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"<br />
41520031421 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"<br />
41520031421 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"<br />
41520031422 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"<br />
41520031422 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"<br />
41520031423 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"<br />
41520031423 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"<br />
41520031424 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"<br />
41520031424 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"<br />
41520031425 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"<br />
41520031425 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"<br />
41520087047 ULTIMED INC CAREONE ULTRA THIN LANCET<br />
41520087048 ULTIMED INC CAREONE THIN LANCET<br />
41520087049 ULTIMED INC CAREONE LANCING DEVICE<br />
41735003771 OWEN MUMFORD, INC PC SUPER THIN 30G LANCETS<br />
42167000640 HARRINGTON HOLD RELIAMED SAFETY SEAL LANCETS<br />
42167001090 HARRINGTON HOLD RELIAMED SAFETY SEAL LANCETS<br />
42167001110 HARRINGTON HOLD RELIAMED LANCING DEVICE<br />
43820000008 BOCA PHARMACAL ULTI-LANCE AUTO-AD DEVICE<br />
43820000008 BOCA PHARMACAL ULTI-LANCE AUTO-AD DEVICE<br />
47884017101 OAK TREE INTERN EASYMAX V GLUCOSE SYSTEM KIT<br />
47884017140 OAK TREE INTERN EASYMAX SPEAKING CONTROL SOLN<br />
Page 29 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
47884017250 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
47884017300 OAK TREE INTERN EASYMAX L GLUCOSE SYSTEM KIT<br />
47884017301 OAK TREE INTERN EASYMAX L BLOOD GLUCOSE SYSTEM<br />
47884017500 OAK TREE INTERN EASYMAX N GLUCOSE SYSTEM KIT<br />
47884017501 OAK TREE INTERN EASYMAX N BLOOD GLUCOSE SYSTEM<br />
47884017525 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
47884017540 OAK TREE INTERN EASYMAX NORMAL CONTROL SOLN<br />
47884017541 OAK TREE INTERN EASYMAX HIGH CONTROL SOLN<br />
47884017542 OAK TREE INTERN EASYMAX LOW CONTROL SOLN<br />
47884017550 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
49348095050 MCKESSON CORPORATION VALU-RITE V-R GLUCOSE TEST STRIP<br />
49614000011 MEDICINE SHOPPE INTERNATIONAL, BLOOD INC. GLUCOSE TEST STRIPS<br />
49614000012 MEDICINE SHOPPE INTERNATIONAL, BLOOD INC. GLUCOSE TEST STRIPS<br />
49614000113 MEDICINE SHOPPE INTERNATIONAL, BLOOD INC. GLUCOSE SYSTEM PAK<br />
49614062678 MEDICINE SHOPPE INTERNATIONAL, ULTRA INC. COMFORT 1 ML SYRINGE<br />
49614062778 MEDICINE SHOPPE INTERNATIONAL, ULTRA INC. COMFORT 0.5 ML SYRINGE<br />
49614062878 MEDICINE SHOPPE INTERNATIONAL, ULTRA INC. COMFORT 3/10 ML SYR<br />
49614063081 MEDICINE SHOPPE INTERNATIONAL, LANCETS INC.<br />
50081000300 ENTRA HEALTH SYSTEM MYGLUCOHEALTH MONITORING KIT<br />
50081000301 ENTRA HEALTH SYSTEM MYGLUCOHEALTH TEST STRIPS<br />
50081000303 ENTRA HEALTH SYSTEM MYGLUCOHEALTH 30G LANCETS<br />
50428001771 CVS CVS THIN LANCETS<br />
50428001772 CVS CVS THIN LANCETS<br />
50428001773 CVS CVS LANCETS<br />
50428008873 CVS CVS LANCING DEVICE<br />
50428008873 CVS CVS LANCING DEVICE<br />
50428147530 CVS CVS BLOOD GLUCOSE TEST SRIP<br />
50428194178 CVS CVS BLOOD GLUCOSE STRIPS<br />
50428235155 CVS CVS ULTRA THIN LANCETS<br />
50428235157 CVS CVS ULTRA THIN LANCETS<br />
50924001901 ROCHE DIAGNOSTI ACCU-CHEK COMPACT PLUS KIT<br />
50924004301 ROCHE DIAGNOSTI COAGUCHEK LANCETS<br />
50924007920 ROCHE DIAGNOSTI ACCU-CHEK SAFE-T-PRO LANCETS<br />
50924013024 ROCHE DIAGNOSTI SOFTCLIX LANCETS<br />
50924014110 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS<br />
50924030201 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY KIT<br />
50924030202 ROCHE DIAGNOSTI ACCU-CHEK COMPACT GLUCOSE SOL<br />
50924031410 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS<br />
50924035706 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN<br />
50924036550 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP<br />
50924037350 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP<br />
50924038110 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP<br />
50924039002 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN<br />
50924039002 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN<br />
50924040303 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN<br />
50924041102 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN<br />
50924044601 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET KIT<br />
50924044601 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET KIT<br />
50924045001 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET<br />
50924047550 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE TEST STRIP<br />
50924047602 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE GLUCOSE SOL<br />
50924047701 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE CARE KIT<br />
Page 30 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
50924050125 ROCHE DIAGNOSTI CHEMSTRIP BG (VISUAL ONLY)<br />
50924050250 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II)<br />
50924050810 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II)<br />
50924055001 ROCHE DIAGNOSTI ACCU-CHEK GLUCOSE SOLUTION<br />
50924056050 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS<br />
50924056610 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS<br />
50924058001 ROCHE DIAGNOSTI SOFT TOUCH LANCET DEVICE<br />
50924058510 ROCHE DIAGNOSTI SOFT TOUCH LANCETS<br />
50924076501 ROCHE DIAGNOSTI ACCU-CHEK III DIABETES METR<br />
50924076601 ROCHE DIAGNOSTI ACCU-CHEK III DIABETES KIT<br />
50924085201 ROCHE DIAGNOSTI ACCU-CHEK EASY GLUCOSE SOLN<br />
50924086001 ROCHE DIAGNOSTI ACCU-CHEK ADVANTAGE KIT<br />
50924087001 ROCHE DIAGNOSTI ACCU-CHEK ADVANTAGE METER<br />
50924087710 ROCHE DIAGNOSTI ACCU-CHEK INSTANT TEST STRP<br />
50924088110 ROCHE DIAGNOSTI ACCU-CHEK COMFORT CURVE STRIP<br />
50924088250 ROCHE DIAGNOSTI ACCU-CHEK COMFORT CURVE STRIP<br />
50924088401 ROCHE DIAGNOSTI ACCU-CHEK COMPACT DRUM STRIPS<br />
50924088901 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE METER<br />
50924091125 ROCHE DIAGNOSTI ACCU-CHEK INSTANT PLUS STRIP<br />
50924091350 ROCHE DIAGNOSTI ACCU-CHEK INSTANT TEST STRP<br />
50924091401 ROCHE DIAGNOSTI ACCU-CHEK INSTANT CARE KIT<br />
50924091901 ROCHE DIAGNOSTI ACCU-CHEK CONTROL SOLUTION<br />
50924093720 ROCHE DIAGNOSTI SOFT TOUCH LANCETS<br />
50924095110 ROCHE DIAGNOSTI ACCU-CHEK COMPACT PLUS METER<br />
50924095120 ROCHE DIAGNOSTI SOFT TOUCH SAFE-T-PRO<br />
50924095701 ROCHE DIAGNOSTI SOFTCLIX LANCET DEVICE<br />
50924097110 ROCHE DIAGNOSTI SOFTCLIX LANCETS<br />
50924097601 ROCHE DIAGNOSTI ACCU-CHEK INSTANTPLUS KIT<br />
50924098101 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCETS<br />
50924098850 ROCHE DIAGNOSTI ACCU-CHEK COMPACT DRUM STRIPS<br />
50924098901 ROCHE DIAGNOSTI ACCU-CHEK ADVAN GLUCOSE SOL<br />
51028000102 LINKS MEDICAL MEDLANCE PLUS UNIVERSAL LANCET<br />
51028000103 LINKS MEDICAL MEDLANCE PLUS LITE LANCETS<br />
51028000121 LINKS MEDICAL MEDLANCE PLUS 21G LANCETS<br />
51028000125 LINKS MEDICAL MEDLANCE PLUS 25G LANCETS<br />
51028000128 LINKS MEDICAL ACTI-LANCE 28G LANCETS<br />
51028000158 LINKS MEDICAL MICRODOT BLOOD GLUCOSE SYSTEM<br />
51028000171 LINKS MEDICAL MICRODOT NORMAL CONTROL SOLUT<br />
51028000172 LINKS MEDICAL MICRODOT HIGH-LOW CONTROL SOL<br />
51028000172 LINKS MEDICAL MICRODOT HIGH-LOW CONTROL SOL<br />
51028000175 LINKS MEDICAL MICRODOT TEST STRIPS<br />
51290000200 BIONOSTICS METER-CHECK CONTROL SOLN NORM<br />
51290000201 BIONOSTICS METER-CHECK CONTROL SOLN NORM<br />
51290000202 BIONOSTICS METER-CHECK CONTROL SOLN NORM<br />
51290000203 BIONOSTICS METER-CHECK CONTROL SOLN NORM<br />
51496840101 AIR-TITE NORM-JECT 1 ML SYRINGE<br />
51709000502 DELTA HI-TECH AIMSCO INS SYR 0.5 ML 28GX1/2"<br />
51709000503 DELTA HI-TECH AIMSCO INS SYR 1 ML 28GX1/2"<br />
51709000528 DELTA HI-TECH AIMSCO INS SYR 0.5 ML 29GX1/2"<br />
51709000529 DELTA HI-TECH AIMSCO INS SYR 1 ML 29GX1/2"<br />
51709000532 DELTA HI-TECH AIMSCO INSULIN .5ML SYRINGE<br />
51709000534 DELTA HI-TECH AIMSCO INSULIN 1ML SYRINGE<br />
Page 31 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
51709000618 DELTA HI-TECH AIMSCO SYRING 0.5 ML 30GX5/16"<br />
51709000620 DELTA HI-TECH AIMSCO INS SYR 1 ML 30GX5/16"<br />
51709000722 DELTA HI-TECH AIMSCO INS SYR 0.3 ML 30GX5/16<br />
51709000724 DELTA HI-TECH AIMSCO INS SYR 0.3 ML 29GX1/2"<br />
51709000726 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET<br />
51709000727 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET<br />
51709000728 DELTA HI-TECH AIMSCO ULTR-THIN II 30G LANCET<br />
51709000729 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET<br />
51709000740 DELTA HI-TECH AIMSCO SYRING 0.3 ML 31GX5/16"<br />
51709000742 DELTA HI-TECH AIMSCO SYRING 0.5 ML 31GX5/16"<br />
51709000760 DELTA HI-TECH AIMSCO LANCET DEVICE<br />
53459000071 VIP INTERNATION<br />
EZ SMART SYSTEM KIT<br />
53459000072 VIP INTERNATION<br />
EZ SMART TEST STRIPS<br />
53459000073 VIP INTERNATION<br />
EZ SMART BLOOD GLUCOSE LANCETS<br />
53459000076 VIP INTERNATION<br />
EZ SMART PLUS SYSTEM KIT<br />
53459000077 VIP INTERNATION<br />
EZ SMART PLUS TEST STRIPS<br />
53459000100 VIP INTERNATION<br />
EZ SMART TEST STRIPS<br />
53459000770 VIP INTERNATION<br />
EZ SMART NORMAL CONTROL SOLN<br />
53459000780 VIP INTERNATION<br />
EZ SMART LOW CONTROL SOLUTION<br />
53459000790 VIP INTERNATION<br />
EZ SMART HIGH CONTROL SOLUTION<br />
53459001727 VIP INTERNATION<br />
EZ SMART TEST STRIPS<br />
53459001737 VIP INTERNATION<br />
EZ SMART TEST STRIPS<br />
53885000623 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN<br />
53885000692 LIFESCAN ONE TOUCH DELICA LANCING DEV<br />
53885000692 LIFESCAN ONE TOUCH DELICA LANCING DEV<br />
53885000693 LIFESCAN ONE TOUCH DELICA LANCETS<br />
53885004610 LIFESCAN LIFESCAN FINE POINT LANCETS<br />
53885004810 LIFESCAN FAST TAKE TEST STRIPS<br />
53885005210 LIFESCAN SURESTEP TEST STRIPS<br />
53885010207 LIFESCAN LANCETS<br />
53885013920 LIFESCAN ONE TOUCH SURESOFT LANCING DEV<br />
53885014020 LIFESCAN ONE TOUCH SURESOFT LANCING DEV<br />
53885014110 LIFESCAN ONE TOUCH SURESOFT LANCING DEV<br />
53885014201 LIFESCAN ONE TOUCH DELICA LANCING DEV<br />
53885014201 LIFESCAN ONE TOUCH DELICA LANCING DEV<br />
53885014301 LIFESCAN ONE TOUCH DELICA LANCETS<br />
53885019725 LIFESCAN ONE TOUCH TEST STRIPS<br />
53885019850 LIFESCAN ONE TOUCH TEST STRIPS<br />
53885020801 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885024450 LIFESCAN ONE TOUCH ULTRA TEST STRIPS<br />
53885024510 LIFESCAN ONE TOUCH ULTRA TEST STRIPS<br />
53885024701 LIFESCAN ONE TOUCH ULTRA SYSTEM KIT<br />
53885027202 LIFESCAN ONE TOUCH GLUC-CONTROL SOLN<br />
53885029901 LIFESCAN ONE TOUCH PATIENT START KIT<br />
53885032501 LIFESCAN ONE TOUCH BASIC SYSTEM KIT<br />
53885034101 LIFESCAN SURESTEP SYSTEM<br />
53885035601 LIFESCAN PENLET PLUS BLOOD SAMPLER KIT<br />
53885035601 LIFESCAN PENLET PLUS BLOOD SAMPLER KIT<br />
53885035950 LIFESCAN SURESTEP TEST STRIPS<br />
53885037410 LIFESCAN ONE TOUCH TEST STRIPS<br />
53885039310 LIFESCAN ONE TOUCH ULTRASOFT LANCETS<br />
53885041601 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN<br />
Page 32 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
53885041901 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885042001 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885042101 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885044450 LIFESCAN FAST TAKE TEST STRIPS<br />
53885044801 LIFESCAN ONE TOUCH ULTRA 2 GLUCOSE SYST<br />
53885045802 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN<br />
53885052401 LIFESCAN ONE TOUCH ULTRA SMART METER<br />
53885055101 LIFESCAN ONE TOUCH ULTRALINK SYSTEM<br />
53885055201 LIFESCAN ONE TOUCH ULTRALINK SYSTEM<br />
53885063702 LIFESCAN SURESTEP GLUC CONTROL SOLN<br />
53885079325 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885079425 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885079525 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885079750 LIFESCAN SURESTEP PRO TEST STRIPS<br />
53885079805 LIFESCAN SURESTEP PRO LINEARITY KIT<br />
53885085002 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885085002 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885085102 LIFESCAN SURESTEP PRO CONTROL SOLN<br />
53885091101 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885091201 LIFESCAN ONE TOUCH ULTRAMINI METER<br />
53885093701 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN<br />
53885099425 LIFESCAN ONE TOUCH ULTRA TEST STRIPS<br />
54569137200 A-S MEDICATION INSULIN SYRINGE 28GX0.5 ML<br />
54569250500 A-S MEDICATION INSULIN U100-1 ML SYRINGE<br />
54569420800 A-S MEDICATION ONE TOUCH TEST STRIPS<br />
54868082400 PHYSICIANS TC. ACCU-CHEK ADVANTAGE STRIPS<br />
54868086300 PHYSICIANS TC. GLUCOSTIX REAGENT STRIPS<br />
54868131100 PHYSICIANS TC. INSULIN SYRINGE 1 ML 28GX1/2"<br />
54868324300 PHYSICIANS TC. ACCU-CHEK COMPACT STRIPS<br />
54868324301 PHYSICIANS TC. ACCU-CHEK COMPACT TEST DRUM<br />
54868359000 PHYSICIANS TC. ACCU-CHEK ACTIVE TEST STRIP<br />
54868493100 PHYSICIANS TC. SOFTCLIX LANCETS<br />
54868526500 PHYSICIANS TC. ONE TOUCH ULTRA TEST STRIPS<br />
54868579600 PHYSICIANS TC. ACCU-CHEK CMFRT CURVE STRIP<br />
54868579700 PHYSICIANS TC. ASCENSIA AUTODISC STRIPS<br />
54868579800 PHYSICIANS TC. ONE TOUCH ULTRASOFT LANCETS<br />
54868580600 PHYSICIANS TC. BD TEST STRIPS<br />
54868580700 PHYSICIANS TC. BD ULTRA FINE LANCETS<br />
56151014201 NIPRO DIAGNOSTIC GENTLE DRAW LANCING DEVICE<br />
56151014260 NIPRO DIAGNOSTIC LANCETS<br />
56151020101 NIPRO DIAGNOSTIC WALGREENS STARTER KIT<br />
56151020160 NIPRO DIAGNOSTIC WALGREENS LANCING DEVICE<br />
56151020201 NIPRO DIAGNOSTIC LEADER STARTER KIT<br />
56151020401 NIPRO DIAGNOSTIC KERR STARTER KIT<br />
56151020801 NIPRO DIAGNOSTIC NAVARRO STARTER KIT<br />
56151020901 NIPRO DIAGNOSTIC EXPRESS MED STARTER KIT<br />
56151021101 NIPRO DIAGNOSTIC GOOD NEIGH STARTER KIT<br />
56151021201 NIPRO DIAGNOSTIC LONG STARTER KIT<br />
56151021301 NIPRO DIAGNOSTIC W-D STARTER KIT<br />
56151021302 NIPRO DIAGNOSTIC WINN DIXIE MEDIC VALUE PACK<br />
56151021401 NIPRO DIAGNOSTIC LIFE MEDICAL STARTER KIT<br />
56151021601 NIPRO DIAGNOSTIC DIABETIC.COM STARTER KIT<br />
Page 33 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
56151021701 NIPRO DIAGNOSTIC TRUE CARE STARTER KIT<br />
56151021901 NIPRO DIAGNOSTIC MEIJER STARTER KIT<br />
56151022401 NIPRO DIAGNOSTIC SHOPRITE VALUE PACK<br />
56151022702 NIPRO DIAGNOSTIC KINRAY VALUE PACK<br />
56151030101 NIPRO DIAGNOSTIC WALGREENS TEST STRIP<br />
56151030150 NIPRO DIAGNOSTIC WALGREENS TEST STRIP<br />
56151030201 NIPRO DIAGNOSTIC LEADER TEST STRIP<br />
56151030250 NIPRO DIAGNOSTIC LEADER TEST STRIP<br />
56151030350 NIPRO DIAGNOSTIC HEALTH ALLIANCE STRIP<br />
56151030450 NIPRO DIAGNOSTIC KERR TEST STRIPS<br />
56151030650 NIPRO DIAGNOSTIC DUANE READE TEST STRIPS<br />
56151030850 NIPRO DIAGNOSTIC NAVARRO TEST STRIPS<br />
56151030950 NIPRO DIAGNOSTIC EXPRESS MED TEST STRIPS<br />
56151031101 NIPRO DIAGNOSTIC GOOD NEIGH TEST STRIP<br />
56151031150 NIPRO DIAGNOSTIC GOOD NEIGH TEST STRIP<br />
56151031250 NIPRO DIAGNOSTIC LONG TEST STRIP<br />
56151031301 NIPRO DIAGNOSTIC W-D TEST STRIP<br />
56151031350 NIPRO DIAGNOSTIC W-D TEST STRIP<br />
56151031950 NIPRO DIAGNOSTIC MEIJER TEST STRIP<br />
56151032401 NIPRO DIAGNOSTIC SHOPRITE TEST STRIPS<br />
56151032450 NIPRO DIAGNOSTIC SHOPRITE TEST STRIPS<br />
56151032701 NIPRO DIAGNOSTIC KINRAY TEST STRIPS<br />
56151032750 NIPRO DIAGNOSTIC KINRAY TEST STRIPS<br />
56151050401 NIPRO DIAGNOSTIC PRESTIGE METER<br />
56151052501 NIPRO DIAGNOSTIC PRESTIGE BLOOD GLUCOSE METR<br />
56151055001 NIPRO DIAGNOSTIC PSS TEST STRIP<br />
56151055050 NIPRO DIAGNOSTIC PSS TEST STRIP<br />
56151055550 NIPRO DIAGNOSTIC PRESTIGE TEST STRIPS<br />
56151056301 NIPRO DIAGNOSTIC PRESTIGE GLUCOSE CONTROL<br />
56151056601 NIPRO DIAGNOSTIC PRESTIGE GLUCOSE CONTROL<br />
56151057801 NIPRO DIAGNOSTIC PRESTIGE VALUE PACK<br />
56151081001 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS<br />
56151081350 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS<br />
56151082525 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS<br />
56151085050 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS<br />
56151086001 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL<br />
56151086101 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL<br />
56151086301 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL<br />
56151086401 NIPRO DIAGNOSTIC TRUECONTROL GLUCOSE SOLUTION<br />
56151086501 NIPRO DIAGNOSTIC TRUECONTROL GLUCOSE SOLUTION<br />
56151087101 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLUTION LOW<br />
56151087201 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLN NORMAL<br />
56151087301 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLN HIGH<br />
56151088050 NIPRO DIAGNOSTIC SIDEKICK BLOOD GLUCOSE SYSTEM<br />
56151088050 NIPRO DIAGNOSTIC SIDEKICK BLOOD GLUCOSE SYSTEM<br />
56151088801 NIPRO DIAGNOSTIC SM TRUETRACK SMART SYSTEM<br />
56151088880 NIPRO DIAGNOSTIC TRUETRACK SMART SYSTEM<br />
56151090090 NIPRO DIAGNOSTIC PRESTIGE SMART SYSTEM METER<br />
56151091001 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP<br />
56151092002 NIPRO DIAGNOSTIC PRESTIGE SMART SYS VALUE PK<br />
56151095050 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP<br />
56151099902 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP<br />
Page 34 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
56151099990 NIPRO DIAGNOSTIC PRESTIGE SMART SYS IQ KIT<br />
56151103001 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS<br />
56151103025 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS<br />
56151103050 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS<br />
56151109801 NIPRO DIAGNOSTIC LIBERTY LEV 1 GLUCOSE CTRL SOL<br />
56151109901 NIPRO DIAGNOSTIC LIBERTY LEV 2 GLUCOSE CTRL SOL<br />
56151109950 NIPRO DIAGNOSTIC LIBERTY TEST STRIPS<br />
56151124001 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM<br />
56151128901 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM<br />
56151129801 NIPRO DIAGNOSTIC LIBERTY BLOOD GLUCOSE MONITOR<br />
56151134001 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM<br />
56151138901 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM<br />
56151181350 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS<br />
57515003219 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"<br />
57515003259 ULTIMED INC ULTICARE INS 0.5 ML 29GX1/2"<br />
57515007201 ULTIMED INC ULTICARE THIN 28G LANCETS<br />
57515007219 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE<br />
57515007219 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE<br />
57515007239 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE<br />
57515007239 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE<br />
57515007259 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE<br />
57515007259 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE<br />
57515007315 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
57515007319 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
57515007319 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE<br />
57515007335 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
57515007339 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
57515007339 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE<br />
57515007355 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
57515007359 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
57515007359 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE<br />
57515007419 ULTIMED INC ULTIGUARD 31GX1 ML SYRINGE<br />
57515007439 ULTIMED INC ULTIGUARD 31GX0.3 ML SYRINGE<br />
57515007459 ULTIMED INC ULTIGUARD 31GX0.5 ML SYRINGE<br />
57515008218 ULTIMED INC ULTICARE INS SYR 1 ML 28GX1/2"<br />
57515008258 ULTIMED INC ULTICARE SYRIN 0.5 ML 28GX1/2"<br />
57515008259 ULTIMED INC INS SYR U100 0.5 ML 29GX1/2"<br />
57515009219 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"<br />
57515009239 ULTIMED INC ULTICARE SYRIN 0.3 ML 29GX1/2"<br />
57515009259 ULTIMED INC ULTICARE U100 0.5 ML 29GX1/2"<br />
57515009315 ULTIMED INC ULTICARE INSULIN SYR U100 1 ML<br />
57515009319 ULTIMED INC CAREONE INS SYR 1 ML 30GX5/16"<br />
57515009335 ULTIMED INC ULTICARE INSUL SYR U100 0.3 ML<br />
57515009339 ULTIMED INC ULTICARE U100 0.3 ML 30GX5/16"<br />
57515009355 ULTIMED INC ULTICARE INSUL SYR U100 0.5 ML<br />
57515009359 ULTIMED INC ULTICARE SYR 0.5 ML 30GX5/16"<br />
57515009419 ULTIMED INC ULTCARE INS SYR 1 ML 31GX5/16"<br />
57515009439 ULTIMED INC ULTICARE SYR 0.3 ML 31GX5/16"<br />
57515009459 ULTIMED INC ULTICARE SYR 0.5 ML 31GX5/16"<br />
57515059259 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML<br />
57515059319 ULTIMED INC ORSINI INSUL SYR U100 1 ML<br />
57515059359 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML<br />
Page 35 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
57599004305 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
57599006305 ABBOTT DIABETES PRECISION PCX PLUS TEST STR<br />
57599011605 ABBOTT DIABETES PRECISION POINT OF CARE STR<br />
57599013801 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
57599013901 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
57599031201 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
57599033901 ABBOTT DIABETES PRECISION PCX PLUS TEST STR<br />
57599055001 ABBOTT DIABETES MEDISENSE H-L CONTROL SOLUTION<br />
57599055101 ABBOTT DIABETES MEDISENSE H-M-L CONTROL SOLN<br />
57599055201 ABBOTT DIABETES MEDISENSE MID CONTROL SOLUTION<br />
57599104104 ABBOTT DIABETES OPTIUM EZ TEST STRIP<br />
57599104205 ABBOTT DIABETES OPTIUM EZ TEST STRIP<br />
57599471102 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
57599713701 ABBOTT DIABETES ULTRATLC LANCETS<br />
57599713805 ABBOTT DIABETES ULTRATLC LANCETS<br />
57599740004 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599740105 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599741102 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
57599743201 ABBOTT DIABETES MEDISENSE CONTROL SOLUTION<br />
57599813803 ABBOTT DIABETES ULTRATLC THIN LANCETS<br />
57599822801 ABBOTT DIABETES PRECISION Q-I-D PEN<br />
57599833501 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599833601 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599841101 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
57599843601 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
57599854601 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599854701 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599854801 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599854901 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599855001 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599857301 ABBOTT DIABETES PRECISION COLORED METER<br />
57599857401 ABBOTT DIABETES PRECISION COLORED METER<br />
57599857501 ABBOTT DIABETES PRECISION COLORED METER<br />
57599857601 ABBOTT DIABETES PRECISION COLORED METER<br />
57599868102 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
57599868105 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
57599868205 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
57599868206 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
57599872901 ABBOTT DIABETES EXACTECH TEST STRIPS<br />
57599873001 ABBOTT DIABETES EXACTECH TEST STRIPS<br />
57599873201 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599873204 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599873301 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599873305 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
57599874605 ABBOTT DIABETES UNISTIK 2 NORMAL 0.81MM DEVICE<br />
57599874605 ABBOTT DIABETES UNISTIK 2 NORMAL 0.81MM DEVICE<br />
57599874705 ABBOTT DIABETES UNISTIK 2 EXTRA 0.81 MM DEVICE<br />
57599874705 ABBOTT DIABETES UNISTIK 2 EXTRA 0.81 MM DEVICE<br />
57599875705 ABBOTT DIABETES PRECISION PCX TEST STRIPS<br />
57599881401 ABBOTT DIABETES PRECISION XTRA MONITOR<br />
57599889401 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
57599889501 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
Page 36 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
57599912101 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
57599913404 ABBOTT DIABETES OPTIUM TEST STRIP<br />
57599913505 ABBOTT DIABETES OPTIUM TEST STRIP<br />
57599956505 ABBOTT DIABETES PRECISION PCX TEST STRIPS<br />
57599969405 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
57599969504 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
57599972804 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
57599983701 ABBOTT DIABETES PRECISION XTRA MONITOR<br />
57599983804 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
57599987705 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
57599987805 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
59707000100 UNIQUEONE PHARM SURE-JECT INSU SYR U100 1 ML<br />
59707000101 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707000102 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML<br />
59707000103 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707000104 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML<br />
59707000105 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML<br />
59707000106 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707000107 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML<br />
59707000110 UNIQUEONE PHARM SURE-LANCE THIN LANCET<br />
59707000112 UNIQUEONE PHARM SURE-LANCE ULTRA THIN LANCET<br />
59707000155 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI METER<br />
59707000156 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI STRIP<br />
59707000157 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI SOLN<br />
59707000166 UNIQUEONE PHARM SURE-LANCE FLAT LANCETS<br />
59707010001 UNIQUEONE PHARM SURE-PEN LANCING DEVICE<br />
59707012801 UNIQUEONE PHARM SURE-JECT INSU SYR U100 1 ML<br />
59707012850 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707012901 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML<br />
59707012930 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML<br />
59707012950 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707013001 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML<br />
59707013030 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML<br />
59707013050 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML<br />
59707013101 UNIQUEONE PHARM SURE-JECT INSULIN SYRINGE 1 ML<br />
59707013130 UNIQUEONE PHARM SURE-JECT INSULIN SYR 0.3 ML<br />
59707013150 UNIQUEONE PHARM SURE-JECT INSULIN SYR 0.5 ML<br />
59707026101 UNIQUEONE PHARM SURE-LANCE LANCET<br />
59707028101 UNIQUEONE PHARM SURE-LANCE THIN LANCET<br />
59707028128 UNIQUEONE PHARM SURE-LANCE FLAT LANCETS<br />
59707030101 UNIQUEONE PHARM SURE-LANCE ULTRA THIN LANCET<br />
59707051001 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI SOLN<br />
59707055001 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI STRIP<br />
59707055101 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI METER<br />
59779032301 CVS/PHARMACY CVS LANCETS-THIN<br />
59779032302 CVS/PHARMACY CVS LANCETS-THIN<br />
59779032304 CVS/PHARMACY CVS LANCETS-ORIGINAL<br />
59779114599 CVS/PHARMACY CVS SYRINGE 3/10 ML<br />
59779114796 CVS/PHARMACY CVS SYRINGE 1/2 ML<br />
59779114799 CVS/PHARMACY CVS INSULIN SYR 1 ML 29GX1/2"<br />
59779114803 CVS/PHARMACY CVS SYRINGE 3/10 ML<br />
59779114811 CVS/PHARMACY CVS SYRINGE 1/2 ML<br />
Page 37 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
60171097001 ENTRA HEALTH SYSTEM MYGLUCOHEALTH MONITORING KIT<br />
60171097003 ENTRA HEALTH SYSTEM MYGLUCOHEALTH TEST STRIPS<br />
61059000419 OWEN MUMFORD US UNILET GP LANCET<br />
61059000751 OWEN MUMFORD US UNISTIK 2 NORMAL 0.81MM DEVICE<br />
61059000751 OWEN MUMFORD US UNISTIK 2 NORMAL 0.81MM DEVICE<br />
61059000851 OWEN MUMFORD US UNISTIK 2 EXTRA 0.81 MM DEVICE<br />
61059000851 OWEN MUMFORD US UNISTIK 2 EXTRA 0.81 MM DEVICE<br />
61059000914 OWEN MUMFORD US UNILET GP LANCET<br />
61059001119 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
61059001515 OWEN MUMFORD US UNILET GP LANCET SUPERLITE<br />
61059002116 OWEN MUMFORD US UNILET LANCET<br />
61059003113 OWEN MUMFORD US UNILET LANCET SUPERLITE<br />
61059003519 OWEN MUMFORD US UNILET LANCET SUPERLITE<br />
61059005301 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
61059005351 OWEN MUMFORD US UNILET EXCELITE II LANCET<br />
61059005711 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE<br />
61059005711 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE<br />
61059006718 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
61059006718 OWEN MUMFORD US UNISTIK 3 MM DEVICE<br />
61059007517 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
61059007517 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
61059007715 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
61059007715 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE<br />
61059008514 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059008514 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059008712 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059008712 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059009511 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059009511 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE<br />
61059010111 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE<br />
61059012313 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV<br />
61059015714 OWEN MUMFORD US DR LANCET<br />
61059025714 OWEN MUMFORD US ULTRA THIN LANCETS<br />
61059025735 OWEN MUMFORD US ULTRA THIN 28G LANCETS<br />
61059025736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET<br />
61059026013 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
61059026013 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
61059026518 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
61059026518 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE<br />
61059027010 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV<br />
61059027119 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV<br />
61059035714 OWEN MUMFORD US DR ULTRA THIN LANCET<br />
61059035726 OWEN MUMFORD US LIVE BETTER ULTRA THIN LANCET<br />
61059043514 OWEN MUMFORD US ALTERNATE SITE LANCETS<br />
61059046011 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
61059046516 OWEN MUMFORD US UNILET COMFORTOUCH LANCET<br />
61059051015 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
61059051510 OWEN MUMFORD US UNILET EXCELITE LANCET<br />
61059065711 OWEN MUMFORD US COMFORT LANCETS<br />
61059065714 OWEN MUMFORD US SUPER THIN LANCETS<br />
61059065726 OWEN MUMFORD US LIVE BETTER SUPER THIN LANCET<br />
61059065735 OWEN MUMFORD US SUPER THIN 30G LANCETS<br />
Page 38 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
61059065736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET<br />
61059070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING<br />
61059070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING<br />
61059074212 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE<br />
61059074212 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE<br />
61059076216 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
61059076216 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE<br />
61059100219 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
61059100219 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
61059104217 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
61059104217 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
61059106211 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
61059106211 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC<br />
63323090490 APP PHARMACEUTICALS, LLC. FLOW-EZE VENTED NEEDLE<br />
63706001110 MEDTRONIC MINIM MINILET THIN LANCETS<br />
65702010110 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA MONITORING KIT<br />
65702010210 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA METER<br />
65702010310 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA TEST STRIPS<br />
65702010410 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA TEST STRIPS<br />
65702010610 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA TEST STRIPS<br />
65702010710 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA SOLUTION<br />
65702010710 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA SOLUTION<br />
65702012410 ROCHE DIAGNOSTI<br />
ACCU-CHEK SOFTCLIX LANCETS<br />
65702015610 ROCHE DIAGNOSTI<br />
ACCU-CHEK SOFTCLIX LANCETS<br />
65702021210 ROCHE DIAGNOSTI<br />
ACCU-CHEK AVIVA TEST STRIPS<br />
65702021510 ROCHE DIAGNOSTI<br />
ACCU-CHEK COMFORT CURVE STRIP<br />
65702022310 ROCHE DIAGNOSTI<br />
ACCU-CHEK COMPACT STRIPS<br />
65702027410 ROCHE DIAGNOSTI<br />
ACCUTREND GLUCOSE TEST STRIP<br />
65702027510 ROCHE DIAGNOSTI<br />
ACCUTREND GLUCOSE CONTROL<br />
65702027510 ROCHE DIAGNOSTI<br />
ACCUTREND GLUCOSE CONTROL<br />
65702036910 ROCHE DIAGNOSTI<br />
ACCU-CHEK COMPACT BLUE CONTROL<br />
65702036910 ROCHE DIAGNOSTI<br />
ACCU-CHEK COMPACT BLUE CONTROL<br />
65702040010 ROCHE DIAGNOSTI<br />
ACCU-CHECK SOFTCLIX LANCET KIT<br />
65702040010 ROCHE DIAGNOSTI<br />
ACCU-CHECK SOFTCLIX LANCET KIT<br />
66004005501 SOLARTEK PROD.I ULTIMA MONITOR KIT<br />
66004012104 SOLARTEK PROD.I ULTIMA TEST STRIPS<br />
66004012205 SOLARTEK PROD.I ULTIMA TEST STRIPS<br />
66004085004 SOLARTEK PROD.I BLOOD GLUCOSE TEST STRIPS<br />
66004085105 SOLARTEK PROD.I BLOOD GLUCOSE TEST STRIPS<br />
66004097309 SOLARTEK PROD.I RELION ULTIMA TEST STRIPS<br />
66852000490 AMIRA MEDICAL AT-LAST BLOOD GLUCOSE SYSTM<br />
66852000539 AMIRA MEDICAL AT-LAST LANCETS<br />
66852000547 AMIRA MEDICAL AT-LAST TEST STRIPS<br />
66852001171 AMIRA MEDICAL AT-LAST TEST STRIPS<br />
68016001670 CHAIN DRUG CONSORTIUM, LLC PV LANCING DEVICE<br />
68016001676 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYSTEM<br />
68016001677 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYS STRIPS<br />
68016001678 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYS STRIPS<br />
68016030554 CHAIN DRUG CONSORTIUM, LLC PV ULTRA THIN LANCETS<br />
68016030754 CHAIN DRUG CONSORTIUM, LLC PV ULTRA THIN LANCETS<br />
68016051054 CHAIN DRUG CONSORTIUM, LLC PV LANCING DEVICE<br />
68016065035 CHAIN DRUG CONSORTIUM, LLC PV INSUL SYR 0.3 ML 31GX5/16"<br />
Page 39 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
68016065055 CHAIN DRUG CONSORTIUM, LLC PV INSUL SYR 0.5 ML 31GX5/16"<br />
68016065105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYR 1 ML 31GX5/16"<br />
68016070055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML<br />
68016070105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 1 ML<br />
68016080055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML<br />
68016080105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 1 ML<br />
68016090055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML<br />
68016090105 CHAIN DRUG CONSORTIUM, LLC PV INS SYRIN 1 ML 29GX1/2"<br />
75537000501 ROCHE DIAGNOSTI<br />
CHEMSTRIP BG (VISUAL ONLY)<br />
75537000502 ROCHE DIAGNOSTI<br />
CHEMSTRIP BG(ACCU-CHEK II)<br />
75537000508 ROCHE DIAGNOSTI<br />
CHEMSTRIP BG(ACCU-CHEK II)<br />
75537000535 ROCHE DIAGNOSTI<br />
TRACER BG TEST STRIP<br />
75537000560 ROCHE DIAGNOSTI<br />
ACCU-CHEK EASY TEST STRIPS<br />
75537000566 ROCHE DIAGNOSTI<br />
ACCU-CHEK EASY TEST STRIPS<br />
75537000852 ROCHE DIAGNOSTI<br />
ACCU-CHEK EASY GLUCOSE SOLN<br />
75537000877 ROCHE DIAGNOSTI<br />
ACCU-CHEK INSTANT TEST STRP<br />
75537000914 ROCHE DIAGNOSTI<br />
ACCU-CHEK INSTANT CARE KIT<br />
75537030250 ROCHE DIAGNOSTI<br />
ACCU-CHEK SIMPLICITY KIT<br />
75537030276 ROCHE DIAGNOSTI<br />
ACCU-CHEK SIMPLICITY STRIPS<br />
75537030314 ROCHE DIAGNOSTI<br />
ACCU-CHEK SIMPLICITY STRIPS<br />
75537031429 ROCHE DIAGNOSTI<br />
SOFTCLIX LANCETS<br />
76300001701 MEDTRONIC MINIM PARADIGM REAL-TIME SYSTEM<br />
76300001701 MEDTRONIC MINIM PARADIGM REAL-TIME SYSTEM<br />
76300007202 MEDTRONIC MINIM GUARDIAN REAL-TIME GLU MONITOR<br />
76300007202 MEDTRONIC MINIM GUARDIAN REAL-TIME GLU MONITOR<br />
76300010310 MEDTRONIC MINIM MINIMED RESERVOIR 3 ML<br />
76300070701 MEDTRONIC MINIM MINILINK REAL-TIME TRANSMITTER<br />
80196073405 MEDLINE INDUS. EVENCARE CONTROL SOLUTION<br />
80196073405 MEDLINE INDUS. EVENCARE CONTROL SOLUTION<br />
80196073413 MEDLINE INDUS. EVENCARE MONITORING SYSTEM<br />
80196073463 MEDLINE INDUS. EVENCARE GLUCOSE TST STRIPS<br />
81131031162 WAL-MART STORES RELION INS SYR 1 ML 29GX1/2"<br />
81131031163 WAL-MART STORES RELION INS SYR 1 ML 29GX1/2"<br />
81131031164 WAL-MART STORES RELION INS SYR 0.5 ML 29GX1/2"<br />
81131031165 WAL-MART STORES RELION INS SYR 0.5 ML 29GX1/2"<br />
81131031166 WAL-MART STORES RELION INS SYR 0.3 ML 29GX1/2"<br />
81131031167 WAL-MART STORES RELION INS SYR 0.3 ML 29GX1/2"<br />
81131031168 WAL-MART STORES RELION INS SYR 1 ML 30GX5/16"<br />
81131031169 WAL-MART STORES RELION INS SYR 1 ML 30GX5/16"<br />
81131031170 WAL-MART STORES RELION SYR 0.5 ML 30GX5/16"<br />
81131031171 WAL-MART STORES RELION SYR 0.5 ML 30GX5/16"<br />
81131031172 WAL-MART STORES RELION INS SYR 0.3 ML 30GX5/16<br />
81131031173 WAL-MART STORES RELION INS SYR 0.3 ML 30GX5/16<br />
81131031174 WAL-MART STORES RELION INS SYR 1 ML 31GX5/16"<br />
81131031175 WAL-MART STORES RELION INS SYR 1 ML 31GX5/16"<br />
81131031176 WAL-MART STORES RELION SYRING 0.5 ML 31GX5/16"<br />
81131031177 WAL-MART STORES RELION SYRING 0.5 ML 31GX5/16"<br />
81131031178 WAL-MART STORES RELION SYRING 0.3 ML 31GX5/16"<br />
81131031179 WAL-MART STORES RELION SYRING 0.3 ML 31GX5/16"<br />
81306021214 ACCESS LLC RELION THIN LANCETS<br />
81306021314 ACCESS LLC RELION THIN LANCETS<br />
81306022114 ACCESS LLC RELION LANCETS<br />
Page 40 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
81306022314 ACCESS LLC RELION THIN LANCETS<br />
81306051413 ACCESS LLC RELION INSULIN SYR 0.3 ML<br />
81306051423 ACCESS LLC RELION INSULIN SYR 0.3 ML<br />
81306051523 ACCESS LLC RELION INSULIN SYR 0.5 ML<br />
81306051613 ACCESS LLC RELION INSULIN SYRINGE 1 ML<br />
81306051623 ACCESS LLC RELION INSULIN SYRINGE 1 ML<br />
81306052413 ACCESS LLC RELI-ON INSULIN 0.3 ML SYR<br />
81306052513 ACCESS LLC RELI-ON INSULIN 0.5 ML SYR<br />
81306052613 ACCESS LLC RELI-ON INSULIN 1 ML SYR<br />
82468014443 FAMILY PHARMACY FP LANCETS THIN<br />
82468061430 FAMILY PHARMACY FP INSULIN 1 ML SYRINGE<br />
82468061432 FAMILY PHARMACY FP INSULIN 0.5 ML SYRINGE<br />
82468061433 FAMILY PHARMACY FP INSULIN 1 ML SYRINGE<br />
85017000000 OAK TREE INTERN EASYMAX N GLUCOSE SYSTEM KIT<br />
85017000001 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
85017000002 OAK TREE INTERN EASYMAX NORMAL CONTROL SOLN<br />
85017000003 OAK TREE INTERN EASYMAX HIGH CONTROL SOLN<br />
85017000004 OAK TREE INTERN EASYMAX LOW CONTROL SOLN<br />
85017000007 OAK TREE INTERN EASYMAX V GLUCOSE SYSTEM KIT<br />
85017000008 OAK TREE INTERN EASYMAX L GLUCOSE SYSTEM KIT<br />
85017000009 OAK TREE INTERN EASYMAX L BLOOD GLUCOSE SYSTEM<br />
85017000010 OAK TREE INTERN EASYMAX SPEAKING CONTROL SOLN<br />
85017000015 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
85017000016 OAK TREE INTERN EASYMAX N BLOOD GLUCOSE SYSTEM<br />
85017000023 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS<br />
85325000001 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
85325000002 I-SENS, INC. CARESENS N TEST STRIPS<br />
85325000004 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
85325000005 I-SENS, INC. CARESENS N TEST STRIPS<br />
85325000011 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
85325000015 I-SENS, INC. ACURA PLUS STARTER KIT<br />
85325000016 I-SENS, INC. ACURA PLUS METER KIT<br />
85325000017 I-SENS, INC. ACURA PLUS METER KIT<br />
85325000019 I-SENS, INC. CARESENS N TEST STRIPS<br />
85325000020 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST<br />
85930001101 VERTEX DIAGNOST ULTRATRAK TEST STRIP<br />
85930001103 VERTEX DIAGNOST ULTRATRAK CONTROL SOLUTION<br />
85930001103 VERTEX DIAGNOST ULTRATRAK CONTROL SOLUTION<br />
85930001104 VERTEX DIAGNOST ULTRATRAK CONTROL SOL NORMAL<br />
85930001107 VERTEX DIAGNOST ULTRATRAK BLOOD GLUCOSE METER<br />
85930001108 VERTEX DIAGNOST ULTRATRAK PRO METER KIT<br />
86227018525 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 30GX1/2"<br />
86227018635 ALLISON MEDICAL PUB INSUL SYR 0.3 ML 31GX5/16"<br />
86227018745 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 31GX5/16"<br />
86227018855 ALLISON MEDICAL PUB INSULIN SYR 1 ML 31GX5/16"<br />
86227018995 ALLISON MEDICAL PUB INS SYRIN 0.3 ML 30GX1/2"<br />
86227019075 ALLISON MEDICAL PUB INS SYRINGE 1 ML 30GX1/2"<br />
86227028105 ALLISON MEDICAL SURE COMFORT 28G LANCETS<br />
86227028205 ALLISON MEDICAL SURE COMFORT 28G LANCETS<br />
86227030105 ALLISON MEDICAL SURE COMFORT 30G LANCETS<br />
86227030205 ALLISON MEDICAL SURE COMFORT 30G LANCETS<br />
86227052205 ALLISON MEDICAL SURE COMFORT LANCING PEN<br />
Page 41 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
86227062035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE<br />
86227062055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE<br />
86227062105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE<br />
86227065035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE<br />
86227065045 ALLISON MEDICAL SURE COMFORT 0.3 ML SYRINGE<br />
86227065055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE<br />
86227065105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE<br />
86227070035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE<br />
86227070055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE<br />
86227070105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE<br />
86227080055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE<br />
86227080105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE<br />
86227090035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE<br />
86227090055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE<br />
86227090105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE<br />
86227921625 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 30GX1/2"<br />
86227921635 ALLISON MEDICAL PUB INSUL SYR 0.3 ML 31GX5/16"<br />
86227921645 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 31GX5/16"<br />
86227921655 ALLISON MEDICAL PUB INSULIN SYR 1 ML 31GX5/16"<br />
87701033674 BRITE LIFE BL TEST STRIPS<br />
87701039908 BRITE LIFE GNP SUPER THIN LANCETS<br />
87701039972 BRITE LIFE GNP INSUL SYR 0.5 ML 31GX5/16"<br />
87701039973 BRITE LIFE GNP INSULIN SYR 1 ML 31GX5/16"<br />
87701039974 BRITE LIFE GNP INSUL SYR 0.3 ML 31GX5/16"<br />
87701044288 BRITE LIFE BL INSULIN 0.3 ML SYRINGE<br />
87701044671 BRITE LIFE GNP THIN LANCETS<br />
87701052620 BRITE LIFE GNP LANCING SYSTEM DEVICE<br />
87701057044 BRITE LIFE GNP LANCETS<br />
87701057046 BRITE LIFE GNP LANCETS<br />
87701057048 BRITE LIFE BL LANCETS<br />
87701065329 BRITE LIFE BL INSULIN 1 ML SYRINGE<br />
87701065340 BRITE LIFE BL INSULIN 0.5 ML SYRINGE<br />
87701065343 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE<br />
87701065352 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR<br />
87701065354 BRITE LIFE GNP ULTRA COMFORT 3/10 ML SYR<br />
87701066838 BRITE LIFE BL REAGENT STRIPS<br />
87701066840 BRITE LIFE BL REAGENT STRIPS<br />
87701074702 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR<br />
87701074723 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE<br />
87701074725 BRITE LIFE GNP ULTRA COMFORT 3/10 ML SYR<br />
87701074728 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR<br />
87701074745 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE<br />
87701083729 BRITE LIFE BL THIN LANCETS<br />
87701088246 BRITE LIFE GNP COLOR LANCETS<br />
87701095986 BRITE LIFE GNP THIN LANCETS<br />
89105200001 MPA-DIABETIC CHOICEDM CLARUS TEST STRIPS<br />
89105200002 MPA-DIABETIC CHOICEDM CLARUS CONTROL SOLN<br />
89105200008 MPA-DIABETIC CHOICEDM CLARUS MONITOR SYSTEM<br />
89123700113 HOME AIDE DIAGN EASY CHECK CONTROL SOLN HIGH<br />
89123700114 HOME AIDE DIAGN EASY CHECK CONTROL SOLN LOW<br />
89123700118 HOME AIDE DIAGN EASY STEP BLOOD GLUCOSE METER<br />
89123700121 HOME AIDE DIAGN EASY STEP GLUCOSE SYSTEM KIT<br />
Page 42 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
89123700141 HOME AIDE DIAGN EASY TRAK BLOOD GLUCOSE METER<br />
89123700142 HOME AIDE DIAGN EASY TRAK GLUCOSE TEST STRIP<br />
89123700143 HOME AIDE DIAGN EASY TRAK CONTROL SOLN NORMAL<br />
89123700144 HOME AIDE DIAGN EASY TRAK GLUCOSE SYSTEM KIT<br />
89123700145 HOME AIDE DIAGN EASY TRAK CONTROL SOLN HIGH<br />
89123700146 HOME AIDE DIAGN EASY TRAK CONTROL SOLN LOW<br />
89123700147 HOME AIDE DIAGN EASY TALK BLOOD GLUCOSE METER<br />
89123700148 HOME AIDE DIAGN EASY TALK GLUCOSE TEST STRIP<br />
89123700149 HOME AIDE DIAGN EASY TALK CONTROL SOLN LOW<br />
89123700151 HOME AIDE DIAGN EASY TALK GLUCOSE SYSTEM KIT<br />
89123700152 HOME AIDE DIAGN EASY TALK HIGH CONTROL SOLN<br />
90166005015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 30GX1/2"<br />
90166005035 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 30GX1/2"<br />
90166005055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 30GX1/2"<br />
90166005615 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 30GX5/16"<br />
90166005635 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 30GX5/16"<br />
90166005655 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 30GX5/16"<br />
90166012102 GLOBAL DIABETIC E-Z PULL & CLICK LANCING DEV<br />
90166012804 GLOBAL DIABETIC INJECT EASE 28G LANCETS<br />
90166013004 GLOBAL DIABETIC INJECT EASE 30G LANCETS<br />
90166015615 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 31GX5/16"<br />
90166015635 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 31GX5/16"<br />
90166015655 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 31GX5/16"<br />
90166085015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 28GX1/2"<br />
90166085055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 28GX1/2"<br />
90166095015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 29GX1/2"<br />
90166095035 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 29GX1/2"<br />
90166095055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 29GX1/2"<br />
91237000100 HOME AIDE DIAGN EASY CHECK GLUCOSE METER<br />
91237000101 HOME AIDE DIAGN EASY CHECK GLUCOSE TEST STRIP<br />
91237000102 HOME AIDE DIAGN EASY CHECK GLUCOSE CNTRL SOLN<br />
91237000104 HOME AIDE DIAGN EASY TOUCH LANCETS<br />
91237000105 HOME AIDE DIAGN EASY CLICK LANCING DEVICE<br />
91237000108 HOME AIDE DIAGN EASY COMFORT INSULIN 1 ML SYR<br />
91237000109 HOME AIDE DIAGN EASY COMFORT 0.5 ML SYRINGE<br />
91237000110 HOME AIDE DIAGN EASY COMFORT 0.3 ML SYRINGE<br />
91237000112 HOME AIDE DIAGN EASY CHECK BLOOD GLUCOSE SYS<br />
91237000113 HOME AIDE DIAGN EASY CHECK CONTROL SOLN HIGH<br />
91237000114 HOME AIDE DIAGN EASY CHECK CONTROL SOLN LOW<br />
91237000115 HOME AIDE DIAGN EASY TOUCH LANCETS<br />
91237000116 HOME AIDE DIAGN EASY TOUCH LANCETS<br />
91237000118 HOME AIDE DIAGN EASY STEP BLOOD GLUCOSE METER<br />
91237000121 HOME AIDE DIAGN EASY STEP GLUCOSE SYSTEM KIT<br />
91899001884 MEDICINE SHOP MS E-ZJECT LANCETS<br />
91899042912 MEDICINE SHOP MS INSUL SYR 0.3 ML 31GX5/16"<br />
91899043012 MEDICINE SHOP MS INSUL SYR 0.5 ML 31GX5/16"<br />
91899043112 MEDICINE SHOP MS INSULIN SYR 1 ML 31GX5/16"<br />
91899060778 MEDICINE SHOP MS INS SYR 0.5 ML 29GX1/2"<br />
91899060878 MEDICINE SHOP MS INS SYR 1 ML 29GX1/2"<br />
91899060978 MEDICINE SHOP MS INSULIN SYR 0.3 ML 29GX1/2"<br />
91899062178 MEDICINE SHOP MS LANCETS<br />
91899062181 MEDICINE SHOP MS LANCETS<br />
Page 43 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
91899062678 MEDICINE SHOP MS INS SYRINGE 1 ML 30GX1/2"<br />
91899062778 MEDICINE SHOP MS INSUL SYR 0.5 ML 30GX1/2"<br />
91899062878 MEDICINE SHOP MS INSULIN SYRINGE 0.3 ML<br />
91899063078 MEDICINE SHOP MS THIN LANCETS<br />
91899063178 MEDICINE SHOP MS SUPER THIN LANCETS<br />
92896000001 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 1 ML<br />
92896000002 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 0.5 ML<br />
92896000003 FIFTY50 PHARMAC<br />
FIFTY50 INSULIN SYRINGE 0.3 ML<br />
92896000008 FIFTY50 PHARMAC<br />
FIFTY50 2.0 GLUCOSE METER<br />
92896000009 FIFTY50 PHARMAC<br />
FIFTY50 GLUCOSE TEST STRIP<br />
92896000016 FIFTY50 PHARMAC<br />
FIFTY50 GLUCOSE CONTROL SOLN<br />
92896000019 FIFTY50 PHARMAC<br />
FIFTY50 SAFETY SEAL LANCETS<br />
92896000800 FIFTY50 PHARMAC<br />
FIFTY50 LANCING DEVICE<br />
92896000810 FIFTY50 PHARMAC<br />
FIFTY50 SAFETY SEAL LANCETS<br />
93351012710 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE<br />
93815070043 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
93815070550 ABBOTT DIABETES MEDISENSE H-L CONTROL SOLUTION<br />
93815070551 ABBOTT DIABETES MEDISENSE H-M-L CONTROL SOLN<br />
93815070552 ABBOTT DIABETES MEDISENSE MID CONTROL SOLUTION<br />
93815071041 ABBOTT DIABETES OPTIUM EZ TEST STRIP<br />
93815071042 ABBOTT DIABETES OPTIUM EZ TEST STRIP<br />
93815080063 ABBOTT DIABETES PRECISION PCX PLUS TEST STR<br />
93815080116 ABBOTT DIABETES PRECISION POINT OF CARE STR<br />
93815080138 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
93815080139 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
93815080312 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL<br />
93815080339 ABBOTT DIABETES PRECISION PCX PLUS TEST STR<br />
93815097137 ABBOTT DIABETES ULTRATLC LANCETS<br />
93815097138 ABBOTT DIABETES ULTRATLC LANCETS<br />
93815097400 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815097401 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815097411 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
93815097432 ABBOTT DIABETES MEDISENSE CONTROL SOLUTION<br />
93815098138 ABBOTT DIABETES ULTRATLC THIN LANCETS<br />
93815098335 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815098336 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815098436 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
93815098546 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098547 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098548 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098549 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098550 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098681 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
93815098682 ABBOTT DIABETES MEDISENSE THIN LANCETS<br />
93815098732 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815098733 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS<br />
93815098757 ABBOTT DIABETES PRECISION PCX TEST STRIPS<br />
93815098814 ABBOTT DIABETES PRECISION XTRA MONITOR<br />
93815098894 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098895 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE<br />
93815098929 ABBOTT DIABETES PRECISION LINK DIRECT MONIT<br />
93815099121 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
Page 44 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
93815099134 ABBOTT DIABETES OPTIUM TEST STRIP<br />
93815099135 ABBOTT DIABETES OPTIUM TEST STRIP<br />
93815099565 ABBOTT DIABETES PRECISION PCX TEST STRIPS<br />
93815099694 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815099695 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815099728 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815099837 ABBOTT DIABETES PRECISION XTRA MONITOR<br />
93815099838 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815099877 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815099878 ABBOTT DIABETES PRECISION XTRA TEST STRIPS<br />
93815974116 ABBOTT DIABETES PRECISION CONTROL SOLUTION<br />
94030000201 OMNIS HEALTH EMBRACE BLOOD GLUCOSE SYSTEM<br />
94030000202 OMNIS HEALTH EMBRACE TEST STRIPS<br />
94030000207 OMNIS HEALTH EMBRACE GLUC CONTROL SOLN LOW<br />
94030000209 OMNIS HEALTH VICTORY BLOOD GLUCOSE MONITOR<br />
94030000210 OMNIS HEALTH VICTORY GLUCOSE TEST STRIPS<br />
94030000211 OMNIS HEALTH VICTORY HIGH-LOW CONTROL SOLN<br />
94030000211 OMNIS HEALTH VICTORY HIGH-LOW CONTROL SOLN<br />
94030201001 OMNIS HEALTH EMBRACE BLOOD GLUCOSE SYSTEM<br />
94030201003 OMNIS HEALTH EMBRACE TEST STRIPS<br />
94030201006 OMNIS HEALTH EMBRACE GLUC CONTROL SOLN LOW<br />
94046000100 DIABETIC SUPPLY<br />
ADVOCATE TEST STRIP<br />
94046000101 DIABETIC SUPPLY<br />
ADVOCATE CONTROL SOLUTION LOW<br />
94046000102 DIABETIC SUPPLY<br />
ADVOCATE BLOOD GLUCOSE MONITOR<br />
94046000103 DIABETIC SUPPLY<br />
ADVOCATE BLOOD GLUCOSE MONITOR<br />
94046000104 DIABETIC SUPPLY<br />
ADVOCATE CONTROL SOLUTION HIGH<br />
94046000105 DIABETIC SUPPLY<br />
ADVOCATE LANCING DEVICE<br />
94046000106 DIABETIC SUPPLY<br />
ADVOCATE LANCET<br />
94046000107 DIABETIC SUPPLY<br />
ADVOCATE BLOOD GLUCOSE MONITOR<br />
94046000109 DIABETIC SUPPLY<br />
ADVOCATE LANCETS<br />
94046000111 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE GLU MONITOR<br />
94046000113 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE TEST STRIP<br />
94046000118 DIABETIC SUPPLY<br />
ADVOCATE LANCETS<br />
94046000124 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE TEST STRIP<br />
94046000126 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE TEST STRIP<br />
94046000133 DIABETIC SUPPLY<br />
ADVOCATE BLOOD GLUCOSE MONITOR<br />
94046000134 DIABETIC SUPPLY<br />
ADVOCATE BLOOD GLUCOSE MONITOR<br />
94046000135 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE GLU MONITOR<br />
94046000136 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE GLU MONITOR<br />
94046000139 DIABETIC SUPPLY<br />
ADVOCATE REDI-CODE TEST STRIP<br />
94046000140 DIABETIC SUPPLY<br />
ADVOCATE CONTROL SOLUTION LOW<br />
94046000141 DIABETIC SUPPLY<br />
ADVOCATE TEST STRIP<br />
94441021545 SAV-ON SAV-ON LANCETS<br />
94441021546 SAV-ON SAV-ON LANCETS<br />
94441021547 SAV-ON SAV-ON LANCETS<br />
96295010295 LEADER LEADER COLORED LANCETS<br />
96295010494 LEADER LEADER INS SYR 0.5 ML 28GX1/2"<br />
96295010495 LEADER LEADER INS SYR 1 ML 28GX1/2"<br />
96295010496 LEADER LEADER INS SYR 0.5 ML 29GX1/2"<br />
96295010497 LEADER LEADER INS SYR 1 ML 29GX1/2"<br />
96295010498 LEADER LEADER INS SYR 0.3 ML 29GX1/2"<br />
96295010629 LEADER LEADER INSULIN SYRINGE 0.3 ML<br />
Page 45 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
96295010643 LEADER LEADER INS SYR 0.5 ML 30GX1/2"<br />
96295010645 LEADER LEADER INS SYR 1 ML 30GX1/2"<br />
96295010677 LEADER LEADER THIN LANCETS<br />
96295010841 LEADER LEADER THIN LANCETS<br />
96295010948 LEADER LEADER STARTER KIT<br />
96295011105 LEADER LEADER SUPER THIN LANCETS<br />
96295011261 LEADER LEADER SYRING 0.5 ML 31GX5/16"<br />
96295011262 LEADER LEADER INS SYR 1 ML 31GX5/16"<br />
96295011263 LEADER LEADER SYRING 0.3 ML 31GX5/16"<br />
96295011503 LEADER LEADER E-ZJECT LANCETS<br />
96295011708 LEADER LANCING DEVICE<br />
98302000100 SIMPLE DIAGNOST<br />
SIMPLE DIAGNSTIC LANCET DEVICE<br />
98302000102 SIMPLE DIAGNOST<br />
CLEVER CHEK TEST STRIPS<br />
98302000103 SIMPLE DIAGNOST<br />
CLEVER CHEK CONTROL SOLUTION<br />
98302000104 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE 30G LANCETS<br />
98302000106 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE 28G LANCETS<br />
98302000107 SIMPLE DIAGNOST<br />
CLEVER CHEK BLOOD GLUCOSE SYST<br />
98302000108 SIMPLE DIAGNOST<br />
CLEVER CHEK TEST STRIPS<br />
98302000109 SIMPLE DIAGNOST<br />
CLEVER CHEK CONTROL SOLUTION<br />
98302000110 SIMPLE DIAGNOST<br />
CLEVER CHEK CONTROL SOLUTION<br />
98302000111 SIMPLE DIAGNOST<br />
CLEVER CHEK BLOOD GLUCOSE SYST<br />
98302000112 SIMPLE DIAGNOST<br />
CLEVER CHEK BLOOD GLUCOSE SYST<br />
98302000115 SIMPLE DIAGNOST<br />
CLEVER CHEK ULTRA THIN LANCETS<br />
98302000116 SIMPLE DIAGNOST<br />
CLEVER CHEK BLOOD GLUCOSE SYST<br />
98302000118 SIMPLE DIAGNOST<br />
CLEVER CHEK TEST STRIPS<br />
98302000120 SIMPLE DIAGNOST<br />
CLEVER CHEK TEST STRIPS<br />
98302000121 SIMPLE DIAGNOST<br />
CLEVER CHEK BLOOD GLUCOSE SYST<br />
98302000125 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE 30G LANCETS<br />
98302000126 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE 28G LANCETS<br />
98302000127 SIMPLE DIAGNOST<br />
CLEVER CHEK 30G LANCETS<br />
98302000128 SIMPLE DIAGNOST<br />
CLEVER CHOICE PRO TEST STRIP<br />
98302000129 SIMPLE DIAGNOST<br />
CLEVER CHOICE PRO GLUCOSE MTR<br />
98302000131 SIMPLE DIAGNOST<br />
CLEVER CHOICE GLUCOSE MONITOR<br />
98302000132 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE GLUCOSE SYS<br />
98302000133 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE TEST STRIPS<br />
98302000160 SIMPLE DIAGNOST<br />
PHARMACIST CHOICE 31G LANCETS<br />
98302000170 SIMPLE DIAGNOST<br />
CLEVER CHOICE MICRO TEST STRIP<br />
98302000180 SIMPLE DIAGNOST<br />
CLEVER CHOICE MICRO MONITOR<br />
98939000200 FOR A CARE INC. FORA D10 BLOOD GLUCOSE SYSTEM<br />
98939000201 FOR A CARE INC. FORA D10 GLUCOSE TEST STRIPS<br />
98939000204 FOR A CARE INC. FORA HIGH CONTROL SOLUTION<br />
98939000205 FOR A CARE INC. FORA LOW CONTROL SOLUTION<br />
98939000206 FOR A CARE INC. FORA NORMAL CONTROL SOLUTION<br />
98939000207 FOR A CARE INC. FORA V12 BLOOD GLUCOSE SYSTEM<br />
98939000209 FOR A CARE INC. FORA V10 BLOOD GLUCOSE SYSTEM<br />
98939000210 FOR A CARE INC. FORA V10 GLUCOSE TEST STRIP<br />
98939000212 FOR A CARE INC. FORA D15C GLUCOSE TEST STRIPS<br />
98939000216 FOR A CARE INC. FORA D15Z GLUCOSE TEST STRIPS<br />
98939000217 FOR A CARE INC. FORA V20 BLOOD GLUCOSE SYSTEM<br />
98939000218 FOR A CARE INC. FORA V20 GLUCOSE TEST STRIPS<br />
98939000219 FOR A CARE INC. FORA V22 BLOOD GLUCOSE SYSTEM<br />
98939000220 FOR A CARE INC. FORA V22 GLUCOSE TEST STRIP<br />
Page 46 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
98939000226 FOR A CARE INC. FORA V12 BLOOD GLUCOSE SYSTEM<br />
98939000227 FOR A CARE INC. FORA V12 GLUCOSE TEST STRIP<br />
98939000229 FOR A CARE INC. FORA G30A BLOOD GLUCOSE SYSTEM<br />
98939000231 FOR A CARE INC. FORA G30A GLUCOSE TEST STRIP<br />
98939000233 FOR A CARE INC. FORA G20 BLOOD GLUCOSE SYSTEM<br />
98939000234 FOR A CARE INC. FORA G20 GLUCOSE TEST STRIPS<br />
98939000235 FOR A CARE INC. FORA V10 BLOOD GLUCOSE SYSTEM<br />
98939000236 FOR A CARE INC. FORA V10 GLUCOSE TEST STRIP<br />
98939000238 FOR A CARE INC. FORA D15G GLUCOSE TEST STRIPS<br />
98939000244 FOR A CARE INC. FORA D20 BLOOD GLUCOSE SYSTEM<br />
98939000245 FOR A CARE INC. FORA D20 GLUCOSE TEST STRIPS<br />
98939000246 FOR A CARE INC. FORA G90 BLOOD GLUCOSE SYSTEM<br />
98939000247 FOR A CARE INC. FORA G90 GLUCOSE TEST STRIP<br />
98939000256 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM<br />
98939000257 FOR A CARE INC. FORA G71A GLUCOSE TEST STRIPS<br />
98939000258 FOR A CARE INC. FORA LANCING DEVICE<br />
98939000259 FOR A CARE INC. FORA V30A BLOOD GLUCOSE SYSTEM<br />
98939000260 FOR A CARE INC. FORA V30A GLUCOSE TEST STRIP<br />
98939000261 FOR A CARE INC. FORA LANCETS<br />
98939000265 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM<br />
98939000266 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM<br />
98939000267 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM<br />
99073011001 ABBOTT DIABETES FREESTYLE SYSTEM KIT<br />
99073011004 ABBOTT DIABETES FREESTYLE SYSTEM KIT<br />
99073012050 ABBOTT DIABETES FREESTYLE TEST STRIPS<br />
99073012051 ABBOTT DIABETES FREESTYLE SIDEKICK II VALPK<br />
99073012101 ABBOTT DIABETES FREESTYLE TEST STRIPS<br />
99073012301 ABBOTT DIABETES FREESTYLE TEST STRIPS<br />
99073012401 ABBOTT DIABETES FREESTYLE TEST STRIPS NFRS<br />
99073012450 ABBOTT DIABETES FREESTYLE TEST STRIPS NFRS<br />
99073013001 ABBOTT DIABETES FREESTYLE LANCETS<br />
99073014001 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073014002 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073014003 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073014003 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073017001 ABBOTT DIABETES FREESTYLE FLASH SYSTEM KIT<br />
99073070428 ABBOTT DIABETES FREESTYLE UNISTIK 2 LANCETS<br />
99073070432 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073070432 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION<br />
99073070683 ABBOTT DIABETES FREESTYLE NAVIGATOR SENSOR KIT<br />
99073070792 ABBOTT DIABETES FREESTYLE TEST STRIPS<br />
99073070804 ABBOTT DIABETES FREESTYLE LITE METER NFRS<br />
99073070805 ABBOTT DIABETES FREESTYLE LITE METER<br />
99073070819 ABBOTT DIABETES FREESTYLE LITE TEST STRIP NFRS<br />
99073070822 ABBOTT DIABETES FREESTYLE LITE TEST STRIP<br />
99073070823 ABBOTT DIABETES FREESTYLE LITE TEST STRIP NFRS<br />
99073070827 ABBOTT DIABETES FREESTYLE LITE TEST STRIP<br />
99073070847 ABBOTT DIABETES FREESTYLE FREEDOM KIT<br />
99073070914 ABBOTT DIABETES FREESTYLE FREEDOM LITE METER<br />
99073070920 ABBOTT DIABETES FREESTYLE FREEDOM LITE NFRS<br />
99073071097 ABBOTT DIABETES FREESTYLE PREC 1 ML 30GX5/16"<br />
99073071098 ABBOTT DIABETES FREESTYLE PREC 0.5 ML 30GX5/16<br />
Page 47 of 48
Oregon Health Authority<br />
Division of Medical Assistance Programs<br />
Allowable NDCs <strong>for</strong> Diabetic Supply Billing - Effective 8/1/2011<br />
For <strong>billing</strong> guidelines and examples:<br />
Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply<br />
Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html.<br />
NDC Code Labeler Name Label Name Desc<br />
99073071099 ABBOTT DIABETES FREESTYLE PREC 0.5 ML 31GX5/16<br />
99073071100 ABBOTT DIABETES FREESTYLE PREC 1 ML 31GX5/16"<br />
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