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Oregon Health Authority Division of Medical Assistance Programs Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011 For billing guidelines and examples: Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html. NDC Code Labeler Name Label Name Desc 38396043477 CAN-AM/ACCESS FP INSULIN 0.5 ML SYRINGE 38396044164 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR 38396044264 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE 38396044364 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR 38396044455 CAN-AM/ACCESS RENEW ADVANCED MICRO-LANCETS 38396044464 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE 38396044564 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR 38396044664 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR 38396044764 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE 38396044864 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR 38396044902 CAN-AM/ACCESS RELION THIN LANCETS 38396044964 CAN-AM/ACCESS GNP INSUL SYR 0.3 ML 31GX5/16" 38396045002 CAN-AM/ACCESS RELION LANCETS 38396045064 CAN-AM/ACCESS GNP INSUL SYR 0.5 ML 31GX5/16" 38396045102 CAN-AM/ACCESS RELION THIN LANCETS 38396045164 CAN-AM/ACCESS GNP INSULIN SYR 1 ML 31GX5/16" 38396045202 CAN-AM/ACCESS RELION THIN LANCETS 38396045302 CAN-AM/ACCESS RELION ULTRA THIN COL LANCET 38396045339 CAN-AM/ACCESS SM INSUL SYR 0.3 ML 31GX5/16" 38396045402 CAN-AM/ACCESS RELION ULTRA THIN LANCET 38396045532 CAN-AM/ACCESS WALGREENS SUPER THIN LANCET 38396046339 CAN-AM/ACCESS SM INSUL SYR 0.5 ML 31GX5/16" 38396047339 CAN-AM/ACCESS SM INSULIN SYR 1 ML 31GX5/16" 38396050101 CAN-AM/ACCESS RELION LANCING DEVICE 38396050132 CAN-AM/ACCESS WALGREENS LANCETS 38396050175 CAN-AM/ACCESS CVS THIN LANCETS 38396050178 CAN-AM/ACCESS W&F 30G LANCETS 38396050232 CAN-AM/ACCESS WALGREENS THIN LANCETS 38396050275 CAN-AM/ACCESS CVS LANCETS 38396050332 CAN-AM/ACCESS WALGREENS THIN LANCETS 38396050375 CAN-AM/ACCESS CVS THIN LANCETS 38396050432 CAN-AM/ACCESS WALGREENS ULTRA THIN LANCETS 38396051075 CAN-AM/ACCESS CVS LANCING DEVICE 38396051075 CAN-AM/ACCESS CVS LANCING DEVICE 38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM 38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM 38396052175 CAN-AM/ACCESS CVS ULTRA THIN LANCETS 38396052275 CAN-AM/ACCESS CVS ULTRA THIN LANCETS 38396054764 CAN-AM/ACCESS GNP SUPER THIN LANCETS 38396060118 CAN-AM/ACCESS KROGER LANCING DEVICE 38396070339 CAN-AM/ACCESS SM LANCETS 38396071339 CAN-AM/ACCESS SM THIN LANCETS 38396072339 CAN-AM/ACCESS SM SUPER THIN LANCETS 38396073339 CAN-AM/ACCESS SM LANCETS 38396074339 CAN-AM/ACCESS SM COLORED LANCETS 38396075339 CAN-AM/ACCESS SM THIN LANCETS 38396076339 CAN-AM/ACCESS SM INSULIN SYR 0.5 ML 28GX1/2" 38396077339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 28GX1/2" 38396078339 CAN-AM/ACCESS SM INSULIN SYR 0.3 ML 29GX1/2" 38396079339 CAN-AM/ACCESS SM INS SYR 0.5 ML 29GX1/2" 38396080339 CAN-AM/ACCESS SM INS SYR 1 ML 29GX1/2" 38396081339 CAN-AM/ACCESS SM INS SYRING 0.3 ML 30GX5/16" Page 26 of 48
Oregon Health Authority Division of Medical Assistance Programs Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011 For billing guidelines and examples: Refer to OAR 410-122-0520 (Glucose Monitors and Diabetic Supplies) and the Diabetic Supply Billing Examples at www.dhs.state.or.us/policy/healthplan/guides/dme/main.html. NDC Code Labeler Name Label Name Desc 38396082339 CAN-AM/ACCESS SM INS SYR 0.5 ML 30GX5/16" 38396083339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 30GX5/16" 38396090002 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS 38396090178 CAN-AM/ACCESS W&F THIN LANCETS 38396090180 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS 38396091825 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS 38396091925 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS 38415001630 SPECIALTY MED INSULIN SYRINGE 1 ML 30GX5/16" 38415001631 SPECIALTY MED INSULIN SYRINGE 1 ML 31GX5/16" 38415003529 SPECIALTY MED INSULIN SYRIN 0.3 ML 29GX1/2" 38415003531 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16" 38415003630 SPECIALTY MED INSULIN SYR 0.3 ML 30GX5/16" 38415003631 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16" 38415005129 SPECIALTY MED INSULIN SYRIN 1 ML 29GX1/2" 38415005529 SPECIALTY MED INSULIN SYRING 0.5 ML 29GX1/2" 38415005630 SPECIALTY MED INSULIN SYRIN 0.5 ML 30GX5/16" 38415005631 SPECIALTY MED INSULIN SYRIN 0.5 ML 31GX5/16" 38415010001 SPECIALTY MED SAFETY-LET LANCETS 38415010028 SPECIALTY MED LANCETS 38415010029 SPECIALTY MED ASSURE ULTRA THIN LANCETS 38415010030 SPECIALTY MED LANCETS 38415020801 SPECIALTY MED AQUA LANCE LANCING DEVICE 38415030028 SPECIALTY MED LANCETS 38415030030 SPECIALTY MED LANCETS 38415040028 SPECIALTY MED LANCETS 38415042302 SPECIALTY MED SURECHEK TEST STRIPS 38415042308 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN 38415042401 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER 38415042402 SPECIALTY MED SURE EDGE TEST STRIPS 38415042440 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415042460 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415042480 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415051001 SPECIALTY MED LANCING DEVICE 38415051002 SPECIALTY MED ALTERNATE SITE LANCING DEVICE 38415051208 SPECIALTY MED AQUA LANCE LANCING DEVICE 38415060023 SPECIALTY MED LANCETS 38415060025 SPECIALTY MED LANCETS 38415423010 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR 38415423120 SPECIALTY MED SURECHEK TEST STRIPS 38415423240 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR 38415423830 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN 38415424010 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER 38415424110 SPECIALTY MED SURE EDGE TEST STRIPS 38415424410 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415424620 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415424830 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN 38415425110 SPECIALTY MED VOCAL POINT TEST STRIP 38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE 38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE 40986001668 CHAIN DRUG CONS PV ULTRA THIN LANCETS 40986001669 CHAIN DRUG CONS PV ULTRA THIN LANCETS 40986001670 CHAIN DRUG CONS PV LANCING DEVICE Page 27 of 48
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