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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 40986001676 CHAIN DRUG CONS PV TRUETRACK SMART SYSTEM 40986001677 CHAIN DRUG CONS PV TRUETRACK SMART SYS STRIPS 40986001678 CHAIN DRUG CONS PV TRUETRACK SMART SYS STRIPS 40986002136 CHAIN DRUG CONS PV INSULIN SYRINGE 0.5 ML 40986002137 CHAIN DRUG CONS PV INSULIN SYRINGE 1 ML 40986002138 CHAIN DRUG CONS PV INSULIN SYRINGE 0.5 ML 40986002139 CHAIN DRUG CONS PV INS SYRIN 1 ML 29GX1/2" 40986002140 CHAIN DRUG CONS PV INSULIN SYRINGE 0.5 ML 40986002141 CHAIN DRUG CONS PV INSULIN SYRINGE 1 ML 40986002142 CHAIN DRUG CONS PV INSUL SYR 0.3 ML 31GX5/16" 40986002143 CHAIN DRUG CONS PV INSUL SYR 0.5 ML 31GX5/16" 40986002144 CHAIN DRUG CONS PV INSULIN SYR 1 ML 31GX5/16" 41163026310 EQUALINE VITAMI EQL INS SYR 0.3 ML 29GX1/2" 41163026311 EQUALINE VITAMI EQL INS SYR 0.5 ML 29GX1/2" 41163026312 EQUALINE VITAMI EQL INSULIN SYR 1 ML 29GX1/2" 41163026313 EQUALINE VITAMI EQL INS SYR 0.3 ML 30GX5/16" 41163026314 EQUALINE VITAMI EQL INS SYR 0.5 ML 30GX5/16" 41163026315 EQUALINE VITAMI EQL INSULIN SYR 1 ML 30GX5/16" 41163040141 EQUALINE VITAMI INSULIN SYRINGE 1 ML 31GX5/16" 41163040241 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 31GX5/16" 41163040341 EQUALINE VITAMI EQL INSUL SYR 0.3 ML 31GX5/16" 41163042682 EQUALINE VITAMI EQL INSUL SYR 0.5 ML 31GX5/16" 41163042683 EQUALINE VITAMI EQL INSULIN SYR 1 ML 31GX5/16" 41163042684 EQUALINE VITAMI EQL INSUL SYR 0.3 ML 31GX5/16" 41163263109 EQUALINE VITAMI INSULIN SYRIN 0.3 ML 29GX1/2" 41163402203 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 29GX1/2" 41163402205 EQUALINE VITAMI INSULIN SYRINGE 1 ML 29GX1/2" 41163402206 EQUALINE VITAMI INSULIN SYRINGE 1 ML 30GX5/16" 41163402207 EQUALINE VITAMI INSULIN SYRIN 0.5 ML 30GX5/16" 41163402208 EQUALINE VITAMI INSULIN SYRIN 0.3 ML 30GX5/16" 41250036930 MEIJER INC. MEIJER SUPER THIN LANCETS 41250088304 MEIJER INC. MEIJER LANCETS 41250088305 MEIJER INC. MEIJER THIN GAUGE LANCETS 41250088306 MEIJER INC. MEIJER THIN GAUGE LANCETS 41280021545 MEIJER INC. OSCO LANCETS 41280021546 MEIJER INC. OSCO LANCETS 41280021547 MEIJER INC. OSCO LANCETS 41318071768 ULTIMED INC SCHNUCKS SYR 0.5 ML 29GX1/2" 41318071769 ULTIMED INC SCHNUCKS SYR 0.5 ML 30GX5/16" 41405129301 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML 41405129310 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML 41405129350 ULTIMED INC GLUCOPRO U100 INSULIN 1 ML SYR 41405130301 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML 41405130310 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML 41405130350 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML 41405130801 ULTIMED INC GLUCOPRO SYRINGE U100 1 ML 41405130810 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML 41405130850 ULTIMED INC GLUCOPRO INSULIN SYR U100 1 ML 41405131810 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML 41405131850 ULTIMED INC GLUCOPRO INSULIN SYR 1 ML 41405329301 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405329310 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML Page 28 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 41405329350 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405330301 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405330310 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405330350 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405330810 ULTIMED INC GLUCOPRO INSUL SYR U100 0.3 ML 41405330850 ULTIMED INC GLUCOPRO INSULIN SYR 0.3 ML 41405331801 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405331810 ULTIMED INC GLUCOPRO U100 INSUL SYR 0.3 ML 41405529301 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML 41405529310 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML 41405529350 ULTIMED INC GLUCOPRO SYRINGE U100 0.5 ML 41405530301 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41405530310 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41405530350 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41405530801 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML 41405530810 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML 41405530850 ULTIMED INC GLUCOPRO INSUL SYR U100 0.5 ML 41405531801 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41405531810 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41405531850 ULTIMED INC GLUCOPRO INSULIN SYR 0.5 ML 41415001578 PUBLIX SUPERMKT PUB INS SYRIN 0.3 ML 30GX1/2" 41415001678 PUBLIX SUPERMKT PUB INSUL SYR 0.3 ML 31GX5/16" 41415001778 PUBLIX SUPERMKT PUB INSUL SYR 0.5 ML 30GX1/2" 41415001878 PUBLIX SUPERMKT PUB INSUL SYR 0.5 ML 31GX5/16" 41415001978 PUBLIX SUPERMKT PUB INS SYRINGE 1 ML 30GX1/2" 41415002078 PUBLIX SUPERMKT PUB INSULIN SYR 1 ML 31GX5/16" 41415003178 PUBLIX SUPERMKT PUB ADVANCED LANCING DEVICE 41415003178 PUBLIX SUPERMKT PUB ADVANCED LANCING DEVICE 41415003278 PUBLIX SUPERMKT PUB LANCETS 41520031420 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5" 41520031420 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5" 41520031421 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5" 41520031421 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5" 41520031422 ULTIMED INC CAREONE SYR 1 ML 29GX0.5" 41520031422 ULTIMED INC CAREONE SYR 1 ML 29GX0.5" 41520031423 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16" 41520031423 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16" 41520031424 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16" 41520031424 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16" 41520031425 ULTIMED INC CAREONE SYR 1 ML 30GX5/16" 41520031425 ULTIMED INC CAREONE SYR 1 ML 30GX5/16" 41520087047 ULTIMED INC CAREONE ULTRA THIN LANCET 41520087048 ULTIMED INC CAREONE THIN LANCET 41520087049 ULTIMED INC CAREONE LANCING DEVICE 41735003771 OWEN MUMFORD, INC PC SUPER THIN 30G LANCETS 42167000640 HARRINGTON HOLD RELIAMED SAFETY SEAL LANCETS 42167001090 HARRINGTON HOLD RELIAMED SAFETY SEAL LANCETS 42167001110 HARRINGTON HOLD RELIAMED LANCING DEVICE 43820000008 BOCA PHARMACAL ULTI-LANCE AUTO-AD DEVICE 43820000008 BOCA PHARMACAL ULTI-LANCE AUTO-AD DEVICE 47884017101 OAK TREE INTERN EASYMAX V GLUCOSE SYSTEM KIT 47884017140 OAK TREE INTERN EASYMAX SPEAKING CONTROL SOLN Page 29 of 48
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