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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 />
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 />
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