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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 57599004305 ABBOTT DIABETES MEDISENSE THIN LANCETS 57599006305 ABBOTT DIABETES PRECISION PCX PLUS TEST STR 57599011605 ABBOTT DIABETES PRECISION POINT OF CARE STR 57599013801 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL 57599013901 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL 57599031201 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL 57599033901 ABBOTT DIABETES PRECISION PCX PLUS TEST STR 57599055001 ABBOTT DIABETES MEDISENSE H-L CONTROL SOLUTION 57599055101 ABBOTT DIABETES MEDISENSE H-M-L CONTROL SOLN 57599055201 ABBOTT DIABETES MEDISENSE MID CONTROL SOLUTION 57599104104 ABBOTT DIABETES OPTIUM EZ TEST STRIP 57599104205 ABBOTT DIABETES OPTIUM EZ TEST STRIP 57599471102 ABBOTT DIABETES PRECISION CONTROL SOLUTION 57599713701 ABBOTT DIABETES ULTRATLC LANCETS 57599713805 ABBOTT DIABETES ULTRATLC LANCETS 57599740004 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599740105 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599741102 ABBOTT DIABETES PRECISION CONTROL SOLUTION 57599743201 ABBOTT DIABETES MEDISENSE CONTROL SOLUTION 57599813803 ABBOTT DIABETES ULTRATLC THIN LANCETS 57599822801 ABBOTT DIABETES PRECISION Q-I-D PEN 57599833501 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599833601 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599841101 ABBOTT DIABETES PRECISION CONTROL SOLUTION 57599843601 ABBOTT DIABETES PRECISION CONTROL SOLUTION 57599854601 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599854701 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599854801 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599854901 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599855001 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599857301 ABBOTT DIABETES PRECISION COLORED METER 57599857401 ABBOTT DIABETES PRECISION COLORED METER 57599857501 ABBOTT DIABETES PRECISION COLORED METER 57599857601 ABBOTT DIABETES PRECISION COLORED METER 57599868102 ABBOTT DIABETES MEDISENSE THIN LANCETS 57599868105 ABBOTT DIABETES MEDISENSE THIN LANCETS 57599868205 ABBOTT DIABETES MEDISENSE THIN LANCETS 57599868206 ABBOTT DIABETES MEDISENSE THIN LANCETS 57599872901 ABBOTT DIABETES EXACTECH TEST STRIPS 57599873001 ABBOTT DIABETES EXACTECH TEST STRIPS 57599873201 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599873204 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599873301 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599873305 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS 57599874605 ABBOTT DIABETES UNISTIK 2 NORMAL 0.81MM DEVICE 57599874605 ABBOTT DIABETES UNISTIK 2 NORMAL 0.81MM DEVICE 57599874705 ABBOTT DIABETES UNISTIK 2 EXTRA 0.81 MM DEVICE 57599874705 ABBOTT DIABETES UNISTIK 2 EXTRA 0.81 MM DEVICE 57599875705 ABBOTT DIABETES PRECISION PCX TEST STRIPS 57599881401 ABBOTT DIABETES PRECISION XTRA MONITOR 57599889401 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE 57599889501 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE Page 36 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 57599912101 ABBOTT DIABETES PRECISION CONTROL SOLUTION 57599913404 ABBOTT DIABETES OPTIUM TEST STRIP 57599913505 ABBOTT DIABETES OPTIUM TEST STRIP 57599956505 ABBOTT DIABETES PRECISION PCX TEST STRIPS 57599969405 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 57599969504 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 57599972804 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 57599983701 ABBOTT DIABETES PRECISION XTRA MONITOR 57599983804 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 57599987705 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 57599987805 ABBOTT DIABETES PRECISION XTRA TEST STRIPS 59707000100 UNIQUEONE PHARM SURE-JECT INSU SYR U100 1 ML 59707000101 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707000102 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML 59707000103 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707000104 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML 59707000105 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML 59707000106 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707000107 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML 59707000110 UNIQUEONE PHARM SURE-LANCE THIN LANCET 59707000112 UNIQUEONE PHARM SURE-LANCE ULTRA THIN LANCET 59707000155 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI METER 59707000156 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI STRIP 59707000157 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI SOLN 59707000166 UNIQUEONE PHARM SURE-LANCE FLAT LANCETS 59707010001 UNIQUEONE PHARM SURE-PEN LANCING DEVICE 59707012801 UNIQUEONE PHARM SURE-JECT INSU SYR U100 1 ML 59707012850 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707012901 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML 59707012930 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML 59707012950 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707013001 UNIQUEONE PHARM SURE-JECT INSUL SYR U100 1 ML 59707013030 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.3 ML 59707013050 UNIQUEONE PHARM SURE-JECT INSU SYR U100 0.5 ML 59707013101 UNIQUEONE PHARM SURE-JECT INSULIN SYRINGE 1 ML 59707013130 UNIQUEONE PHARM SURE-JECT INSULIN SYR 0.3 ML 59707013150 UNIQUEONE PHARM SURE-JECT INSULIN SYR 0.5 ML 59707026101 UNIQUEONE PHARM SURE-LANCE LANCET 59707028101 UNIQUEONE PHARM SURE-LANCE THIN LANCET 59707028128 UNIQUEONE PHARM SURE-LANCE FLAT LANCETS 59707030101 UNIQUEONE PHARM SURE-LANCE ULTRA THIN LANCET 59707051001 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI SOLN 59707055001 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI STRIP 59707055101 UNIQUEONE PHARM SURE-TEST EASYPLUS MINI METER 59779032301 CVS/PHARMACY CVS LANCETS-THIN 59779032302 CVS/PHARMACY CVS LANCETS-THIN 59779032304 CVS/PHARMACY CVS LANCETS-ORIGINAL 59779114599 CVS/PHARMACY CVS SYRINGE 3/10 ML 59779114796 CVS/PHARMACY CVS SYRINGE 1/2 ML 59779114799 CVS/PHARMACY CVS INSULIN SYR 1 ML 29GX1/2" 59779114803 CVS/PHARMACY CVS SYRINGE 3/10 ML 59779114811 CVS/PHARMACY CVS SYRINGE 1/2 ML Page 37 of 48
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