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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 68016065055 CHAIN DRUG CONSORTIUM, LLC PV INSUL SYR 0.5 ML 31GX5/16" 68016065105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYR 1 ML 31GX5/16" 68016070055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML 68016070105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 1 ML 68016080055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML 68016080105 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 1 ML 68016090055 CHAIN DRUG CONSORTIUM, LLC PV INSULIN SYRINGE 0.5 ML 68016090105 CHAIN DRUG CONSORTIUM, LLC PV INS SYRIN 1 ML 29GX1/2" 75537000501 ROCHE DIAGNOSTI CHEMSTRIP BG (VISUAL ONLY) 75537000502 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II) 75537000508 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II) 75537000535 ROCHE DIAGNOSTI TRACER BG TEST STRIP 75537000560 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS 75537000566 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS 75537000852 ROCHE DIAGNOSTI ACCU-CHEK EASY GLUCOSE SOLN 75537000877 ROCHE DIAGNOSTI ACCU-CHEK INSTANT TEST STRP 75537000914 ROCHE DIAGNOSTI ACCU-CHEK INSTANT CARE KIT 75537030250 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY KIT 75537030276 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS 75537030314 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS 75537031429 ROCHE DIAGNOSTI SOFTCLIX LANCETS 76300001701 MEDTRONIC MINIM PARADIGM REAL-TIME SYSTEM 76300001701 MEDTRONIC MINIM PARADIGM REAL-TIME SYSTEM 76300007202 MEDTRONIC MINIM GUARDIAN REAL-TIME GLU MONITOR 76300007202 MEDTRONIC MINIM GUARDIAN REAL-TIME GLU MONITOR 76300010310 MEDTRONIC MINIM MINIMED RESERVOIR 3 ML 76300070701 MEDTRONIC MINIM MINILINK REAL-TIME TRANSMITTER 80196073405 MEDLINE INDUS. EVENCARE CONTROL SOLUTION 80196073405 MEDLINE INDUS. EVENCARE CONTROL SOLUTION 80196073413 MEDLINE INDUS. EVENCARE MONITORING SYSTEM 80196073463 MEDLINE INDUS. EVENCARE GLUCOSE TST STRIPS 81131031162 WAL-MART STORES RELION INS SYR 1 ML 29GX1/2" 81131031163 WAL-MART STORES RELION INS SYR 1 ML 29GX1/2" 81131031164 WAL-MART STORES RELION INS SYR 0.5 ML 29GX1/2" 81131031165 WAL-MART STORES RELION INS SYR 0.5 ML 29GX1/2" 81131031166 WAL-MART STORES RELION INS SYR 0.3 ML 29GX1/2" 81131031167 WAL-MART STORES RELION INS SYR 0.3 ML 29GX1/2" 81131031168 WAL-MART STORES RELION INS SYR 1 ML 30GX5/16" 81131031169 WAL-MART STORES RELION INS SYR 1 ML 30GX5/16" 81131031170 WAL-MART STORES RELION SYR 0.5 ML 30GX5/16" 81131031171 WAL-MART STORES RELION SYR 0.5 ML 30GX5/16" 81131031172 WAL-MART STORES RELION INS SYR 0.3 ML 30GX5/16 81131031173 WAL-MART STORES RELION INS SYR 0.3 ML 30GX5/16 81131031174 WAL-MART STORES RELION INS SYR 1 ML 31GX5/16" 81131031175 WAL-MART STORES RELION INS SYR 1 ML 31GX5/16" 81131031176 WAL-MART STORES RELION SYRING 0.5 ML 31GX5/16" 81131031177 WAL-MART STORES RELION SYRING 0.5 ML 31GX5/16" 81131031178 WAL-MART STORES RELION SYRING 0.3 ML 31GX5/16" 81131031179 WAL-MART STORES RELION SYRING 0.3 ML 31GX5/16" 81306021214 ACCESS LLC RELION THIN LANCETS 81306021314 ACCESS LLC RELION THIN LANCETS 81306022114 ACCESS LLC RELION LANCETS Page 40 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 81306022314 ACCESS LLC RELION THIN LANCETS 81306051413 ACCESS LLC RELION INSULIN SYR 0.3 ML 81306051423 ACCESS LLC RELION INSULIN SYR 0.3 ML 81306051523 ACCESS LLC RELION INSULIN SYR 0.5 ML 81306051613 ACCESS LLC RELION INSULIN SYRINGE 1 ML 81306051623 ACCESS LLC RELION INSULIN SYRINGE 1 ML 81306052413 ACCESS LLC RELI-ON INSULIN 0.3 ML SYR 81306052513 ACCESS LLC RELI-ON INSULIN 0.5 ML SYR 81306052613 ACCESS LLC RELI-ON INSULIN 1 ML SYR 82468014443 FAMILY PHARMACY FP LANCETS THIN 82468061430 FAMILY PHARMACY FP INSULIN 1 ML SYRINGE 82468061432 FAMILY PHARMACY FP INSULIN 0.5 ML SYRINGE 82468061433 FAMILY PHARMACY FP INSULIN 1 ML SYRINGE 85017000000 OAK TREE INTERN EASYMAX N GLUCOSE SYSTEM KIT 85017000001 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS 85017000002 OAK TREE INTERN EASYMAX NORMAL CONTROL SOLN 85017000003 OAK TREE INTERN EASYMAX HIGH CONTROL SOLN 85017000004 OAK TREE INTERN EASYMAX LOW CONTROL SOLN 85017000007 OAK TREE INTERN EASYMAX V GLUCOSE SYSTEM KIT 85017000008 OAK TREE INTERN EASYMAX L GLUCOSE SYSTEM KIT 85017000009 OAK TREE INTERN EASYMAX L BLOOD GLUCOSE SYSTEM 85017000010 OAK TREE INTERN EASYMAX SPEAKING CONTROL SOLN 85017000015 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS 85017000016 OAK TREE INTERN EASYMAX N BLOOD GLUCOSE SYSTEM 85017000023 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS 85325000001 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST 85325000002 I-SENS, INC. CARESENS N TEST STRIPS 85325000004 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST 85325000005 I-SENS, INC. CARESENS N TEST STRIPS 85325000011 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST 85325000015 I-SENS, INC. ACURA PLUS STARTER KIT 85325000016 I-SENS, INC. ACURA PLUS METER KIT 85325000017 I-SENS, INC. ACURA PLUS METER KIT 85325000019 I-SENS, INC. CARESENS N TEST STRIPS 85325000020 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST 85930001101 VERTEX DIAGNOST ULTRATRAK TEST STRIP 85930001103 VERTEX DIAGNOST ULTRATRAK CONTROL SOLUTION 85930001103 VERTEX DIAGNOST ULTRATRAK CONTROL SOLUTION 85930001104 VERTEX DIAGNOST ULTRATRAK CONTROL SOL NORMAL 85930001107 VERTEX DIAGNOST ULTRATRAK BLOOD GLUCOSE METER 85930001108 VERTEX DIAGNOST ULTRATRAK PRO METER KIT 86227018525 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 30GX1/2" 86227018635 ALLISON MEDICAL PUB INSUL SYR 0.3 ML 31GX5/16" 86227018745 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 31GX5/16" 86227018855 ALLISON MEDICAL PUB INSULIN SYR 1 ML 31GX5/16" 86227018995 ALLISON MEDICAL PUB INS SYRIN 0.3 ML 30GX1/2" 86227019075 ALLISON MEDICAL PUB INS SYRINGE 1 ML 30GX1/2" 86227028105 ALLISON MEDICAL SURE COMFORT 28G LANCETS 86227028205 ALLISON MEDICAL SURE COMFORT 28G LANCETS 86227030105 ALLISON MEDICAL SURE COMFORT 30G LANCETS 86227030205 ALLISON MEDICAL SURE COMFORT 30G LANCETS 86227052205 ALLISON MEDICAL SURE COMFORT LANCING PEN Page 41 of 48
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