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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 08290843801 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16" 08290844001 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16" 08290846502 BD BECTON DICKINSON B-D INSULIN U100 SYRINGE 08290846601 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2" 08290846801 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16" 08317015001 ARKRAY USA HAEMOLANCE, RETRACTABLE 08317035050 ARKRAY USA HAEMOLANCE, RETRACTABLE 08317330000 ARKRAY USA QUICKTEK TEST STRIPS 08317330001 ARKRAY USA QUICKTEK METER 08317330501 ARKRAY USA QUICKTEK CONTROL SOLUTION 08317331100 ARKRAY USA QUICKTEK KIT 08317335050 ARKRAY USA QUICKTEK TEST STRIPS 08317410000 ARKRAY USA ADVANCE MICRO-DRAW TEST STRIPS 08317410012 ARKRAY USA HYPOLANCE AST LANCING KIT 08317410012 ARKRAY USA HYPOLANCE AST LANCING KIT 08317410501 ARKRAY USA ADVANCE MICRO-DRAW CONTRL SOLN 08317415050 ARKRAY USA ADVANCE MICRO-DRAW TEST STRIPS 08317420001 ARKRAY USA ADVANCE INTUITION METER 08317420005 ARKRAY USA ADVANCE NORMAL CONTROL SOLN 08317420050 ARKRAY USA ADVANCE TEST STRIPS 08317421100 ARKRAY USA ADVANCE INTUITION METER 08317460001 ARKRAY USA ASSURE PRO METER 08317460006 ARKRAY USA ASSURE PRO CONTROL SOLUTION 08317460006 ARKRAY USA ASSURE PRO CONTROL SOLUTION 08317460050 ARKRAY USA ASSURE PRO TEST STRIPS 08317460100 ARKRAY USA ASSURE PRO TEST STRIPS 08317500001 ARKRAY USA ASSURE PLATINUM GLUCOSE METER 08317500005 ARKRAY USA ASSURE DOSE CONTROL SOLUTION 08317500006 ARKRAY USA ASSURE DOSE CONTROL SOLUTION 08317500006 ARKRAY USA ASSURE DOSE CONTROL SOLUTION 08317500050 ARKRAY USA ASSURE PLATINUM TEST STRIPS 08317500100 ARKRAY USA ASSURE PLATINUM TEST STRIPS 08317550602 ARKRAY USA ASSURE 3 CONTROL SOLUTION 08317550602 ARKRAY USA ASSURE 3 CONTROL SOLUTION 08317551000 ARKRAY USA ASSURE 3 TEST STRIPS 08317555050 ARKRAY USA ASSURE 3 TEST STRIPS 08317560001 ARKRAY USA ASSURE 4 BLOOD GLUCOSE METER 08317560006 ARKRAY USA ASSURE 4 CONTROL SOLUTION 08317560050 ARKRAY USA ASSURE 4 TEST STRIPS 08317560100 ARKRAY USA ASSURE 4 TEST STRIPS 08317630005 ARKRAY USA POCKETCHEM EZ CONTROL SOLUTION 08317630050 ARKRAY USA POCKETCHEM EZ TEST STRIPS 08317631101 ARKRAY USA POCKETCHEM EZ METER KIT 08317660001 ARKRAY USA SELECT-LITE LANCING DEVICE 08317660015 ARKRAY USA MULTI-LANCET DEVICE 08317710001 ARKRAY USA RELION MICRO SYSTEM 08317710050 ARKRAY USA RELION MICRO TEST STRIPS 08317712002 ARKRAY USA RELION CONFIRM SYSTEM KIT 08317712003 ARKRAY USA RELION CONFIRM SYSTEM KIT 08317712020 ARKRAY USA RELION CONFIRM-MICRO TEST STRP 08317712100 ARKRAY USA RELION CONFIRM-MICRO TEST STRP 08317720001 ARKRAY USA GLUCOCARD 01 BLOOD GLUCOSE MTR Page 6 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 08317720005 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION 08317720050 ARKRAY USA GLUCOCARD 01 SENSOR TEST STRIP 08317721100 ARKRAY USA GLUCOCARD 01 METER KIT 08317731100 ARKRAY USA GLUCOCARD 01-MINI METER KIT 08317740006 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION 08317740006 ARKRAY USA GLUCOCARD 01 CONTROL SOLUTION 08317740050 ARKRAY USA GLUCOCARD 01 SENSOR TEST STRIP 08317741100 ARKRAY USA GLUCOCARD 01 METER KIT 08317750005 ARKRAY USA GLUCOCARD X-METER CONTROL SOLN 08317750050 ARKRAY USA GLUCOCARD X-SENSOR TEST STRIPS 08317751100 ARKRAY USA GLUCOCARD X-METER SYSTEM KIT 08317752050 ARKRAY USA GLUCOCARD X-SENSOR TEST STRIPS 08317760050 ARKRAY USA GLUCOCARD VITAL SENSOR STRIP 08317761101 ARKRAY USA GLUCOCARD VITAL METER KIT 08317761102 ARKRAY USA GLUCOCARD VITAL METER KIT 08317761103 ARKRAY USA GLUCOCARD VITAL METER KIT 08317762050 ARKRAY USA GLUCOCARD VITAL SENSOR STRIP 08317880125 ARKRAY USA TECHLITE BLOOD LANCET 08317880128 ARKRAY USA TECHLITE BLOOD LANCET 08317880225 ARKRAY USA TECHLITE BLOOD LANCET 08317880228 ARKRAY USA TECHLITE BLOOD LANCET 08317880300 ARKRAY USA TECHLITE AST LANCETS 08317950000 ARKRAY USA HAEMOLANCE LANCET 08317955000 ARKRAY USA HAEMOLANCE LANCET 08317980125 ARKRAY USA ASSURE LANCE LANCET 08317980128 ARKRAY USA ASSURE LANCE MICRO FLOW LANCET 08317980225 ARKRAY USA ASSURE LANCE LANCET 08317980228 ARKRAY USA ASSURE LANCE MICRO FLOW LANCET 08317990200 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990250 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990400 ARKRAY USA HAEMOLANCE PLUS LANCET 08317990600 ARKRAY USA HAEMOLANCE PLUS LANCET 08317990700 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990750 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990800 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990900 ARKRAY USA HAEMOLANCE PLUS LANCETS 08317990950 ARKRAY USA HAEMOLANCE PLUS LANCETS 08321000123 PRODIGY DIABETE LANCETS 08321000170 PRODIGY DIABETE SAFETY LANCETS 08321081028 PRODIGY DIABETE LANCETS 08321081030 PRODIGY DIABETE LANCETS 30G 08321081038 PRODIGY DIABETE LANCETS 28G 08321081128 PRODIGY DIABETE LANCETS 08321083225 PRODIGY DIABETE LANCING DEVICE 08321240110 PRODIGY DIABETE LANCETS 08321240128 PRODIGY DIABETE LANCETS 28G 08321240130 PRODIGY DIABETE SAFETY LANCETS 08321240160 PRODIGY DIABETE SAFETY LANCETS 08321240228 PRODIGY DIABETE LANCETS 28G 08326200001 BOCA MEDICAL SAFETY LANCET 2MM 08326261001 BOCA MEDICAL ULTILET CLASSIC 26G LANCETS 08326280001 BOCA MEDICAL ULTILET LANCETS Page 7 of 48
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