Oregon Health Authority

Division of Medical Assistance Programs

Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011

For billing guidelines and examples:

NDC Code Labeler Name Label Name Desc

00193144001 BAYER HEALTHCARE BREEZE 2 METER

00193145001 BAYER HEALTHCARE BREEZE 2 METER

00193146550 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP

00193146621 BAYER HEALTHCARE BREEZE 2 DISC TEST STRIP

00193148901 BAYER HEALTHCARE BREEZE 2 SOLUTION

00193149001 BAYER HEALTHCARE BREEZE 2 SOLUTION

00193149101 BAYER HEALTHCARE BREEZE 2 SOLUTION

00193237021 BAYER HEALTHCARE GLUCOFILM TEST STRIPS

00193237150 BAYER HEALTHCARE GLUCOFILM TEST STRIPS

00193237225 BAYER HEALTHCARE GLUCOFILM TEST STRIPS

00193237321 BAYER HEALTHCARE GLUCOSTIX REAGENT STRIPS

00193237525 BAYER HEALTHCARE GLUCOSTIX REAGENT STRIPS

00193288821 BAYER HEALTHCARE DEXTROSTIX REAGENT STRIPS

00193364402 BAYER HEALTHCARE GLUCOMETER DEX CONTROL SOLN

00193364502 BAYER HEALTHCARE GLUCOMETER DEX CONTROL SOLN

00193392602 BAYER HEALTHCARE GLUCOMETER ELITE CNTRL SOLN

00193392702 BAYER HEALTHCARE GLUCOMETER ELITE CNTRL SOLN

00193545002 BAYER HEALTHCARE GLUCOFILM CONTROL - LOW

00193545102 BAYER HEALTHCARE GLUCOFILM CONTROL - NORMAL

00193545202 BAYER HEALTHCARE GLUCOFILM CONTROL - HIGH

00193596531 BAYER HEALTHCARE FINGERSTIX LANCETS

00193597610 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE

00193597901 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE

00193597901 BAYER HEALTHCARE GLUCOLET 2 LANCING DEVICE

00193618101 BAYER HEALTHCARE DIDGET METER

00193654621 BAYER HEALTHCARE MICROLET LANCETS

00193656801 BAYER HEALTHCARE SINGLE-LET LANCETS

00193658621 BAYER HEALTHCARE MICROLET LANCETS

00193660601 BAYER HEALTHCARE MICROLET 2 LANCING DEVICE

00193660601 BAYER HEALTHCARE MICROLET 2 LANCING DEVICE

00193707025 BAYER HEALTHCARE CONTOUR TEST STRIPS

00193708050 BAYER HEALTHCARE CONTOUR TEST STRIPS

00193709021 BAYER HEALTHCARE CONTOUR TEST STRIPS

00193710901 BAYER HEALTHCARE CONTOUR SOLUTION

00193711001 BAYER HEALTHCARE CONTOUR SOLUTION

00193711101 BAYER HEALTHCARE CONTOUR SOLUTION

00193715101 BAYER HEALTHCARE CONTOUR METER

00193718301 BAYER HEALTHCARE CONTOUR METER

00193718401 BAYER HEALTHCARE CONTOUR METER

00193718901 BAYER HEALTHCARE CONTOUR METER

00193719101 BAYER HEALTHCARE CONTOUR METER

00193739301 BAYER HEALTHCARE CONTOUR USB METER

00536991501 WATSON PHARMA, INC. INSULIN SYRINGE U100 1 ML

00536991601 WATSON PHARMA, INC. INSULIN SYRINGE U100 0.5 ML

00904437525 MAJOR PHARMACEUTICALS E-Z JECT LANCETS

00904437560 MAJOR PHARMACEUTICALS MAJOR COMFORT LANCETS

08080852801 TYCO HEALTHCARE GROUP LP KENDALL DIV. MONOJECT 0.5 ML SYRN 28GX1/2"

08189001666 CAN-AM CARE CORPORATION LANCETS

08189750220 CAN-AM CARE CORPORATION RELION LANCET

08189750510 CAN-AM CARE CORPORATION COMFORT LANCETS

08189850310 CAN-AM CARE CORPORATION RELION THIN LANCET

08189850320 CAN-AM CARE CORPORATION RELION THIN LANCET

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.

Page 1 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:

NDC Code Labeler Name Label Name Desc

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.

08189850920 CAN-AM CARE CORPORATION SUPER THIN LANCETS

08214015720 OWEN MUMFORD US THIN LANCET

08214015721 OWEN MUMFORD US CAREONE THIN LANCET

08214015724 OWEN MUMFORD US AURORA THIN LANCETS

08214018718 OWEN MUMFORD US KN LANCETS

08214020718 OWEN MUMFORD US KN THIN LANCETS

08214020740 OWEN MUMFORD US TODAY'S HLTH ULTRA THIN LANCET

08214025714 OWEN MUMFORD US ULTRA THIN LANCETS

08214025720 OWEN MUMFORD US ULTRA THIN 28 G LANCET

08214025735 OWEN MUMFORD US ULTRA THIN 28G LANCETS

08214025740 OWEN MUMFORD US TODAY'S HLTH ULTRA THIN LANCET

08214026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08214026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08214026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08214026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08214027001 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV

08214027020 OWEN MUMFORD US ADVANCED LANCING DEVICE

08214027020 OWEN MUMFORD US ADVANCED LANCING DEVICE

08214027101 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV

08214030720 OWEN MUMFORD US ULTRA THIN LANCET

08214035720 OWEN MUMFORD US ULTRA THIN LANCET

08214035721 OWEN MUMFORD US CAREONE ULTRA THIN LANCET

08214035726 OWEN MUMFORD US LIVE BETTER ULTRA THIN LANCET

08214035729 OWEN MUMFORD US PUB LANCETS

08214040001 OWEN MUMFORD US UNILET LANCET

08214041401 OWEN MUMFORD US UNILET GP LANCET

08214041801 OWEN MUMFORD US UNILET GP LANCET

08214043514 OWEN MUMFORD US ALTERNATE SITE LANCETS

08214043520 OWEN MUMFORD US ALTERNATE SITE 26 G LANCET

08214044001 OWEN MUMFORD US UNILET LANCET SUPERLITE

08214044501 OWEN MUMFORD US UNILET LANCET SUPERLITE

08214045001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08214045501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08214046001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08214046501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08214046520 OWEN MUMFORD US SUPER THIN 30 G LANCET

08214048715 OWEN MUMFORD US ADVANCED TRAVEL LANCETS 28G

08214051001 OWEN MUMFORD US UNILET EXCELITE LANCET

08214051501 OWEN MUMFORD US UNILET EXCELITE LANCET

08214053001 OWEN MUMFORD US UNILET EXCELITE II LANCET

08214053501 OWEN MUMFORD US UNILET EXCELITE II LANCET

08214057601 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV

08214060001 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE

08214060001 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE

08214061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE

08214061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE

08214065711 OWEN MUMFORD US COMFORT LANCETS

08214065714 OWEN MUMFORD US SUPER THIN LANCETS

08214065720 OWEN MUMFORD US SUPER THIN LANCET

08214065724 OWEN MUMFORD US AURORA SUPER THIN LANCET

08214065726 OWEN MUMFORD US LIVE BETTER SUPER THIN LANCET

08214065735 OWEN MUMFORD US SUPER THIN 30G LANCETS

Page 2 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:

NDC Code Labeler Name Label Name Desc

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.

08214065740 OWEN MUMFORD US TODAY'S HLTH SUPER THIN LANCET

08214070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08214070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08214070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08214070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08214070720 OWEN MUMFORD US LANCING DEVICE

08214070721 OWEN MUMFORD US CAREONE LANCING DEVICE

08214070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING

08214070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING

08214070729 OWEN MUMFORD US PUB ADVANCED LANCING DEVICE

08214070729 OWEN MUMFORD US PUB ADVANCED LANCING DEVICE

08214070734 OWEN MUMFORD US LANCING DEVICE

08214070740 OWEN MUMFORD US TODAY'S HEALTH LANCING DEVICE

08214071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214074201 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE

08214074201 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE

08214075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08214076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

08214076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

08214090001 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE

08214092001 OWEN MUMFORD US UNILET GP LANCET

08214092501 OWEN MUMFORD US UNILET GP LANCET

08214100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214104201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214104201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214106201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214106201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08214465714 OWEN MUMFORD US SUPER THIN LANCETS

08214515714 OWEN MUMFORD US DR LANCET

08214535714 OWEN MUMFORD US DR ULTRA THIN LANCET

08214535716 OWEN MUMFORD US PC SUPER THIN 30G LANCETS

08222072016 ULTIMED INC ULTICARE THIN 28G LANCETS

08222072191 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE

08222072191 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE

08222072399 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE

08222072399 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE

08222072597 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE

08222072597 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE

08222073150 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

08222073198 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

08222073198 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

08222073358 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

08222073396 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

08222073396 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

08222073556 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

08222073594 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

08222073594 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

Page 3 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:

NDC Code Labeler Name Label Name Desc

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.

08222074195 ULTIMED INC ULTIGUARD 31GX1 ML SYRINGE

08222074393 ULTIMED INC ULTIGUARD 31GX0.3 ML SYRINGE

08222074591 ULTIMED INC ULTIGUARD 31GX0.5 ML SYRINGE

08222082183 ULTIMED INC ULTICARE INS SYR 1 ML 28GX1/2"

08222082589 ULTIMED INC ULTICARE SYRIN 0.5 ML 28GX1/2"

08222092199 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"

08222092397 ULTIMED INC ULTICARE SYRIN 0.3 ML 29GX1/2"

08222092595 ULTIMED INC ULTICARE U100 0.5 ML 29GX1/2"

08222093158 ULTIMED INC ULTICARE INSULIN SYR U100 1 ML

08222093196 ULTIMED INC ULTCARE INS SYR 1 ML 30GX5/16"

08222093356 ULTIMED INC ULTICARE INSUL SYR U100 0.3 ML

08222093394 ULTIMED INC ULTICARE U100 0.3 ML 30GX5/16"

08222093554 ULTIMED INC ULTICARE INSUL SYR U100 0.5 ML

08222093592 ULTIMED INC ULTICARE SYR 0.5 ML 30GX5/16"

08222094193 ULTIMED INC ULTCARE INS SYR 1 ML 31GX5/16"

08222094391 ULTIMED INC ULTICARE SYR 0.3 ML 31GX5/16"

08222094599 ULTIMED INC ULTICARE SYR 0.5 ML 31GX5/16"

08238049001 AMIRA MEDICAL AT-LAST BLOOD GLUCOSE SYSTM

08238053904 AMIRA MEDICAL AT-LAST LANCETS

08238054702 AMIRA MEDICAL AT-LAST TEST STRIPS

08238115301 AMIRA MEDICAL AT LAST CONTROL SOLUTION

08238117104 AMIRA MEDICAL AT-LAST TEST STRIPS

08271033100 MED.PLASTIC DEV LANCETS THIN

08271035100 MED.PLASTIC DEV LANCETS THIN

08271036100 MED.PLASTIC DEV LANCETS ULTRA THIN

08271036200 MED.PLASTIC DEV LANCETS ULTRA THIN

08271138100 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS

08271138200 MED.PLASTIC DEV MEDLANCE PLUS UNIVERSAL LANCET

08271138400 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS

08271310100 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE

08271310200 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE

08271310300 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE

08271352300 MED.PLASTIC DEV INSUMED SYR 0.3 ML 31GX5/16"

08278110011 MED.PLASTIC DEV GLUCOSOURCE LANCING DEVICE

08278220011 MED.PLASTIC DEV GLUCOSOURCE LANCETS

08287126001 EXEL INT'L INC. EXEL INSUL SYR 0.5 ML 28GX1/2"

08287126002 EXEL INT'L INC. EXEL INSULIN SYRN 27G-1/2 ML

08287126014 EXEL INT'L INC. EXEL U100 0.3 ML 30GX5/16"

08287126015 EXEL INT'L INC. EXEL U100 0.5 ML 30GX5/16"

08287126016 EXEL INT'L INC. EXEL U100 1 ML 30GX5/16"

08287126018 EXEL INT'L INC. EXEL U100 0.3 ML 29GX1/2"

08287126020 EXEL INT'L INC. EXEL INSULIN SYRINGE 27G-1 ML

08287126022 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2

08287126026 EXEL INT'L INC. EXEL U100 0.5 ML 28GX1/2"

08287126027 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2

08287126028 EXEL INT'L INC. EXEL U100 0.5 ML 29GX1/2"

08287126029 EXEL INT'L INC. EXEL U100 INS SYR 1 ML 29GX1/2

08290305934 BD BECTON DICKINSON BD SAFTGLD INS SYR 0.5 ML 30G

08290305935 BD BECTON DICKINSON BD SAFTGLD INS SYR 0.3 ML 29G

08290305937 BD BECTON DICKINSON BD SAFTGLD INS 0.3 ML 31GX5/16

08290309300 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"

08290309301 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 29GX1/2"

Page 4 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:

NDC Code Labeler Name Label Name Desc

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.

08290309305 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"

08290309306 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 29GX1/2"

08290309309 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290309310 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX1/2"

08290309311 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"

08290322057 BD BECTON DICKINSON BD LANCETS 33G

08290322065 BD BECTON DICKINSON BD LANCETS 33G

08290325657 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX5/8"

08290325772 BD BECTON DICKINSON BD LANCETS 30G

08290325773 BD BECTON DICKINSON BD LANCETS 30G

08290325775 BD BECTON DICKINSON BD LANCET DEVICE

08290328278 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"

08290328279 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2"

08290328280 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"

08290328281 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290328282 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"

08290328283 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"

08290328289 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"

08290328290 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16"

08290328291 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"

08290328410 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290328411 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"

08290328412 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX5/8"

08290328418 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"

08290328430 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"

08290328431 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"

08290328438 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"

08290328440 BD BECTON DICKINSON BD INSULIN SYR 0.3ML 31GX5/16"

08290328465 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"

08290328466 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 30GX1/2"

08290328468 BD BECTON DICKINSON BD INSULIN SYR 0.5ML 31GX5/16"

08290329411 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"

08290329412 BD BECTON DICKINSON BD INSULIN SYR 1 ML 27GX5/8"

08290329420 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290329424 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290329430 BD BECTON DICKINSON BD INSULIN U100-3/10 ML SYR

08290329461 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"

08290329464 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"

08290329465 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 28GX1/2"

08290329466 BD BECTON DICKINSON BD INSULIN SYR 0.5 ML 29GX1/2"

08290329622 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX1"

08290329651 BD BECTON DICKINSON BD INSULIN SYR 1 ML 25GX5/8"

08290329652 BD BECTON DICKINSON BD INSULIN SYR 1 ML 26GX1/2"

08290366592 BD BECTON DICKINSON BD LANCETS MICROTAINER 30G

08290366593 BD BECTON DICKINSON BD LANCETS MICROTAINER 21G

08290366594 BD BECTON DICKINSON BD LANCETS MICROTAINER

08290593001 BD BECTON DICKINSON BD INSULIN SYR 1 ML 29GX1/2"

08290841002 BD BECTON DICKINSON BD INSULIN SYR 1 ML 28GX1/2"

08290841101 BD BECTON DICKINSON BD INSULIN SYR 1 ML 30GX1/2"

08290841801 BD BECTON DICKINSON BD INSULIN SYR 1 ML 31GX5/16"

08290843002 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 28GX1/2"

08290843101 BD BECTON DICKINSON BD INSULIN SYR 0.3 ML 30GX1/2"

Page 5 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:

NDC Code Labeler Name Label Name Desc

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.

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:

NDC Code Labeler Name Label Name Desc

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.

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

Oregon Health Authority

Division of Medical Assistance Programs

Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011

For billing guidelines and examples:

NDC Code Labeler Name Label Name Desc

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.

08326280002 BOCA MEDICAL ULTILET LANCETS

08326281001 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS

08326281002 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS

08326281101 BOCA MEDICAL PUBLIX 28G LANCET

08326281102 BOCA MEDICAL PUBLIX 28G LANCET

08326284001 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS

08326284101 BOCA MEDICAL ULTILET CLASSIC 28G LANCETS

08326290110 BOCA MEDICAL INSULIN SYRINGE 1 ML

08326290130 BOCA MEDICAL INSULIN SYRINGE 0.3 ML

08326290150 BOCA MEDICAL INSULIN SYRINGE 0.5 ML

08326290310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML

08326290330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML

08326290350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML

08326300001 BOCA MEDICAL ULTILET 30G LANCETS

08326300110 BOCA MEDICAL INSULIN SYRINGE 1 ML

08326300130 BOCA MEDICAL INSULIN SYRINGE 0.3 ML

08326300150 BOCA MEDICAL INSULIN SYRINGE 0.5 ML

08326300210 BOCA MEDICAL INSULIN SYRINGE 1 ML

08326300230 BOCA MEDICAL INSULIN SYRINGE 0.3 ML

08326300310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML

08326300330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML

08326300350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML

08326301001 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS

08326302001 BOCA MEDICAL ULTILET BASIC 30G LANCETS

08326304001 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS

08326304101 BOCA MEDICAL ULTILET CLASSIC 30G LANCETS

08326310310 BOCA MEDICAL ULTILET INSULIN SYRINGE 1 ML

08326310330 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.3 ML

08326310350 BOCA MEDICAL ULTILET INSULIN SYRINGE 0.5 ML

08326412801 BOCA MEDICAL ULTILET 28G LANCETS

08327048609 MEDLINE INDUS. EVENCARE MONITORING SYSTEM

08327048629 MEDLINE INDUS. EVENCARE GLUCOSE TST STRIPS

08327048692 MEDLINE INDUS. EVENCARE CONTROL SOLUTION

08327048692 MEDLINE INDUS. EVENCARE CONTROL SOLUTION

08327052029 MEDLINE INDUS. EVENCARE TEST STRIPS

08367010102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC

08367010202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 1CC

08367011102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 1CC

08367011202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC

08367012202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC

08367013202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1CC

08367033202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.3CC

08367050102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.5CC

08367050202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 0.5CC

08367051102 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 1/2CC

08367051202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSUL SYR 0.5CC

08367052202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INSULIN SYR 0.5CC

08367053202 RX HOLDINGS, LLC (DBA RX ELITE) ELITE-THIN INS SYR 0.5CC

08396705014 CAN-AM CARE RA HEALTH CARE LANCING DEVICE

08396705014 CAN-AM CARE RA HEALTH CARE LANCING DEVICE

08396800100 CAN-AM CARE ULTRA COMFORT 0.5 ML 28GX1/2"

08396800200 CAN-AM CARE ULTRA COMFORT 1 ML 28GX1/2"

Page 8 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:

NDC Code Labeler Name Label Name Desc

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.

08396800300 CAN-AM CARE ULTRA COMFORT 0.3 ML 29GX1/2"

08396800400 CAN-AM CARE ULTRA COMFORT 0.5 ML 29GX1/2"

08396800500 CAN-AM CARE ULTRA COMFORT 1 ML 29GX1/2"

08396800600 CAN-AM CARE ULTRA COMFORT 0.3 ML 30GX5/16"

08396800700 CAN-AM CARE ULTRA COMFORT 0.5 ML 30GX5/16"

08396800800 CAN-AM CARE ULTRA COMFORT 1 ML 30GX5/16"

08396800900 CAN-AM CARE ULTRA COMFORT 0.3 ML 31GX5/16"

08396801000 CAN-AM CARE ULTRA COMFORT 0.5 ML 31GX5/16"

08396801100 CAN-AM CARE ULTRA COMFORT 1 ML 31GX5/16"

08396900400 CAN-AM CARE CLICKFINE UNIVERSAL 31G X 1/4"

08396900500 CAN-AM CARE CLICKFINE UNIVERSAL 31GX5/16"

08463000301 US DIAGNOSTICS EASYGLUCO MONITORING SYSTEM

08463010301 US DIAGNOSTICS EASYGLUCO METER

08463020350 US DIAGNOSTICS EASYGLUCO TEST STRIPS

08463020401 US DIAGNOSTICS EASYGLUCO TEST STRIPS

08463120350 US DIAGNOSTICS EASY GLUCO G2 TEST STRIP

08463120401 US DIAGNOSTICS EASY GLUCO G2 TEST STRIP

08463220350 US DIAGNOSTICS CONTROL G3 TEST STRIP

08463220401 US DIAGNOSTICS CONTROL G3 TEST STRIP

08463310301 US DIAGNOSTICS CONTROL MONITORING SYSTEM

08463320350 US DIAGNOSTICS CONTROL TEST STRIPS

08463320401 US DIAGNOSTICS CONTROL TEST STRIPS

08463382001 US DIAGNOSTICS LANCING DEVICE

08463400300 US DIAGNOSTICS G-4 MONITORING STARTER KIT

08463400301 US DIAGNOSTICS G-4 MONITORING SYSTEM

08463400501 US DIAGNOSTICS MAXIMA CONTROL SOLUTION

08463410300 US DIAGNOSTICS G-4 BLOOD GLUCOSE METER

08463410301 US DIAGNOSTICS G-4 BLOOD GLUCOSE METER

08463410501 US DIAGNOSTICS MAXIMA CONTROL SOLUTION

08463420300 US DIAGNOSTICS G-4 TEST STRIPS

08463420301 US DIAGNOSTICS MAXIMA CONTROL SOLUTION

08463420350 US DIAGNOSTICS MAXIMA TEST STRIP

08463430301 US DIAGNOSTICS MAXIMA CONTROL SOLUTION

08463500301 US DIAGNOSTICS INFINITY STARTER KIT

08463500401 US DIAGNOSTICS INFINITY STARTER KIT

08463500501 US DIAGNOSTICS INFINITY CONTROL SOLN NORMAL

08463510301 US DIAGNOSTICS INFINITY METER KIT

08463510501 US DIAGNOSTICS INFINITY CONTROL SOLN HIGH

08463520350 US DIAGNOSTICS INFINITY TEST STRIPS

08463520501 US DIAGNOSTICS INFINITY CONTROL SOLN LOW

08463600301 US DIAGNOSTICS ACURA STARTER KIT

08463600501 US DIAGNOSTICS ACURA CONTROL SOLUTION NORMAL

08463610301 US DIAGNOSTICS ACURA METER KIT

08463610501 US DIAGNOSTICS ACURA CONTROL SOLUTION HIGH

08463620350 US DIAGNOSTICS ACURA TEST STRIPS

08463620501 US DIAGNOSTICS ACURA CONTROL SOLUTION LOW

08463700301 US DIAGNOSTICS ACURA PLUS STARTER KIT

08463701228 US DIAGNOSTICS LANCETS 28G

08463702930 US DIAGNOSTICS LANCETS 30G

08463710300 US DIAGNOSTICS ACURA PLUS METER KIT

08463710301 US DIAGNOSTICS ACURA PLUS METER KIT

08463720350 US DIAGNOSTICS G-4 TEST STRIPS

Page 9 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:

NDC Code Labeler Name Label Name Desc

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.

08463803028 US DIAGNOSTICS SAFETY LANCETS

08463820350 US DIAGNOSTICS INFINITY TEST STRIPS

08470026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08470026001 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08470026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08470026501 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

08470027001 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470027001 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470027101 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470027101 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470027401 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470027401 OWEN MUMFORD US AUTOLET IMPRESS LANCING DEVICE

08470040001 OWEN MUMFORD US UNILET LANCET

08470041401 OWEN MUMFORD US UNILET GP LANCET

08470041801 OWEN MUMFORD US UNILET GP LANCET

08470043001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08470043501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08470044001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08470044501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08470045001 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08470045501 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

08470046001 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08470046501 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

08470051001 OWEN MUMFORD US UNILET EXCELITE LANCET

08470051501 OWEN MUMFORD US UNILET EXCELITE LANCET

08470053001 OWEN MUMFORD US UNILET EXCELITE II LANCET

08470053501 OWEN MUMFORD US UNILET EXCELITE II LANCET

08470057601 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV

08470060001 OWEN MUMFORD US UNISTIK 2.4MM DEVICES

08470060001 OWEN MUMFORD US UNISTIK 2.4MM DEVICES

08470061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE

08470061001 OWEN MUMFORD US UNISTIK 3 MM DEVICE

08470070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470070001 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470070201 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470070401 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470070401 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

08470071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470071001 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470071201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470071401 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470071401 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470074001 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC

08470074001 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC

08470074201 OWEN MUMFORD US UNISTIK 2 1.8 MM LANCING DEVIC

08470074201 OWEN MUMFORD US UNISTIK 2 1.8 MM LANCING DEVIC

08470074701 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC

08470074701 OWEN MUMFORD US UNISTIK 2 COMFORT 1.8 MM DEVIC

08470075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

08470075201 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

Page 10 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:

NDC Code Labeler Name Label Name Desc

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.

08470076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

08470076201 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

08470090001 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE

08470092001 OWEN MUMFORD US UNILET GP LANCET

08470092501 OWEN MUMFORD US UNILET GP LANCET

08470100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08470100201 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08470100401 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08470100401 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

08470100701 OWEN MUMFORD US UNISTIK 3 NORMAL LANCET

08470100801 OWEN MUMFORD US UNISTIK CZT NORMAL LANCET

08470101201 OWEN MUMFORD US UNISTIK 3 EXTRA LANCET

08470101401 OWEN MUMFORD US UNISTIK 3 EXTRA LANCET

08470101801 OWEN MUMFORD US UNISTIK 3 SAFETY LANCET 21G

08470104201 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC

08470104201 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC

08470104401 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC

08470104401 OWEN MUMFORD US UNISTIK 3 COMFORT 1.8 ML DEVIC

08470104701 OWEN MUMFORD US UNISTIK 3 COMFORT LANCET

08470104801 OWEN MUMFORD US UNISTIK CZT COMFORT LANCET

08470106201 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV

08470106201 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV

08470106401 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV

08470106401 OWEN MUMFORD US UNISTIK 3 NEONATAL 1.8 ML DEV

08474010278 ULTIMED INC ULTRACOMFORT 29GX0.5 ML SYR

08474010278 ULTIMED INC ULTRACOMFORT 29GX0.5 ML SYR

08474010378 ULTIMED INC ULTRACOMFORT 29GX1 ML SYRINGE

08474010378 ULTIMED INC ULTRACOMFORT 29GX1 ML SYRINGE

08474010478 ULTIMED INC ULTRACOMFORT 30GX0.5 ML SYR

08474010478 ULTIMED INC ULTRACOMFORT 30GX0.5 ML SYR

08474010578 ULTIMED INC ULTRACOMFORT 30GX1 ML SYRINGE

08474010578 ULTIMED INC ULTRACOMFORT 30GX1 ML SYRINGE

08474010678 ULTIMED INC ULTRACOMFORT 31GX0.5 ML SYR

08474010678 ULTIMED INC ULTRACOMFORT 31GX0.5 ML SYR

08474010778 ULTIMED INC ULTRACOMFORT 31GX1 ML SYRINGE

08474010778 ULTIMED INC ULTRACOMFORT 31GX1 ML SYRINGE

08474010878 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML

08474010978 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML

08474011078 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML

08474011178 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML

08474011278 ULTIMED INC ULTRACOMFORT INSUL SYR 0.5 ML

08474011378 ULTIMED INC ULTRACOMFORT INSULIN SYR 1 ML

08474592590 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML

08474593191 ULTIMED INC ORSINI INSUL SYR U100 1 ML

08474593597 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML

08474721901 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"

08474721901 ULTIMED INC CAREONE SYR 1 ML 29GX0.5"

08474723901 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"

08474723901 ULTIMED INC CAREONE SYR 0.3 ML 29GX0.5"

08474725901 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"

08474725901 ULTIMED INC CAREONE SYR 0.5 ML 29GX0.5"

08474731901 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"

Page 11 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:

NDC Code Labeler Name Label Name Desc

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.

08474731901 ULTIMED INC CAREONE SYR 1 ML 30GX5/16"

08474733901 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"

08474733901 ULTIMED INC CAREONE SYR 0.3 ML 30GX5/16"

08474735901 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"

08474735901 ULTIMED INC CAREONE SYR 0.5 ML 30GX5/16"

08474925900 ULTIMED INC SCHNUCKS SYR 0.5 ML 29GX1/2"

08474935900 ULTIMED INC SCHNUCKS SYR 0.5 ML 30GX5/16"

08480492050 HYPOGUARD EASY PRO PLUS TEST STRIPS

08480492101 HYPOGUARD EASY PRO PLUS SYSTEM KIT

08484050300 DIAGNOSTIC DEVI PRODIGY POCKET GLUCOSE METER

08484050301 DIAGNOSTIC DEVI PRODIGY POCKET GLUCOSE METER

08484050302 DIAGNOSTIC DEVI PRODIGY POCKET GLUCOSE METER

08484050303 DIAGNOSTIC DEVI PRODIGY POCKET GLUCOSE METER

08484050304 DIAGNOSTIC DEVI PRODIGY POCKET GLUCOSE METER

08484050360 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484050361 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484050362 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484050363 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484050364 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484051880 DIAGNOSTIC DEVI PRODIGY AUTOCODE METER KIT

08484051885 DIAGNOSTIC DEVI PRODIGY AUTOCODE METER KIT

08484051890 DIAGNOSTIC DEVI PRODIGY AUTOCODE METER KIT

08484052300 DIAGNOSTIC DEVI PRODIGY GLUCOSE TEST STRIP

08484052400 DIAGNOSTIC DEVI PRODIGY GLUCOSE TEST STRIP

08484052800 DIAGNOSTIC DEVI PRODIGY NO CODING TEST STRIPS

08484052835 DIAGNOSTIC DEVI PRODIGY GLUCOSE TEST STRIP

08484052870 DIAGNOSTIC DEVI PRODIGY AUTOCODE TEST STRIPS

08484052970 DIAGNOSTIC DEVI PRODIGY VOICE GLU TEST STRIP

08484053310 DIAGNOSTIC DEVI PRODIGY CONTROL SOLUTION LOW

08484053350 DIAGNOSTIC DEVI PRODIGY CONTROL SOLUTION

08484056100 DIAGNOSTIC DEVI PRODIGY PREFERRED METER

08484056150 DIAGNOSTIC DEVI PRODIGY PREFERRED METER KIT

08484070120 DIAGNOSTIC DEVI PRODIGY AUTOCODE METER KIT

08484070800 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484070801 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484070802 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484070803 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484070804 DIAGNOSTIC DEVI PRODIGY POCKET METER KIT

08484072500 DIAGNOSTIC DEVI PRODIGY NO CODING TEST STRIPS

08484081028 DIAGNOSTIC DEVI PRODIGY TWIST TOP 28G LANCET

08484082026 DIAGNOSTIC DEVI PRODIGY SAFETY LANCETS

08484082316 DIAGNOSTIC DEVI PRODIGY PRESSURE ACTIVE LANCET

08484082321 DIAGNOSTIC DEVI PRODIGY PRESSURE ACTIVE LANCET

08484082341 DIAGNOSTIC DEVI PRODIGY PRESSURE ACTIVE LANCET

08484083225 DIAGNOSTIC DEVI PRODIGY LANCING DEVICE

08484990250 DIAGNOSTIC DEVI PRODIGY NO CODING TEST STRIPS

08484990310 DIAGNOSTIC DEVI PRODIGY CONTROL SOLUTION LOW

08484990328 DIAGNOSTIC DEVI PRODIGY TWIST TOP 28G LANCET

08484990338 DIAGNOSTIC DEVI PRODIGY PRESSURE ACTIVE LANCET

08484990355 DIAGNOSTIC DEVI PRODIGY LANCING DEVICE

08484990430 DIAGNOSTIC DEVI PRODIGY INS SYR 1ML 28GX1/2"

08484990432 DIAGNOSTIC DEVI PRODIGY INS SYR 1ML 28GX1/2"

Page 12 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:

NDC Code Labeler Name Label Name Desc

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.

08484990435 DIAGNOSTIC DEVI PRODIGY SYRNG 0.5 ML 31GX5/16"

08484990437 DIAGNOSTIC DEVI PRODIGY SYRNG 0.5 ML 31GX5/16"

08484990438 DIAGNOSTIC DEVI PRODIGY SYRNGE 0.3ML 31GX5/16"

08484990480 DIAGNOSTIC DEVI PRODIGY SYRNG 1 ML 29GX1/2"

08489715510 INPHARMA INC. ACTI-LANCE LITE 28G LANCETS

08489715610 INPHARMA INC. ACTI-LANCE 23G LANCETS

08489715710 INPHARMA INC. ACTI-LANCE SPECIAL 17G LANCETS

08489716130 INPHARMA INC. DROPLET 30G LANCETS

08496281501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496281511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496285501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496285511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496291501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496291511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496295501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496295511 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496301601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496301611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496303601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML

08496303611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML

08496305601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496305611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496311601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496311611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496313601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML

08496313611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.3 ML

08496315601 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496315611 MASTERS PHARMAC EASY TOUCH INSULIN SYR 0.5 ML

08496791501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08496801501 MASTERS PHARMAC EASY TOUCH INSULIN SYR 1 ML

08517015722 OWEN MUMFORD US 1ST CHOICE THIN LANCETS

08517025736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET

08517030722 OWEN MUMFORD US 1ST CHOICE ULTRA THIN LANCETS

08517035722 OWEN MUMFORD US 1ST CHOICE ULTRA THIN LANCETS

08517065722 OWEN MUMFORD US 1ST CHOICE SUPER THIN LANCETS

08517065736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET

08521000131 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 1 ML

08521000231 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 0.5 ML

08521000331 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 0.3 ML

08521080001 FIFTY50 PHARMAC FIFTY50 LANCING DEVICE

08521081030 FIFTY50 PHARMAC FIFTY50 SAFETY SEAL LANCETS

08521081032 FIFTY50 PHARMAC FIFTY50 SAFETY SEAL LANCETS

08522000001 HMD MEDICAL, LL ECLIPSE BLOOD GLUCOSE MONITOR

08522000002 HMD MEDICAL, LL ECLIPSE TEST STRIPS

08522000003 HMD MEDICAL, LL ECLIPSE CONTROL SOLN NORMAL

08522000004 HMD MEDICAL, LL ECLIPSE CONTROL SOLUTION LOW

08522000005 HMD MEDICAL, LL ECLIPSE CONTROL SOLUTION HIGH

08522000010 HMD MEDICAL, LL ENVISION MONITORING SYSTEM

08522000011 HMD MEDICAL, LL ENVISION TEST STRIPS

08522000012 HMD MEDICAL, LL ENVISION CONTROL SOLN NORMAL

08522000013 HMD MEDICAL, LL ENVISION CONTROL SOLN HIGH

08522000014 HMD MEDICAL, LL ENVISION CONTROL SOLN LOW

Page 13 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:

NDC Code Labeler Name Label Name Desc

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.

08522000016 HMD MEDICAL, LL EVOLUTION BLOOD GLUCOSE METER

08522000017 HMD MEDICAL, LL EVOLUTION TEST STRIPS

08522000018 HMD MEDICAL, LL EVOLUTION CONTROL SOLN NORMAL

08522000022 HMD MEDICAL, LL ELEMENT BLOOD GLUCOSE METER KT

08522000023 HMD MEDICAL, LL ELEMENT TEST STRIPS

08522000024 HMD MEDICAL, LL ELEMENT CONTROL SOLN NORMAL

08522000025 HMD MEDICAL, LL ELEMENT CONTROL SOLUTION LOW

08522000026 HMD MEDICAL, LL ELEMENT CONTROL SOLUTION HIGH

08522000043 HMD MEDICAL, LL SMARTDIABETES XPRES TEST STRIP

08522000046 HMD MEDICAL, LL SMARTDIABETES XPRES GLUC SYST

08522000050 HMD MEDICAL, LL VANTAGE LANCING DEVICE

08522000052 HMD MEDICAL, LL SMARTDIABETES VANTAGE LANCETS

08522031908 HMD MEDICAL, LL GLUCOLAB CONTROL SOLUTION HIGH

08522031912 HMD MEDICAL, LL GLUCOLAB CONTROL SOLUTION LOW

08522031914 HMD MEDICAL, LL GLUCOLAB CONTROL SOLN NORMAL

08522131100 HMD MEDICAL, LL GLUCOLAB METER KIT

08522201950 HMD MEDICAL, LL GLUCOLAB TEST STRIPS

08524000103 PROGRESSIVE HEA SMARTEST TEST STRIPS

08524000201 PROGRESSIVE HEA SMARTEST CONTROL SOLUTION

08524000403 PROGRESSIVE HEA SMARTEST LANCET

08524001201 PROGRESSIVE HEA SMARTEST EJECT METER

08524001301 PROGRESSIVE HEA SMARTEST PROTEGE METER

08524001401 PROGRESSIVE HEA SMARTEST SMART CODE METER

08524001702 PROGRESSIVE HEA SMARTEST PRONTO GLUCOSE METER

08524001802 PROGRESSIVE HEA SMARTEST PERSONA GLUCOSE METER

08524002201 PROGRESSIVE HEA SMARTEST EJECT METER

08524002301 PROGRESSIVE HEA SMARTEST PROTEGE METER

08524002401 PROGRESSIVE HEA SMARTEST SMART CODE METER

08524002702 PROGRESSIVE HEA SMARTEST PRONTO STARTER KIT

08524002802 PROGRESSIVE HEA SMARTEST PERSONA STARTER KIT

08525010001 CARDIOCOM MULTI GLUCOCOM BLOOD GLUCOSE KIT

08525010150 CARDIOCOM MULTI GLUCOCOM GLUCOSE TEST STRIP

08525010300 CARDIOCOM MULTI GLUCOCOM LANCETS 28G

08525010601 CARDIOCOM MULTI GLUCOCOM BLOOD GLUCOSE METER

08525011001 CARDIOCOM MULTI GLUCOCOM CONTROL SOLUTION

08525011101 CARDIOCOM MULTI GLUCOCOM CONTROL SOLUTION

08525011200 CARDIOCOM MULTI GLUCOCOM LANCETS 30G

08525011300 CARDIOCOM MULTI GLUCOCOM LANCETS 33G

08525011501 CARDIOCOM MULTI GLUCOCOM VALUE KIT

08539000101 INVICTUS SCIENT RIGHTEST GM300 SYSTEM KIT

08539000501 INVICTUS SCIENT RIGHTEST GS300 TEST STRIPS

08539001201 INVICTUS SCIENT RIGHTEST CONTROL SOLUTION HIGH

08539001301 INVICTUS SCIENT RIGHTEST CONTROL SOLN NORMAL

08539002001 INVICTUS SCIENT RIGHTEST GD500 LANCING DEVICE

08539010001 INVICTUS SCIENT RIGHTEST GM100 SYSTEM KIT

08539055003 INVICTUS SCIENT RIGHTEST GM550 SYSTEM KIT

08539060000 INVICTUS SCIENT RIGHTEST GL300 LANCETS

08539105002 INVICTUS SCIENT RIGHTEST GS100 TEST STRIPS

08539505003 INVICTUS SCIENT RIGHTEST GS550 TEST STRIPS

08548043416 NOVA BIOMEDICAL NOVA MAX GLUCOSE TEST STRIP

08548043421 NOVA BIOMEDICAL NOVA SUREFLEX LANCETS

08548043423 NOVA BIOMEDICAL NOVA MAX GLUCOSE TEST STRIP

Page 14 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:

NDC Code Labeler Name Label Name Desc

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.

08548043433 NOVA BIOMEDICAL NOVA SUREFLEX LANCING DEVICE

08548043435 NOVA BIOMEDICAL NOVA MAX BLOOD GLUCOSE METER

08548043436 NOVA BIOMEDICAL NOVA MAX BLOOD GLUCOSE METER

08548043437 NOVA BIOMEDICAL NOVA MAX GLUCOSE TEST STRIP

08548043446 NOVA BIOMEDICAL NOVA MAX GLUCOSE CONTROL SOLN

08548043447 NOVA BIOMEDICAL NOVA SUREFLEX LANCING DEVICE

08548043447 NOVA BIOMEDICAL NOVA SUREFLEX LANCING DEVICE

08548043523 NOVA BIOMEDICAL NOVA MAX GLUCOSE TEST STRIP

08548045824 NOVA BIOMEDICAL NOVA MAX BLOOD GLUCOSE METER

08548048738 NOVA BIOMEDICAL NOVA SUREFLEX THIN LANCETS

08554131701 AGAMATRIX, INC. KEYNOTE BLOOD GLUCOSE SYSTEM

08554132801 AGAMATRIX, INC. KEYNOTE GLUCOSE TEST STRIPS

08554133301 AGAMATRIX, INC. WAVESENSE CONTROL SOLN NORMAL

08554197101 AGAMATRIX, INC. WAVESENSE ULTRA THIN LANCETS

08554226502 AGAMATRIX, INC. KEYNOTE GLUCOSE TEST STRIPS

08554229701 AGAMATRIX, INC. WAVESENSE JAZZ SYSTEM KIT

08554232001 AGAMATRIX, INC. WAVESENSE JAZZ TEST STRIPS

08554264901 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT

08554318802 AGAMATRIX, INC. WAVESENSE JAZZ TEST STRIPS

08554332901 AGAMATRIX, INC. WAVESENSE PRESTO TEST STRIPS

08554333702 AGAMATRIX, INC. WAVESENSE PRESTO TEST STRIPS

08554338401 AGAMATRIX, INC. KEYNOTE PRO BLOOD GLUCOSE SYST

08554362901 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT

08554386401 AGAMATRIX, INC. WAVESENSE PRESTO SYSTEM KIT

08554402401 AGAMATRIX, INC. WAVESENSE AMP SYSTEM KIT

08554403601 AGAMATRIX, INC. WAVESENSE AMP TEST STRIPS

08554408801 AGAMATRIX, INC. PRESTO PRO BLOOD GLUCOSE METER

08554424001 AGAMATRIX, INC. BLOOD GLUCOSE TEST STRIPS

08554442601 AGAMATRIX, INC. LIBERTY TEST STRIPS

08554444201 AGAMATRIX, INC. LIBERTY BLOOD GLUCOSE METER

08554453801 AGAMATRIX, INC. LIBERTY CONTROL SOLN NORMAL

08554454601 AGAMATRIX, INC. LIBERTY CONTROL SOLUTION HIGH

08565015915 STERILANCE MEDI TWIST LANCETS

08565016915 STERILANCE MEDI TWIST LANCETS

08565017915 STERILANCE MEDI TWIST LANCETS

08565044415 STERILANCE MEDI LANCETS 26G X 1.8MM

08565045415 STERILANCE MEDI LANCETS 28G X 1.8MM

08565054015 STERILANCE MEDI LANCETS 26G

08565134415 STERILANCE MEDI LANCETS 26G X 1.8MM

08565135415 STERILANCE MEDI LANCETS 28G X 1.8MM

08580301001 BIO-MED USA INC INSULIN SYRINGE 1 ML 30GX1/2"

08580311101 BIO-MED USA INC INSULIN SYRINGE 1 ML 30GX5/16"

08580500201 BIO-MED USA INC INSULIN SYRIN 0.5 ML 30GX5/16"

08580500501 BIO-MED USA INC INSULIN SYRIN 0.5 ML 30GX1/2"

08593211002 VERTEX DIATNOST ULTRATRAK TEST STRIP

08593211102 VERTEX DIATNOST ULTRATRAK PRO GLUCOSE MTR SYS

08593211202 VERTEX DIATNOST ULTRATRAK CONTROL SOL NORMAL

08593211302 VERTEX DIATNOST ULTRATRAK CONTROL SOLUTION

08593211302 VERTEX DIATNOST ULTRATRAK CONTROL SOLUTION

08593211402 VERTEX DIATNOST ULTRALANCE LANCETS 26G

08593211502 VERTEX DIATNOST ULTRALANCE LANCETS 28G

08593211602 VERTEX DIATNOST ULTRATRAK BLOOD GLUCOSE METER

Page 15 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:

NDC Code Labeler Name Label Name Desc

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.

08593211702 VERTEX DIATNOST ULTRATRAK PRO METER KIT

08593211802 VERTEX DIATNOST ULTRATRAK ULTIMATE GLUCOSE MTR

08593212002 VERTEX DIATNOST ULTRATRAK ULTIMATE TEST STRIPS

08593212102 VERTEX DIATNOST ULTRATRAK ULTIMATE CNTRL SOLN

08593212102 VERTEX DIATNOST ULTRATRAK ULTIMATE CNTRL SOLN

08595013001 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML

08595013010 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML

08595022901 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

08595022910 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

08595023001 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

08595023010 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

08595032801 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

08595032810 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

08595032901 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

08595032910 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

08611501001 BIOSENSE MEDICA SOLO V2 METER SYSTEM KIT

08611503050 BIOSENSE MEDICA SOLO V2 TEST STRIPS

08611504000 BIOSENSE MEDICA SOLO V2 30G LANCETS

08611505001 BIOSENSE MEDICA SOLO V2 LANCING DEVICE

08611505001 BIOSENSE MEDICA SOLO V2 LANCING DEVICE

08611506001 BIOSENSE MEDICA SOLO V2 CONTROL SOLUTION HIGH

08611506101 BIOSENSE MEDICA SOLO V2 CONTROL SOLUTION LOW

08617155104 I-SENS, INC. CARESENS N TEST STRIPS

08617155264 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST

08617164104 I-SENS, INC. CARESENS N TEST STRIPS

08617164265 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST

08617164301 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST

08617187104 I-SENS, INC. CARESENS N TEST STRIPS

08617187301 I-SENS, INC. CARESENS N BLOOD GLUCOSE SYST

08617192104 I-SENS, INC. SMART CARESENS N TEST STRIPS

08617192303 I-SENS, INC. SMART CARESENS N GLUCOSE SYSTM

08626000101 GENESIS HEALTH GDRIVE BLOOD GLUCOSE SYSTEM

08626333350 GENESIS HEALTH BLOOD GLUCOSE TEST STRIP

08627073001 DEXCOM, INC. SEVEN PLUS REPLACMNT TRNSMTTER

08627073101 DEXCOM, INC. SEVEN PLUS REPLACEMNT RECEIVER

08627073201 DEXCOM, INC. SEVEN PLUS SYSTEM STARTER KIT

08627073201 DEXCOM, INC. SEVEN PLUS SYSTEM STARTER KIT

08633900001 HTL-STREFE, S.A. DROPLET LANCING DEVICE

08881500014 LEADER MONOJECT INSUL SYR U100 0.5 ML

08881501210 LEADER MONOJECT 1 ML SYRN 28GX1/2"

08881501384 LEADER MONOJECT INSUL SYR U100 1 ML

08881501822 LEADER MONOJECT INSUL SYR U100 1 ML

08881501970 LEADER MONOJECT INSUL SYR U100 1 ML

08881511110 LEADER MONOJECT INSULIN SYR U-100

08881511136 LEADER MONOJECT INSULIN SYR U-100

08881511144 LEADER MONOJECT INSULIN SYRN 3/10 ML

08881511310 LEADER MONOJECT INSULIN SYR 1 ML

08881511336 LEADER MONOJECT INSULIN SYR 0.5 ML

08881511344 LEADER MONOJECT INSULIN SYR 0.3 ML

08881566015 LEADER MONOJECT SAFETY SYRINGE

08881566023 LEADER MONOJECT SAFETY SYRINGE

08881600004 LEADER MONOJECT INSUL SYR U100 0.5 ML

Page 16 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:

NDC Code Labeler Name Label Name Desc

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.

08881600145 LEADER MONOJECT INSUL SYR U100

08881600350 LEADER MONOJECT INSUL SYR U100

08881600700 LEADER MONOJECT INSULIN SYR 0.5 ML

08881600800 LEADER MONOJECT INSULIN SYR 0.3 ML

08881600904 LEADER ULTRA COMFORT 0.5 ML 28GX1/2"

08881601101 LEADER MONOJECT 1 ML SYRN 28GX1/2"

08881601358 LEADER MONOJECT INSUL SYR U100 1 ML

08881601600 LEADER MONOJECT INSULIN SYR 1 ML

08881602018 LEADER MONOLET LANCETS

08881602034 LEADER MONOLET LANCETS

08881602075 LEADER MONOLET LANCETS

08881602117 LEADER MONOJECTOR LANCET DEVICE

08881602125 LEADER MONOJECT BLOOD LANCET STERL

08881602141 LEADER MONOLET LANCETS

08881602190 LEADER MONOLET LANCETS

08881602208 LEADER MONOLET THIN LANCETS

08881602216 LEADER MONOLET THIN LANCETS

08881609004 LEADER ULTRA COMFORT 0.5 ML SYRINGE

08881609101 LEADER ULTRA COMFORT 1 ML SYRINGE

08881609131 LEADER MONOJECT SYRINGE 1 ML

08881609145 LEADER ULTRA COMFORT 0.3 ML 29GX1/2"

08881609231 LEADER MONOJECT SYRINGE 0.5 ML

08881609331 LEADER MONOJECT SYRINGE 0.3 ML

08881609350 LEADER ULTRA COMFORT 0.5 ML 29GX1/2"

08881609358 LEADER ULTRA COMFORT 1 ML 29GX1/2"

08881609600 LEADER ULTRA COMFORT 1 ML 30GX5/16"

08881609700 LEADER ULTRA COMFORT 0.5 ML SYRINGE

08881609800 LEADER ULTRA COMFORT 0.3 ML SYRINGE

08881700408 LEADER INSULIN SYR 1/2 ML BULK PACK

08881701406 LEADER INSULIN SYRINGE 1 ML-HARD PK

08881892910 LEADER MAGELLAN INSULIN SYRINGE 1 ML

08881892930 LEADER MAGELLAN INSULIN SYR 0.3 ML

08881892950 LEADER MAGELLAN INSULIN SYR 0.5 ML

08881893010 LEADER MAGELLAN INSULIN SYRINGE 1 ML

08881893030 LEADER MAGELLAN INSUL SYRINGE 0.3 ML

08881893050 LEADER MAGELLAN INSUL SYRINGE 0.5 ML

08970100160 TERUMO TERUMO INS SYRINGE U100-1/3 ML

08970100161 TERUMO TERUMO INS SYRINGE U100-1/2 ML

08970100827 TERUMO TERUMO INS SYRINGE U100-1 ML

08970100861 TERUMO THINPRO INS SYRIN U100-0.3 ML

08970100863 TERUMO THINPRO INS SYRIN U100-1 ML

08970100864 TERUMO THINPRO INS SYRIN U100-0.5 ML

08970100869 TERUMO THINPRO INS SYRIN U100-0.5 ML

08970100870 TERUMO THINPRO INS SYRIN U100-1 ML

08970100871 TERUMO THINPRO INS SYRIN U100-0.3 ML

08970100872 TERUMO THINPRO INS SYRIN U100-0.5 ML

08970100873 TERUMO THINPRO INS SYRIN U100-1 ML

08970100874 TERUMO THINPRO INS SYRIN U100-0.3 ML

08970100875 TERUMO THINPRO INS SYRIN U100-0.5 ML

08970100876 TERUMO THINPRO INS SYRIN U100-1 ML

08970200521 TERUMO TERUMO INS SYRNG U100-1/2 ML

08970200531 TERUMO TERUMO INS SYRNG U100-1/2 ML

Page 17 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:

NDC Code Labeler Name Label Name Desc

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.

08970200541 TERUMO TERUMO INS SYRNG U100-1/2 ML

08970201021 TERUMO TERUMO INS SYRINGE U100-1 ML

08970201031 TERUMO TERUMO INS SYRINGE U100-1 ML

08970201041 TERUMO TERUMO INS SYRINGE U100-1 ML

08970203031 TERUMO TERUMO INS SYR 0.3 ML 29GX1/2"

10939007033 MCKESSON DRUG SM LANCETS

10939007133 MCKESSON DRUG SM THIN LANCETS

10939007233 MCKESSON DRUG SM SUPER THIN LANCETS

10939007333 MCKESSON DRUG SM LANCETS

10939007433 MCKESSON DRUG SM COLORED LANCETS

10939007533 MCKESSON DRUG SM THIN LANCETS

10939007633 MCKESSON DRUG SM INSULIN SYR 0.5 ML 28GX1/2"

10939007733 MCKESSON DRUG SM INS SYRINGE 1 ML 28GX1/2"

10939007833 MCKESSON DRUG SM INSULIN SYR 0.3 ML 29GX1/2"

10939007933 MCKESSON DRUG SM INS SYR 0.5 ML 29GX1/2"

10939008033 MCKESSON DRUG SM INS SYR 1 ML 29GX1/2"

10939008133 MCKESSON DRUG SM INS SYRING 0.3 ML 30GX5/16"

10939008233 MCKESSON DRUG SM INS SYR 0.5 ML 30GX5/16"

10939008333 MCKESSON DRUG SM INS SYRINGE 1 ML 30GX5/16"

10939033122 MCKESSON DRUG LANCETS

10939033222 MCKESSON DRUG LANCETS

10939056211 MCKESSON DRUG BLOOD GLUCOSE TEST STRIPS

10939056311 MCKESSON DRUG SM LANCETS

10939062722 MCKESSON DRUG SM INS SYRING 0.3 ML 30GX5/16"

10939062822 MCKESSON DRUG SM INS SYRINGE 1 ML 30GX5/16"

10939062922 MCKESSON DRUG SM INS SYR 0.5 ML 30GX5/16"

10939082522 MCKESSON DRUG V-R GLUCOSE TEST STRIP

10939084533 MCKESSON DRUG SM INSUL SYR 0.3 ML 31GX5/16"

10939084633 MCKESSON DRUG SM INSUL SYR 0.5 ML 31GX5/16"

10939084733 MCKESSON DRUG SM INSULIN SYR 1 ML 31GX5/16"

10939090611 MCKESSON DRUG SM INSULIN SYR 0.5 ML 28GX1/2"

10939090711 MCKESSON DRUG SM INS SYRINGE 1 ML 28GX1/2"

10939090811 MCKESSON DRUG SM INSULIN SYR 0.3 ML 29GX1/2"

10939090911 MCKESSON DRUG SM INS SYR 0.5 ML 29GX1/2"

10939091011 MCKESSON DRUG SM INS SYR 1 ML 29GX1/2"

10939091111 MCKESSON DRUG SM THIN LANCETS

10939091211 MCKESSON DRUG SM COLORED LANCETS

11110035224 KROGER KROGER INS SYRINGE 3/10ML

11110035232 KROGER KROGER INS SYRINGE 0.5ML

11822023660 RITE AID CORP. RA EZJECT LANCETS

11822023670 RITE AID CORP. RA EZJECT LANCETS

11822037140 RITE AID CORP. RA TRUETEST GLUCOSE TEST STRIP

11822321570 RITE AID CORP. RA INS SYR 0.5 ML 29GX1/2"

11822321580 RITE AID CORP. RA INS SYR 1 ML 29GX1/2"

11822367950 RITE AID CORP. RA TRUE2GO BLOOD GLUCOSE SYSTM

11822371430 RITE AID CORP. RA TRUETEST GLUCOSE TEST STRIP

11822576430 RITE AID CORP. RA INS SYR 0.5 ML 30GX5/16"

11822576440 RITE AID CORP. RA INS SYRINGE 1 ML 30GX5/16"

11822801460 RITE AID CORP. RA BLOOD GLUCOSE MONITOR

11822989400 RITE AID CORP. RA LANCET-THIN

11917001487 WALGREEN CO. INSULIN 1 ML SYRINGE

11917001489 WALGREEN CO. INSULIN 1/2 ML SYRINGE

Page 18 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:

NDC Code Labeler Name Label Name Desc

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.

11917001492 WALGREEN CO. INSULIN 3/10 ML SYRINGE

11917001648 WALGREEN CO. SUPER THIN LANCETS

11917001668 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS

11917002527 WALGREEN CO. INSULIN 3/10 ML SYRINGE

11917002528 WALGREEN CO. INSULIN 1/2 ML SYRINGE

11917002529 WALGREEN CO. INSULIN 1 ML SYRINGE

11917002536 WALGREEN CO. INSULIN SYRIN 0.5 ML 31GX5/16"

11917003182 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS

11917003277 WALGREEN CO. LANCING DEVICE

11917004813 WALGREEN CO. INSULIN SYRINGE 1 ML 31GX5/16"

11917004814 WALGREEN CO. INSULIN SYRIN 0.5 ML 31GX5/16"

11917004815 WALGREEN CO. INSULIN SYRIN 0.3 ML 31GX5/16"

11917005059 WALGREEN CO. TRUETRACK SMART SYSTEM

11917005075 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS

11917005076 WALGREEN CO. BLOOD GLUCOSE TEST STRIPS

11917006105 WALGREEN CO. WALGREENS THIN LANCETS

11917006109 WALGREEN CO. WALGREENS LANCETS

11917006110 WALGREEN CO. WALGREENS THIN LANCETS

11917006111 WALGREEN CO. WALGREENS ULTRA THIN LANCETS

11917009921 WALGREEN CO. TRUETRACK BLOOD GLUCOSE SYSTEM

11917009960 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS

11917009961 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS

11917010002 WALGREEN CO. TRUE2GO BLOOD GLUCOSE SYSTEM

11917010003 WALGREEN CO. TRUERESULT BLOOD GLUCOSE SYSTM

11917010488 WALGREEN CO. TRUETRACK GLUCOSE TEST STRIPS

11917011158 WALGREEN CO. TRUETEST GLUCOSE TEST STRIPS

11917011815 WALGREEN CO. WALGREENS SUPER THIN LANCET

11917011816 WALGREEN CO. WALGREENS SUPER THIN LANCETS

11917011817 WALGREEN CO. WALGREENS MICRO THIN LANCET

13703010210 RETRACTABLE TEC VANISHPOINT U-100 29X1/2 SYR

13703010211 RETRACTABLE TEC VANISHPOINT U-100 29X1/2 SYR

13703010212 RETRACTABLE TEC VANISHPOINT U-100 29X1/2 SYR

13774020200 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML

13774020202 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.3 ML

13774020210 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

13774020212 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

13774020218 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

13774020220 US MEDICAL INST SAFESNAP INSUL SYRINGE 0.5 ML

13774020226 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

13774020228 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

13774020234 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

13774020236 US MEDICAL INST SAFESNAP INSULIN SYRINGE 1 ML

15127001145 SELECT BRAND DISTRIBUTORS SB INSULN SYR 0.5 ML 30GX5/16"

15127040101 SELECT BRAND DISTRIBUTORS SB INS SYR 1 ML 29GX1/2"

15127040105 SELECT BRAND DISTRIBUTORS SB INS SYR 0.5 ML 29GX1/2"

15127040201 SELECT BRAND DISTRIBUTORS SB INS SYRINGE 1 ML 30GX5/16"

15127040205 SELECT BRAND DISTRIBUTORS SB INS SYR 0.5 ML 30GX5/16"

15127040301 SELECT BRAND DISTRIBUTORS SB INSULIN SYR 1 ML 31GX5/16"

15127040305 SELECT BRAND DISTRIBUTORS SB INSULN SYR 0.5 ML 30GX5/16"

15127099010 SELECT BRAND DISTRIBUTORS SB LANCETS THIN

15127099020 SELECT BRAND DISTRIBUTORS SB LANCETS THIN

15127099110 SELECT BRAND DISTRIBUTORS SB LANCETS ULTRA THIN

Page 19 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:

NDC Code Labeler Name Label Name Desc

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.

15127099120 SELECT BRAND DISTRIBUTORS SB LANCETS ULTRA THIN

15482033005 HYPOGUARD QUICKTEK CONTROL SOLUTION

15482033050 HYPOGUARD QUICKTEK TEST STRIPS

15482033100 HYPOGUARD QUICKTEK TEST STRIPS

15482033110 HYPOGUARD QUICKTEK KIT

15482041005 HYPOGUARD ADVANCE MICRO-DRAW CONTRL SOLN

15482041012 HYPOGUARD HYPOLANCE AST LANCING KIT

15482041012 HYPOGUARD HYPOLANCE AST LANCING KIT

15482041050 HYPOGUARD ADVANCE MICRO-DRAW TEST STRIPS

15482041100 HYPOGUARD ADVANCE MICRO-DRAW TEST STRIPS

15482042000 HYPOGUARD ADVANCE INTUITION METER

15482042005 HYPOGUARD ADVANCE NORMAL CONTROL SOLN

15482042050 HYPOGUARD ADVANCE TEST STRIPS

15482042110 HYPOGUARD ADVANCE INTUITION METER

15482046001 HYPOGUARD ASSURE PRO METER

15482046050 HYPOGUARD ASSURE PRO TEST STRIPS

15482046060 HYPOGUARD ASSURE PRO CONTROL SOLUTION

15482046060 HYPOGUARD ASSURE PRO CONTROL SOLUTION

15482046100 HYPOGUARD ASSURE PRO TEST STRIPS

15482050001 HYPOGUARD ASSURE PLATINUM GLUCOSE METER

15482050005 HYPOGUARD ASSURE DOSE CONTROL SOLUTION

15482050006 HYPOGUARD ASSURE DOSE CONTROL SOLUTION

15482050006 HYPOGUARD ASSURE DOSE CONTROL SOLUTION

15482050050 HYPOGUARD ASSURE PLATINUM TEST STRIPS

15482050100 HYPOGUARD ASSURE PLATINUM TEST STRIPS

15482055006 HYPOGUARD ASSURE 3 CONTROL SOLUTION

15482055006 HYPOGUARD ASSURE 3 CONTROL SOLUTION

15482055050 HYPOGUARD ASSURE 3 TEST STRIPS

15482055100 HYPOGUARD ASSURE 3 TEST STRIPS

15482056001 HYPOGUARD ASSURE 4 BLOOD GLUCOSE METER

15482056006 HYPOGUARD ASSURE 4 CONTROL SOLUTION

15482056050 HYPOGUARD ASSURE 4 TEST STRIPS

15482056100 HYPOGUARD ASSURE 4 TEST STRIPS

15482063005 HYPOGUARD POCKETCHEM EZ CONTROL SOLUTION

15482063050 HYPOGUARD POCKETCHEM EZ TEST STRIPS

15482063110 HYPOGUARD POCKETCHEM EZ METER KIT

15482066015 HYPOGUARD MULTI-LANCET DEVICE

15482066600 HYPOGUARD SELECT-LITE LANCING DEVICE

15482072001 HYPOGUARD GLUCOCARD 01 BLOOD GLUCOSE MTR

15482072005 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION

15482072050 HYPOGUARD GLUCOCARD 01 SENSOR TEST STRIP

15482072110 HYPOGUARD GLUCOCARD 01 METER KIT

15482073110 HYPOGUARD GLUCOCARD 01-MINI METER KIT

15482074006 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION

15482074006 HYPOGUARD GLUCOCARD 01 CONTROL SOLUTION

15482074050 HYPOGUARD GLUCOCARD 01 SENSOR TEST STRIP

15482074110 HYPOGUARD GLUCOCARD 01 METER KIT

15482075005 HYPOGUARD GLUCOCARD X-METER CONTROL SOLN

15482075050 HYPOGUARD GLUCOCARD X-SENSOR TEST STRIPS

15482075110 HYPOGUARD GLUCOCARD X-METER SYSTEM KIT

15482075205 HYPOGUARD GLUCOCARD X-SENSOR TEST STRIPS

15482076050 HYPOGUARD GLUCOCARD VITAL SENSOR STRIP

Page 20 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:

NDC Code Labeler Name Label Name Desc

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.

15482076110 HYPOGUARD GLUCOCARD VITAL METER KIT

15482076112 HYPOGUARD GLUCOCARD VITAL METER KIT

15482076113 HYPOGUARD GLUCOCARD VITAL METER KIT

15482076205 HYPOGUARD GLUCOCARD VITAL SENSOR STRIP

15482088012 HYPOGUARD TECHLITE BLOOD LANCET

15482088018 HYPOGUARD TECHLITE BLOOD LANCET

15482088022 HYPOGUARD TECHLITE BLOOD LANCET

15482088028 HYPOGUARD TECHLITE BLOOD LANCET

15482088030 HYPOGUARD TECHLITE AST LANCETS

15482098018 HYPOGUARD ASSURE LANCE MICRO FLOW LANCET

15482098028 HYPOGUARD ASSURE LANCE MICRO FLOW LANCET

15482099030 HYPOGUARD HAEMOLANCE, RETRACTABLE

15482099035 HYPOGUARD HAEMOLANCE, RETRACTABLE

15482099050 HYPOGUARD HAEMOLANCE LANCET

15482099055 HYPOGUARD HAEMOLANCE LANCET

15482099070 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099075 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099080 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099090 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099095 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099200 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099250 HYPOGUARD HAEMOLANCE PLUS LANCETS

15482099400 HYPOGUARD HAEMOLANCE PLUS LANCET

15482099600 HYPOGUARD HAEMOLANCE PLUS LANCET

15482990305 HYPOGUARD HAEMOLANCE, RETRACTABLE

15482990350 HYPOGUARD HAEMOLANCE, RETRACTABLE

20221026014 EXEL INT'L INC. EXEL U100 0.3 ML 30GX5/16"

20221026015 EXEL INT'L INC. EXEL U100 0.5 ML 30GX5/16"

20221026016 EXEL INT'L INC. EXEL U100 1 ML 30GX5/16"

20221026018 EXEL INT'L INC. EXEL U100 0.3 ML 29GX1/2"

20221026026 EXEL INT'L INC. EXEL U100 0.5 ML 28GX1/2"

20221026027 EXEL INT'L INC. EXEL INS SYR U100 1 ML 28GX1/2

20221026028 EXEL INT'L INC. EXEL U100 0.5 ML 29GX1/2"

20221026029 EXEL INT'L INC. EXEL U100 INS SYR 1 ML 29GX1/2

21292000263 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM

21292000265 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM

21292000291 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS

21292000294 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS

25294000624 NIPRO DIAGNOSTIC AUTO-LANCET MINI LANCING DEV

25294094300 NIPRO DIAGNOSTIC EZ-LETS II LANCETS #EZ-300

28465000331 MED.PLASTIC DEV VITALET 23 GAUGE LANCET

28465000351 MED.PLASTIC DEV VITALET 23 GAUGE LANCET

28465000361 MED.PLASTIC DEV VITALET THIN 26GAUGE LANCET

28465000362 MED.PLASTIC DEV VITALET THIN 26GAUGE LANCET

28465001212 MED.PLASTIC DEV VITALET PRO LANCETS

28465001222 MED.PLASTIC DEV VITALET PRO LANCETS

28465001340 MED.PLASTIC DEV VITALET PRO PLUS LANCETS

28465001350 MED.PLASTIC DEV VITALET PRO PLUS LANCETS

28465001381 MED.PLASTIC DEV MEDLANCE PLUS LITE LANCETS

28465001382 MED.PLASTIC DEV MEDLANCE PLUS UNIVERSAL LANCET

32671000020 MEDICORE LITE TOUCH LANCING DEVICE

32671000500 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR

Page 21 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:

NDC Code Labeler Name Label Name Desc

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.

32671000501 MEDICORE LITE TOUCH INSULIN 1 ML SYR

32671000502 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR

32671000503 MEDICORE LITE TOUCH INSULIN 1 ML SYR

32671000504 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR

32671000505 MEDICORE LITE TOUCH INSULIN 1 ML SYR

32671000506 MEDICORE LITE TOUCH INSULIN 0.3 ML SYR

32671000507 MEDICORE LITE TOUCH INSULIN 0.3 ML SYR

32671000508 MEDICORE LITE TOUCH INSULIN SYR 0.3 ML

32671000509 MEDICORE LITE TOUCH INSULIN SYR 0.5 ML

32671000514 MEDICORE LITE TOUCH INSULIN 0.5 ML SYR

32671000520 MEDICORE LITE TOUCH INSULIN SYR 1 ML

32671020044 MEDICORE AURORA HEALTH LANCET DEVICE

32671020100 MEDICORE MEDI-LANCE LANCETS

32671020133 MEDICORE LITE TOUCH LANCETS

32671020144 MEDICORE AURORA HEALTHCARE LANCETS

32671020200 MEDICORE MEDI-LANCE LANCETS

32671020233 MEDICORE LITE TOUCH LANCETS

32671020244 MEDICORE AURORA HEALTHCARE LANCETS

35515095934 CHAIN DRUG QC ADVANCED LANCING DEVICE

35515095934 CHAIN DRUG QC ADVANCED LANCING DEVICE

35515095935 CHAIN DRUG QC SUPER THIN LANCET

35515095936 CHAIN DRUG QC ULTRA THIN LANCET

37205608104 LEADER INSULIN 1 ML SYRINGE

37205608204 LEADER INSULIN 1/2 ML SYRINGE

37205608304 LEADER INSULIN 3/10 ML SYRINGE

37654049726 SACKS MEDICAL REFUAH PLUS MONITORING SYSTEM

37654049727 SACKS MEDICAL REFUAH PLUS TEST STRIPS

37654049728 SACKS MEDICAL REFUAH PLUS CONTROL SOLUTION

37867099246 CAN-AM/ACCESS MONOJECT SYRINGE 0.3 ML

37867099247 CAN-AM/ACCESS MONOJECT SYRINGE 0.5 ML

37867099248 CAN-AM/ACCESS MONOJECT SYRINGE 1 ML

38396000010 CAN-AM/ACCESS W&F COLORED LANCETS

38396000425 CAN-AM/ACCESS VALUE PLUS LANCING DEVICE

38396000506 CAN-AM/ACCESS KINRAY SYRING 0.3 ML 31GX5/16"

38396000606 CAN-AM/ACCESS KINRAY SYRING 0.5 ML 31GX5/16"

38396000706 CAN-AM/ACCESS KINRAY INS SYR 1 ML 31GX5/16"

38396001078 CAN-AM/ACCESS W&F COLORED LANCETS

38396016201 CAN-AM/ACCESS W&F COLORED LANCETS

38396030100 CAN-AM/ACCESS E-ZJECT THIN LANCETS

38396030108 CAN-AM/ACCESS LEADER THIN LANCETS

38396030112 CAN-AM/ACCESS MS THIN LANCETS

38396030113 CAN-AM/ACCESS FIRST CHOICE THIN LANCETS

38396030114 CAN-AM/ACCESS RA E-ZJECT LANCETS

38396030118 CAN-AM/ACCESS KROGER THIN LANCETS

38396030120 CAN-AM/ACCESS MEIJER THIN GAUGE LANCETS

38396030137 CAN-AM/ACCESS TOPCARE UNIVERSAL1 THIN LANCET

38396030140 CAN-AM/ACCESS EQL LANCETS THIN

38396030157 CAN-AM/ACCESS DRUG MART THIN LANCETS

38396030200 CAN-AM/ACCESS E-ZJECT THIN LANCETS

38396030208 CAN-AM/ACCESS LEADER THIN LANCETS

38396030213 CAN-AM/ACCESS FIRST CHOICE THIN LANCETS

38396030218 CAN-AM/ACCESS KROGER THIN LANCETS

Page 22 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:

NDC Code Labeler Name Label Name Desc

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.

38396030220 CAN-AM/ACCESS MEIJER THIN GAUGE LANCETS

38396030240 CAN-AM/ACCESS EQL LANCETS THIN

38396030300 CAN-AM/ACCESS E-Z JECT LANCETS

38396030312 CAN-AM/ACCESS MS LANCETS

38396030316 CAN-AM/ACCESS H&H THINLET LANCETS

38396030318 CAN-AM/ACCESS KROGER SUPER THIN LANCETS

38396030320 CAN-AM/ACCESS MEIJER LANCETS

38396030400 CAN-AM/ACCESS E-Z JECT LANCETS

38396030412 CAN-AM/ACCESS MS LANCETS

38396030416 CAN-AM/ACCESS H&H THINLET LANCETS

38396030418 CAN-AM/ACCESS KROGER LANCETS

38396030420 CAN-AM/ACCESS MEIJER LANCETS

38396030500 CAN-AM/ACCESS E-Z JECT COLORED LANCETS

38396030508 CAN-AM/ACCESS LEADER SUPER THIN LANCETS

38396030512 CAN-AM/ACCESS MS SUPER THIN LANCETS

38396030513 CAN-AM/ACCESS FIRST CHOICE COLORED LANCET

38396030514 CAN-AM/ACCESS RA E-ZJECT LANCETS

38396030520 CAN-AM/ACCESS MEIJER LANCETS

38396030537 CAN-AM/ACCESS TOPCARE UNIVERSAL1 THIN LANCET

38396030540 CAN-AM/ACCESS EQL SUPER THIN LANCETS

38396030557 CAN-AM/ACCESS DRUG MART ULTRA THIN LANCETS

38396030600 CAN-AM/ACCESS E-Z JECT COLORED LANCETS

38396030608 CAN-AM/ACCESS LEADER COLORED LANCETS

38396030613 CAN-AM/ACCESS FIRST CHOICE COLORED LANCET

38396030640 CAN-AM/ACCESS EQL SUPER THIN LANCETS

38396030740 CAN-AM/ACCESS EQL COLOR LANCETS

38396030800 CAN-AM/ACCESS E-Z JECT SUPER THIN LANCETS

38396030900 CAN-AM/ACCESS E-ZJECT COLORED LANCETS

38396031114 CAN-AM/ACCESS RA E-ZJECT LANCETS

38396031132 CAN-AM/ACCESS WALGREENS SUPER THIN LANCETS

38396031156 CAN-AM/ACCESS PREFERRED PLUS LANCETS

38396031214 CAN-AM/ACCESS RA E-ZJECT LANCETS

38396031225 CAN-AM/ACCESS VALUE PLUS THIN LANCETS

38396031402 CAN-AM/ACCESS RELION ULTRA THIN PLUS LANCETS

38396031506 CAN-AM/ACCESS PREFERRED PLUS THIN LANCETS

38396031600 CAN-AM/ACCESS E-Z JECT MICRO THIN LANCETS

38396031614 CAN-AM/ACCESS RA E-ZJECT MICRO-THIN LANCET

38396031618 CAN-AM/ACCESS UNIVERSAL 1 LANCETS

38396031620 CAN-AM/ACCESS UNIVERSAL 1 33 GAUGE LANCETS

38396031632 CAN-AM/ACCESS WALGREENS MICRO THIN LANCET

38396031664 CAN-AM/ACCESS GNP MICRO THIN 33G LANCETS

38396031702 CAN-AM/ACCESS RELION ULTRA THIN PLUS LANCET

38396031739 CAN-AM/ACCESS SM MICRO THIN LANCETS

38396031775 CAN-AM/ACCESS CVS MICRO THIN LANCETS

38396032225 CAN-AM/ACCESS VALUE PLUS THIN LANCETS

38396032300 CAN-AM/ACCESS VALUE DRUG LANCETS 21G

38396032325 CAN-AM/ACCESS VALUE PLUS SUPER THIN LANCETS

38396032870 CAN-AM/ACCESS LONGS LANCETS 21G

38396032970 CAN-AM/ACCESS LONGS THIN LANCETS 26G

38396033070 CAN-AM/ACCESS LONGS THIN LANCETS 30G

38396033277 CAN-AM/ACCESS FP LANCETS THIN

38396033577 CAN-AM/ACCESS FP LANCETS THIN

Page 23 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:

NDC Code Labeler Name Label Name Desc

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.

38396034264 CAN-AM/ACCESS GNP LANCETS

38396034364 CAN-AM/ACCESS GNP LANCETS

38396034464 CAN-AM/ACCESS GNP THIN LANCETS

38396034564 CAN-AM/ACCESS GNP THIN LANCETS

38396035506 CAN-AM/ACCESS PREFERRED PLUS COLORED LANCETS

38396036606 CAN-AM/ACCESS PREFERRED PLUS COLORED LANCETS

38396040102 CAN-AM/ACCESS RELION SYRING 0.3 ML 31GX5/16"

38396040105 CAN-AM/ACCESS QC INSULIN SYRINGE 1 ML

38396040108 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 28GX1/2"

38396040202 CAN-AM/ACCESS RELION SYRING 0.5 ML 31GX5/16"

38396040205 CAN-AM/ACCESS QC INSULIN SYRINGE 0.5 ML

38396040208 CAN-AM/ACCESS LEADER INS SYR 1 ML 28GX1/2"

38396040212 CAN-AM/ACCESS MS INSULIN SYR 0.3 ML 29GX1/2"

38396040218 CAN-AM/ACCESS KROGER INS SYRINGE 3/10 ML

38396040302 CAN-AM/ACCESS RELION INS SYR 1 ML 31GX5/16"

38396040305 CAN-AM/ACCESS QC INSULIN SYRINGE 0.3 ML

38396040308 CAN-AM/ACCESS LEADER INS SYR 0.3 ML 29GX1/2"

38396040318 CAN-AM/ACCESS KROGER INS SYR 0.5 ML 29GX1/2"

38396040325 CAN-AM/ACCESS KMART VALU PLUS SYR 1/2 ML

38396040405 CAN-AM/ACCESS QC INSULIN SYR 1 ML 31GX5/16"

38396040408 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 29GX1/2"

38396040412 CAN-AM/ACCESS MS INS SYR 0.5 ML 29GX1/2"

38396040425 CAN-AM/ACCESS VALUEPLUS SYR 0.3 ML 29GX1/2"

38396040501 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML

38396040502 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.3 ML

38396040503 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML

38396040504 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML

38396040505 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML

38396040506 CAN-AM/ACCESS FIRST CHOICE SYRINGE 1 ML

38396040507 CAN-AM/ACCESS FIRST CHOICE SYRINGE 0.5 ML

38396040508 CAN-AM/ACCESS LEADER INS SYR 1 ML 29GX1/2"

38396040512 CAN-AM/ACCESS MS INS SYR 1 ML 29GX1/2"

38396040518 CAN-AM/ACCESS KROGER INS SYR 1 ML 29GX1/2"

38396040525 CAN-AM/ACCESS KMART VALU PLUS SYRINGE 1 ML

38396040605 CAN-AM/ACCESS QC INSUL SYR 0.5 ML 31GX5/16"

38396040608 CAN-AM/ACCESS LEADER INSULIN SYRINGE 0.3 ML

38396040612 CAN-AM/ACCESS MS INSULIN SYRINGE 0.3 ML

38396040618 CAN-AM/ACCESS KROGER INSULIN SYRINGE 1 ML

38396040625 CAN-AM/ACCESS KMART VALU PLUS SYRINGE 1 ML

38396040708 CAN-AM/ACCESS LEADER INS SYR 0.5 ML 30GX1/2"

38396040712 CAN-AM/ACCESS MS INSUL SYR 0.5 ML 30GX1/2"

38396040718 CAN-AM/ACCESS KROGER SYR 0.5 ML 30GX5/16"

38396040725 CAN-AM/ACCESS KMART VALU PLUS SYR 1/2 ML

38396040801 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 0.5 ML

38396040802 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 0.3 ML

38396040803 CAN-AM/ACCESS PREFERRED PLUS 0.5 ML 29GX1/2"

38396040804 CAN-AM/ACCESS PREFERRED PLUS SYRINGE 1 ML

38396040805 CAN-AM/ACCESS PREF PLUS SYRING 1 ML 29GX1/2"

38396040806 CAN-AM/ACCESS PREFPLS INS SYR 1 ML 30GX5/16"

38396040807 CAN-AM/ACCESS PREF PLUS SYR 0.5 ML 30GX5/16"

38396040808 CAN-AM/ACCESS PREFERRED PLUS 0.3 ML 30GX5/16

38396040812 CAN-AM/ACCESS MS INS SYRINGE 1 ML 30GX1/2"

Page 24 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:

NDC Code Labeler Name Label Name Desc

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.

38396040818 CAN-AM/ACCESS KROGER INS SYR 0.3 ML 30GX5/16

38396040825 CAN-AM/ACCESS KMART VALU PLUS SYR 3/10 ML

38396040918 CAN-AM/ACCESS KROGER SYRING 0.3 ML 31GX5/16"

38396040970 CAN-AM/ACCESS INSULIN SYRIN 0.3 ML 31GX5/16"

38396041018 CAN-AM/ACCESS KROGER SYRING 0.5 ML 31GX5/16"

38396041070 CAN-AM/ACCESS INSULIN SYRIN 0.5 ML 31GX5/16"

38396041102 CAN-AM/ACCESS RELION INSULIN SYR 0.3 ML

38396041118 CAN-AM/ACCESS KROGER INS SYR 1 ML 31GX5/16"

38396041131 CAN-AM/ACCESS WDMEDIC SYRING 0.3 ML 29GX1/2"

38396041137 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041140 CAN-AM/ACCESS EQL INSULIN 0.3 ML SYRINGE

38396041157 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396041202 CAN-AM/ACCESS RELION INSULIN SYR 0.5 ML

38396041231 CAN-AM/ACCESS WD MEDIC SYR 0.5 ML 29GX1/2"

38396041237 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041240 CAN-AM/ACCESS EQL INSULIN 0.5 ML SYRINGE

38396041302 CAN-AM/ACCESS RELION INS SYR 1 ML 29GX1/2"

38396041331 CAN-AM/ACCESS WD MEDIC SYR 1 ML 29GX1/2"

38396041337 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041340 CAN-AM/ACCESS EQL INS SYR 1 ML 29GX1/2"

38396041357 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396041431 CAN-AM/ACCESS WD MEDIC SYR 0.3 ML 30GX5/16"

38396041437 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041440 CAN-AM/ACCESS EQL INSULIN 0.3 ML SYRINGE

38396041457 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396041531 CAN-AM/ACCESS WD MEDIC SYR 0.5 ML 30GX5/16"

38396041537 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041540 CAN-AM/ACCESS EQL INSULIN 0.5 ML SYRINGE

38396041557 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396041631 CAN-AM/ACCESS WDMEDIC INS SYR 1 ML 30GX5/16"

38396041637 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041640 CAN-AM/ACCESS EQL INSULIN 1 ML SYRINGE

38396041657 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396041808 CAN-AM/ACCESS LEADER INS SYR 1 ML 30GX5/16"

38396041908 CAN-AM/ACCESS LEADER SYRING 0.3 ML 31GX5/16"

38396041937 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396041940 CAN-AM/ACCESS EQL INSUL SYR 0.3 ML 31GX5/16"

38396041957 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396042003 CAN-AM/ACCESS VH INS SYR 0.5 ML 29GX1/2"

38396042005 CAN-AM/ACCESS VH INS SYR 1 ML 29GX1/2"

38396042008 CAN-AM/ACCESS LEADER SYRING 0.5 ML 31GX5/16"

38396042037 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396042040 CAN-AM/ACCESS EQL INSUL SYR 0.5 ML 31GX5/16"

38396042057 CAN-AM/ACCESS DRUG MART ULTRA COMFORT SYR

38396042108 CAN-AM/ACCESS LEADER INS SYR 1 ML 31GX5/16"

38396042137 CAN-AM/ACCESS TOPCARE ULTRA COMFORT SYRINGE

38396042140 CAN-AM/ACCESS EQL INSULIN SYR 1 ML 31GX5/16"

38396042912 CAN-AM/ACCESS MS INSUL SYR 0.3 ML 31GX5/16"

38396043012 CAN-AM/ACCESS MS INSUL SYR 0.5 ML 31GX5/16"

38396043112 CAN-AM/ACCESS MS INSULIN SYR 1 ML 31GX5/16"

38396043277 CAN-AM/ACCESS FP INSULIN 1 ML SYRINGE

38396043377 CAN-AM/ACCESS FP INSULIN 1 ML SYRINGE

Page 25 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:

NDC Code Labeler Name Label Name Desc

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.

38396043477 CAN-AM/ACCESS FP INSULIN 0.5 ML SYRINGE

38396044164 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR

38396044264 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE

38396044364 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR

38396044455 CAN-AM/ACCESS RENEW ADVANCED MICRO-LANCETS

38396044464 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE

38396044564 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR

38396044664 CAN-AM/ACCESS GNP ULTRA COMFORT 0.5 ML SYR

38396044764 CAN-AM/ACCESS GNP ULTRA COMFORT 1 ML SYRINGE

38396044864 CAN-AM/ACCESS GNP ULTRA COMFORT 3/10 ML SYR

38396044902 CAN-AM/ACCESS RELION THIN LANCETS

38396044964 CAN-AM/ACCESS GNP INSUL SYR 0.3 ML 31GX5/16"

38396045002 CAN-AM/ACCESS RELION LANCETS

38396045064 CAN-AM/ACCESS GNP INSUL SYR 0.5 ML 31GX5/16"

38396045102 CAN-AM/ACCESS RELION THIN LANCETS

38396045164 CAN-AM/ACCESS GNP INSULIN SYR 1 ML 31GX5/16"

38396045202 CAN-AM/ACCESS RELION THIN LANCETS

38396045302 CAN-AM/ACCESS RELION ULTRA THIN COL LANCET

38396045339 CAN-AM/ACCESS SM INSUL SYR 0.3 ML 31GX5/16"

38396045402 CAN-AM/ACCESS RELION ULTRA THIN LANCET

38396045532 CAN-AM/ACCESS WALGREENS SUPER THIN LANCET

38396046339 CAN-AM/ACCESS SM INSUL SYR 0.5 ML 31GX5/16"

38396047339 CAN-AM/ACCESS SM INSULIN SYR 1 ML 31GX5/16"

38396050101 CAN-AM/ACCESS RELION LANCING DEVICE

38396050132 CAN-AM/ACCESS WALGREENS LANCETS

38396050175 CAN-AM/ACCESS CVS THIN LANCETS

38396050178 CAN-AM/ACCESS W&F 30G LANCETS

38396050232 CAN-AM/ACCESS WALGREENS THIN LANCETS

38396050275 CAN-AM/ACCESS CVS LANCETS

38396050332 CAN-AM/ACCESS WALGREENS THIN LANCETS

38396050375 CAN-AM/ACCESS CVS THIN LANCETS

38396050432 CAN-AM/ACCESS WALGREENS ULTRA THIN LANCETS

38396051075 CAN-AM/ACCESS CVS LANCING DEVICE

38396051075 CAN-AM/ACCESS CVS LANCING DEVICE

38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM

38396051155 CAN-AM/ACCESS RENEW ADVANCED LANCING SYSTEM

38396052175 CAN-AM/ACCESS CVS ULTRA THIN LANCETS

38396052275 CAN-AM/ACCESS CVS ULTRA THIN LANCETS

38396054764 CAN-AM/ACCESS GNP SUPER THIN LANCETS

38396060118 CAN-AM/ACCESS KROGER LANCING DEVICE

38396070339 CAN-AM/ACCESS SM LANCETS

38396071339 CAN-AM/ACCESS SM THIN LANCETS

38396072339 CAN-AM/ACCESS SM SUPER THIN LANCETS

38396073339 CAN-AM/ACCESS SM LANCETS

38396074339 CAN-AM/ACCESS SM COLORED LANCETS

38396075339 CAN-AM/ACCESS SM THIN LANCETS

38396076339 CAN-AM/ACCESS SM INSULIN SYR 0.5 ML 28GX1/2"

38396077339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 28GX1/2"

38396078339 CAN-AM/ACCESS SM INSULIN SYR 0.3 ML 29GX1/2"

38396079339 CAN-AM/ACCESS SM INS SYR 0.5 ML 29GX1/2"

38396080339 CAN-AM/ACCESS SM INS SYR 1 ML 29GX1/2"

38396081339 CAN-AM/ACCESS SM INS SYRING 0.3 ML 30GX5/16"

Page 26 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:

NDC Code Labeler Name Label Name Desc

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.

38396082339 CAN-AM/ACCESS SM INS SYR 0.5 ML 30GX5/16"

38396083339 CAN-AM/ACCESS SM INS SYRINGE 1 ML 30GX5/16"

38396090002 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS

38396090178 CAN-AM/ACCESS W&F THIN LANCETS

38396090180 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS

38396091825 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS

38396091925 CAN-AM/ACCESS VALUE PLUS STANDARD LANCETS

38415001630 SPECIALTY MED INSULIN SYRINGE 1 ML 30GX5/16"

38415001631 SPECIALTY MED INSULIN SYRINGE 1 ML 31GX5/16"

38415003529 SPECIALTY MED INSULIN SYRIN 0.3 ML 29GX1/2"

38415003531 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16"

38415003630 SPECIALTY MED INSULIN SYR 0.3 ML 30GX5/16"

38415003631 SPECIALTY MED INSULIN SYRIN 0.3 ML 31GX5/16"

38415005129 SPECIALTY MED INSULIN SYRIN 1 ML 29GX1/2"

38415005529 SPECIALTY MED INSULIN SYRING 0.5 ML 29GX1/2"

38415005630 SPECIALTY MED INSULIN SYRIN 0.5 ML 30GX5/16"

38415005631 SPECIALTY MED INSULIN SYRIN 0.5 ML 31GX5/16"

38415010001 SPECIALTY MED SAFETY-LET LANCETS

38415010028 SPECIALTY MED LANCETS

38415010029 SPECIALTY MED ASSURE ULTRA THIN LANCETS

38415010030 SPECIALTY MED LANCETS

38415020801 SPECIALTY MED AQUA LANCE LANCING DEVICE

38415030028 SPECIALTY MED LANCETS

38415030030 SPECIALTY MED LANCETS

38415040028 SPECIALTY MED LANCETS

38415042302 SPECIALTY MED SURECHEK TEST STRIPS

38415042308 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN

38415042401 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER

38415042402 SPECIALTY MED SURE EDGE TEST STRIPS

38415042440 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415042460 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415042480 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415051001 SPECIALTY MED LANCING DEVICE

38415051002 SPECIALTY MED ALTERNATE SITE LANCING DEVICE

38415051208 SPECIALTY MED AQUA LANCE LANCING DEVICE

38415060023 SPECIALTY MED LANCETS

38415060025 SPECIALTY MED LANCETS

38415423010 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR

38415423120 SPECIALTY MED SURECHEK TEST STRIPS

38415423240 SPECIALTY MED SURECHEK BLOOD GLUCOSE MONITOR

38415423830 SPECIALTY MED SURECHEK GLUCOSE CONTROL SOLN

38415424010 SPECIALTY MED SURE EDGE BLOOD GLUCOSE METER

38415424110 SPECIALTY MED SURE EDGE TEST STRIPS

38415424410 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415424620 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415424830 SPECIALTY MED SURE EDGE GLUCOSE CONTROL SOLN

38415425110 SPECIALTY MED VOCAL POINT TEST STRIP

38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE

38470002700 OWEN MUMFORD, INC AUTOLET IMPRESS LANCING DEVICE

40986001668 CHAIN DRUG CONS PV ULTRA THIN LANCETS

40986001669 CHAIN DRUG CONS PV ULTRA THIN LANCETS

40986001670 CHAIN DRUG CONS PV LANCING DEVICE

Page 27 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:

NDC Code Labeler Name Label Name Desc

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.

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:

NDC Code Labeler Name Label Name Desc

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.

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

Oregon Health Authority

Division of Medical Assistance Programs

Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011

For billing guidelines and examples:

NDC Code Labeler Name Label Name Desc

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.

47884017250 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS

47884017300 OAK TREE INTERN EASYMAX L GLUCOSE SYSTEM KIT

47884017301 OAK TREE INTERN EASYMAX L BLOOD GLUCOSE SYSTEM

47884017500 OAK TREE INTERN EASYMAX N GLUCOSE SYSTEM KIT

47884017501 OAK TREE INTERN EASYMAX N BLOOD GLUCOSE SYSTEM

47884017525 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS

47884017540 OAK TREE INTERN EASYMAX NORMAL CONTROL SOLN

47884017541 OAK TREE INTERN EASYMAX HIGH CONTROL SOLN

47884017542 OAK TREE INTERN EASYMAX LOW CONTROL SOLN

47884017550 OAK TREE INTERN EASYMAX GLUCOSE TEST STRIPS

49348095050 MCKESSON CORPORATION VALU-RITE V-R GLUCOSE TEST STRIP

49614000011 MEDICINE SHOPPE INTERNATIONAL, INC. BLOOD GLUCOSE TEST STRIPS

49614000012 MEDICINE SHOPPE INTERNATIONAL, INC. BLOOD GLUCOSE TEST STRIPS

49614000113 MEDICINE SHOPPE INTERNATIONAL, INC. BLOOD GLUCOSE SYSTEM PAK

49614062678 MEDICINE SHOPPE INTERNATIONAL, INC. ULTRA COMFORT 1 ML SYRINGE

49614062778 MEDICINE SHOPPE INTERNATIONAL, INC. ULTRA COMFORT 0.5 ML SYRINGE

49614062878 MEDICINE SHOPPE INTERNATIONAL, INC. ULTRA COMFORT 3/10 ML SYR

49614063081 MEDICINE SHOPPE INTERNATIONAL, INC. LANCETS

50081000300 ENTRA HEALTH SYSTEM MYGLUCOHEALTH MONITORING KIT

50081000301 ENTRA HEALTH SYSTEM MYGLUCOHEALTH TEST STRIPS

50081000303 ENTRA HEALTH SYSTEM MYGLUCOHEALTH 30G LANCETS

50428001771 CVS CVS THIN LANCETS

50428001772 CVS CVS THIN LANCETS

50428001773 CVS CVS LANCETS

50428008873 CVS CVS LANCING DEVICE

50428008873 CVS CVS LANCING DEVICE

50428147530 CVS CVS BLOOD GLUCOSE TEST SRIP

50428194178 CVS CVS BLOOD GLUCOSE STRIPS

50428235155 CVS CVS ULTRA THIN LANCETS

50428235157 CVS CVS ULTRA THIN LANCETS

50924001901 ROCHE DIAGNOSTI ACCU-CHEK COMPACT PLUS KIT

50924004301 ROCHE DIAGNOSTI COAGUCHEK LANCETS

50924007920 ROCHE DIAGNOSTI ACCU-CHEK SAFE-T-PRO LANCETS

50924013024 ROCHE DIAGNOSTI SOFTCLIX LANCETS

50924014110 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS

50924030201 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY KIT

50924030202 ROCHE DIAGNOSTI ACCU-CHEK COMPACT GLUCOSE SOL

50924031410 ROCHE DIAGNOSTI ACCU-CHEK SIMPLICITY STRIPS

50924035706 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN

50924036550 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP

50924037350 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP

50924038110 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE STRIP

50924039002 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN

50924039002 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN

50924040303 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN

50924041102 ROCHE DIAGNOSTI ACCU-CHEK CMFRT CURVE SOLN

50924044601 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET KIT

50924044601 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET KIT

50924045001 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCET

50924047550 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE TEST STRIP

50924047602 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE GLUCOSE SOL

50924047701 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE CARE KIT

Page 30 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:

NDC Code Labeler Name Label Name Desc

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.

50924050125 ROCHE DIAGNOSTI CHEMSTRIP BG (VISUAL ONLY)

50924050250 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II)

50924050810 ROCHE DIAGNOSTI CHEMSTRIP BG(ACCU-CHEK II)

50924055001 ROCHE DIAGNOSTI ACCU-CHEK GLUCOSE SOLUTION

50924056050 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS

50924056610 ROCHE DIAGNOSTI ACCU-CHEK EASY TEST STRIPS

50924058001 ROCHE DIAGNOSTI SOFT TOUCH LANCET DEVICE

50924058510 ROCHE DIAGNOSTI SOFT TOUCH LANCETS

50924076501 ROCHE DIAGNOSTI ACCU-CHEK III DIABETES METR

50924076601 ROCHE DIAGNOSTI ACCU-CHEK III DIABETES KIT

50924085201 ROCHE DIAGNOSTI ACCU-CHEK EASY GLUCOSE SOLN

50924086001 ROCHE DIAGNOSTI ACCU-CHEK ADVANTAGE KIT

50924087001 ROCHE DIAGNOSTI ACCU-CHEK ADVANTAGE METER

50924087710 ROCHE DIAGNOSTI ACCU-CHEK INSTANT TEST STRP

50924088110 ROCHE DIAGNOSTI ACCU-CHEK COMFORT CURVE STRIP

50924088250 ROCHE DIAGNOSTI ACCU-CHEK COMFORT CURVE STRIP

50924088401 ROCHE DIAGNOSTI ACCU-CHEK COMPACT DRUM STRIPS

50924088901 ROCHE DIAGNOSTI ACCU-CHEK ACTIVE METER

50924091125 ROCHE DIAGNOSTI ACCU-CHEK INSTANT PLUS STRIP

50924091350 ROCHE DIAGNOSTI ACCU-CHEK INSTANT TEST STRP

50924091401 ROCHE DIAGNOSTI ACCU-CHEK INSTANT CARE KIT

50924091901 ROCHE DIAGNOSTI ACCU-CHEK CONTROL SOLUTION

50924093720 ROCHE DIAGNOSTI SOFT TOUCH LANCETS

50924095110 ROCHE DIAGNOSTI ACCU-CHEK COMPACT PLUS METER

50924095120 ROCHE DIAGNOSTI SOFT TOUCH SAFE-T-PRO

50924095701 ROCHE DIAGNOSTI SOFTCLIX LANCET DEVICE

50924097110 ROCHE DIAGNOSTI SOFTCLIX LANCETS

50924097601 ROCHE DIAGNOSTI ACCU-CHEK INSTANTPLUS KIT

50924098101 ROCHE DIAGNOSTI ACCU-CHEK MULTICLIX LANCETS

50924098850 ROCHE DIAGNOSTI ACCU-CHEK COMPACT DRUM STRIPS

50924098901 ROCHE DIAGNOSTI ACCU-CHEK ADVAN GLUCOSE SOL

51028000102 LINKS MEDICAL MEDLANCE PLUS UNIVERSAL LANCET

51028000103 LINKS MEDICAL MEDLANCE PLUS LITE LANCETS

51028000121 LINKS MEDICAL MEDLANCE PLUS 21G LANCETS

51028000125 LINKS MEDICAL MEDLANCE PLUS 25G LANCETS

51028000128 LINKS MEDICAL ACTI-LANCE 28G LANCETS

51028000158 LINKS MEDICAL MICRODOT BLOOD GLUCOSE SYSTEM

51028000171 LINKS MEDICAL MICRODOT NORMAL CONTROL SOLUT

51028000172 LINKS MEDICAL MICRODOT HIGH-LOW CONTROL SOL

51028000172 LINKS MEDICAL MICRODOT HIGH-LOW CONTROL SOL

51028000175 LINKS MEDICAL MICRODOT TEST STRIPS

51290000200 BIONOSTICS METER-CHECK CONTROL SOLN NORM

51290000201 BIONOSTICS METER-CHECK CONTROL SOLN NORM

51290000202 BIONOSTICS METER-CHECK CONTROL SOLN NORM

51290000203 BIONOSTICS METER-CHECK CONTROL SOLN NORM

51496840101 AIR-TITE NORM-JECT 1 ML SYRINGE

51709000502 DELTA HI-TECH AIMSCO INS SYR 0.5 ML 28GX1/2"

51709000503 DELTA HI-TECH AIMSCO INS SYR 1 ML 28GX1/2"

51709000528 DELTA HI-TECH AIMSCO INS SYR 0.5 ML 29GX1/2"

51709000529 DELTA HI-TECH AIMSCO INS SYR 1 ML 29GX1/2"

51709000532 DELTA HI-TECH AIMSCO INSULIN .5ML SYRINGE

51709000534 DELTA HI-TECH AIMSCO INSULIN 1ML SYRINGE

Page 31 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:

NDC Code Labeler Name Label Name Desc

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.

51709000618 DELTA HI-TECH AIMSCO SYRING 0.5 ML 30GX5/16"

51709000620 DELTA HI-TECH AIMSCO INS SYR 1 ML 30GX5/16"

51709000722 DELTA HI-TECH AIMSCO INS SYR 0.3 ML 30GX5/16

51709000724 DELTA HI-TECH AIMSCO INS SYR 0.3 ML 29GX1/2"

51709000726 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET

51709000727 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET

51709000728 DELTA HI-TECH AIMSCO ULTR-THIN II 30G LANCET

51709000729 DELTA HI-TECH AIMSCO ULTR-THIN II 28G LANCET

51709000740 DELTA HI-TECH AIMSCO SYRING 0.3 ML 31GX5/16"

51709000742 DELTA HI-TECH AIMSCO SYRING 0.5 ML 31GX5/16"

51709000760 DELTA HI-TECH AIMSCO LANCET DEVICE

53459000071 VIP INTERNATION EZ SMART SYSTEM KIT

53459000072 VIP INTERNATION EZ SMART TEST STRIPS

53459000073 VIP INTERNATION EZ SMART BLOOD GLUCOSE LANCETS

53459000076 VIP INTERNATION EZ SMART PLUS SYSTEM KIT

53459000077 VIP INTERNATION EZ SMART PLUS TEST STRIPS

53459000100 VIP INTERNATION EZ SMART TEST STRIPS

53459000770 VIP INTERNATION EZ SMART NORMAL CONTROL SOLN

53459000780 VIP INTERNATION EZ SMART LOW CONTROL SOLUTION

53459000790 VIP INTERNATION EZ SMART HIGH CONTROL SOLUTION

53459001727 VIP INTERNATION EZ SMART TEST STRIPS

53459001737 VIP INTERNATION EZ SMART TEST STRIPS

53885000623 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN

53885000692 LIFESCAN ONE TOUCH DELICA LANCING DEV

53885000692 LIFESCAN ONE TOUCH DELICA LANCING DEV

53885000693 LIFESCAN ONE TOUCH DELICA LANCETS

53885004610 LIFESCAN LIFESCAN FINE POINT LANCETS

53885004810 LIFESCAN FAST TAKE TEST STRIPS

53885005210 LIFESCAN SURESTEP TEST STRIPS

53885010207 LIFESCAN LANCETS

53885013920 LIFESCAN ONE TOUCH SURESOFT LANCING DEV

53885014020 LIFESCAN ONE TOUCH SURESOFT LANCING DEV

53885014110 LIFESCAN ONE TOUCH SURESOFT LANCING DEV

53885014201 LIFESCAN ONE TOUCH DELICA LANCING DEV

53885014201 LIFESCAN ONE TOUCH DELICA LANCING DEV

53885014301 LIFESCAN ONE TOUCH DELICA LANCETS

53885019725 LIFESCAN ONE TOUCH TEST STRIPS

53885019850 LIFESCAN ONE TOUCH TEST STRIPS

53885020801 LIFESCAN ONE TOUCH ULTRAMINI METER

53885024450 LIFESCAN ONE TOUCH ULTRA TEST STRIPS

53885024510 LIFESCAN ONE TOUCH ULTRA TEST STRIPS

53885024701 LIFESCAN ONE TOUCH ULTRA SYSTEM KIT

53885027202 LIFESCAN ONE TOUCH GLUC-CONTROL SOLN

53885029901 LIFESCAN ONE TOUCH PATIENT START KIT

53885032501 LIFESCAN ONE TOUCH BASIC SYSTEM KIT

53885034101 LIFESCAN SURESTEP SYSTEM

53885035601 LIFESCAN PENLET PLUS BLOOD SAMPLER KIT

53885035601 LIFESCAN PENLET PLUS BLOOD SAMPLER KIT

53885035950 LIFESCAN SURESTEP TEST STRIPS

53885037410 LIFESCAN ONE TOUCH TEST STRIPS

53885039310 LIFESCAN ONE TOUCH ULTRASOFT LANCETS

53885041601 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN

Page 32 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:

NDC Code Labeler Name Label Name Desc

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.

53885041901 LIFESCAN ONE TOUCH ULTRAMINI METER

53885042001 LIFESCAN ONE TOUCH ULTRAMINI METER

53885042101 LIFESCAN ONE TOUCH ULTRAMINI METER

53885044450 LIFESCAN FAST TAKE TEST STRIPS

53885044801 LIFESCAN ONE TOUCH ULTRA 2 GLUCOSE SYST

53885045802 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN

53885052401 LIFESCAN ONE TOUCH ULTRA SMART METER

53885055101 LIFESCAN ONE TOUCH ULTRALINK SYSTEM

53885055201 LIFESCAN ONE TOUCH ULTRALINK SYSTEM

53885063702 LIFESCAN SURESTEP GLUC CONTROL SOLN

53885079325 LIFESCAN SURESTEP PRO CONTROL SOLN

53885079425 LIFESCAN SURESTEP PRO CONTROL SOLN

53885079525 LIFESCAN SURESTEP PRO CONTROL SOLN

53885079750 LIFESCAN SURESTEP PRO TEST STRIPS

53885079805 LIFESCAN SURESTEP PRO LINEARITY KIT

53885085002 LIFESCAN SURESTEP PRO CONTROL SOLN

53885085002 LIFESCAN SURESTEP PRO CONTROL SOLN

53885085102 LIFESCAN SURESTEP PRO CONTROL SOLN

53885091101 LIFESCAN ONE TOUCH ULTRAMINI METER

53885091201 LIFESCAN ONE TOUCH ULTRAMINI METER

53885093701 LIFESCAN ONE TOUCH ULTRA CONTROL SOLN

53885099425 LIFESCAN ONE TOUCH ULTRA TEST STRIPS

54569137200 A-S MEDICATION INSULIN SYRINGE 28GX0.5 ML

54569250500 A-S MEDICATION INSULIN U100-1 ML SYRINGE

54569420800 A-S MEDICATION ONE TOUCH TEST STRIPS

54868082400 PHYSICIANS TC. ACCU-CHEK ADVANTAGE STRIPS

54868086300 PHYSICIANS TC. GLUCOSTIX REAGENT STRIPS

54868131100 PHYSICIANS TC. INSULIN SYRINGE 1 ML 28GX1/2"

54868324300 PHYSICIANS TC. ACCU-CHEK COMPACT STRIPS

54868324301 PHYSICIANS TC. ACCU-CHEK COMPACT TEST DRUM

54868359000 PHYSICIANS TC. ACCU-CHEK ACTIVE TEST STRIP

54868493100 PHYSICIANS TC. SOFTCLIX LANCETS

54868526500 PHYSICIANS TC. ONE TOUCH ULTRA TEST STRIPS

54868579600 PHYSICIANS TC. ACCU-CHEK CMFRT CURVE STRIP

54868579700 PHYSICIANS TC. ASCENSIA AUTODISC STRIPS

54868579800 PHYSICIANS TC. ONE TOUCH ULTRASOFT LANCETS

54868580600 PHYSICIANS TC. BD TEST STRIPS

54868580700 PHYSICIANS TC. BD ULTRA FINE LANCETS

56151014201 NIPRO DIAGNOSTIC GENTLE DRAW LANCING DEVICE

56151014260 NIPRO DIAGNOSTIC LANCETS

56151020101 NIPRO DIAGNOSTIC WALGREENS STARTER KIT

56151020160 NIPRO DIAGNOSTIC WALGREENS LANCING DEVICE

56151020201 NIPRO DIAGNOSTIC LEADER STARTER KIT

56151020401 NIPRO DIAGNOSTIC KERR STARTER KIT

56151020801 NIPRO DIAGNOSTIC NAVARRO STARTER KIT

56151020901 NIPRO DIAGNOSTIC EXPRESS MED STARTER KIT

56151021101 NIPRO DIAGNOSTIC GOOD NEIGH STARTER KIT

56151021201 NIPRO DIAGNOSTIC LONG STARTER KIT

56151021301 NIPRO DIAGNOSTIC W-D STARTER KIT

56151021302 NIPRO DIAGNOSTIC WINN DIXIE MEDIC VALUE PACK

56151021401 NIPRO DIAGNOSTIC LIFE MEDICAL STARTER KIT

56151021601 NIPRO DIAGNOSTIC DIABETIC.COM STARTER KIT

Page 33 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:

NDC Code Labeler Name Label Name Desc

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.

56151021701 NIPRO DIAGNOSTIC TRUE CARE STARTER KIT

56151021901 NIPRO DIAGNOSTIC MEIJER STARTER KIT

56151022401 NIPRO DIAGNOSTIC SHOPRITE VALUE PACK

56151022702 NIPRO DIAGNOSTIC KINRAY VALUE PACK

56151030101 NIPRO DIAGNOSTIC WALGREENS TEST STRIP

56151030150 NIPRO DIAGNOSTIC WALGREENS TEST STRIP

56151030201 NIPRO DIAGNOSTIC LEADER TEST STRIP

56151030250 NIPRO DIAGNOSTIC LEADER TEST STRIP

56151030350 NIPRO DIAGNOSTIC HEALTH ALLIANCE STRIP

56151030450 NIPRO DIAGNOSTIC KERR TEST STRIPS

56151030650 NIPRO DIAGNOSTIC DUANE READE TEST STRIPS

56151030850 NIPRO DIAGNOSTIC NAVARRO TEST STRIPS

56151030950 NIPRO DIAGNOSTIC EXPRESS MED TEST STRIPS

56151031101 NIPRO DIAGNOSTIC GOOD NEIGH TEST STRIP

56151031150 NIPRO DIAGNOSTIC GOOD NEIGH TEST STRIP

56151031250 NIPRO DIAGNOSTIC LONG TEST STRIP

56151031301 NIPRO DIAGNOSTIC W-D TEST STRIP

56151031350 NIPRO DIAGNOSTIC W-D TEST STRIP

56151031950 NIPRO DIAGNOSTIC MEIJER TEST STRIP

56151032401 NIPRO DIAGNOSTIC SHOPRITE TEST STRIPS

56151032450 NIPRO DIAGNOSTIC SHOPRITE TEST STRIPS

56151032701 NIPRO DIAGNOSTIC KINRAY TEST STRIPS

56151032750 NIPRO DIAGNOSTIC KINRAY TEST STRIPS

56151050401 NIPRO DIAGNOSTIC PRESTIGE METER

56151052501 NIPRO DIAGNOSTIC PRESTIGE BLOOD GLUCOSE METR

56151055001 NIPRO DIAGNOSTIC PSS TEST STRIP

56151055050 NIPRO DIAGNOSTIC PSS TEST STRIP

56151055550 NIPRO DIAGNOSTIC PRESTIGE TEST STRIPS

56151056301 NIPRO DIAGNOSTIC PRESTIGE GLUCOSE CONTROL

56151056601 NIPRO DIAGNOSTIC PRESTIGE GLUCOSE CONTROL

56151057801 NIPRO DIAGNOSTIC PRESTIGE VALUE PACK

56151081001 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS

56151081350 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS

56151082525 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS

56151085050 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE TEST STRIPS

56151086001 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL

56151086101 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL

56151086301 NIPRO DIAGNOSTIC TRUETRACK GLUCOSE CONTROL

56151086401 NIPRO DIAGNOSTIC TRUECONTROL GLUCOSE SOLUTION

56151086501 NIPRO DIAGNOSTIC TRUECONTROL GLUCOSE SOLUTION

56151087101 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLUTION LOW

56151087201 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLN NORMAL

56151087301 NIPRO DIAGNOSTIC TRUETEST CONTROL SOLN HIGH

56151088050 NIPRO DIAGNOSTIC SIDEKICK BLOOD GLUCOSE SYSTEM

56151088050 NIPRO DIAGNOSTIC SIDEKICK BLOOD GLUCOSE SYSTEM

56151088801 NIPRO DIAGNOSTIC SM TRUETRACK SMART SYSTEM

56151088880 NIPRO DIAGNOSTIC TRUETRACK SMART SYSTEM

56151090090 NIPRO DIAGNOSTIC PRESTIGE SMART SYSTEM METER

56151091001 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP

56151092002 NIPRO DIAGNOSTIC PRESTIGE SMART SYS VALUE PK

56151095050 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP

56151099902 NIPRO DIAGNOSTIC PRESTIGE SMART SYS TEST STP

Page 34 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:

NDC Code Labeler Name Label Name Desc

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.

56151099990 NIPRO DIAGNOSTIC PRESTIGE SMART SYS IQ KIT

56151103001 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS

56151103025 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS

56151103050 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS

56151109801 NIPRO DIAGNOSTIC LIBERTY LEV 1 GLUCOSE CTRL SOL

56151109901 NIPRO DIAGNOSTIC LIBERTY LEV 2 GLUCOSE CTRL SOL

56151109950 NIPRO DIAGNOSTIC LIBERTY TEST STRIPS

56151124001 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM

56151128901 NIPRO DIAGNOSTIC TRUERESULT BLOOD GLUCOSE SYSTM

56151129801 NIPRO DIAGNOSTIC LIBERTY BLOOD GLUCOSE MONITOR

56151134001 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM

56151138901 NIPRO DIAGNOSTIC TRUE2GO BLOOD GLUCOSE SYSTEM

56151181350 NIPRO DIAGNOSTIC TRUETEST GLUCOSE TEST STRIPS

57515003219 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"

57515003259 ULTIMED INC ULTICARE INS 0.5 ML 29GX1/2"

57515007201 ULTIMED INC ULTICARE THIN 28G LANCETS

57515007219 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE

57515007219 ULTIMED INC ULTIGUARD 29GX1 ML SYRINGE

57515007239 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE

57515007239 ULTIMED INC ULTIGUARD 29GX0.3 ML SYRINGE

57515007259 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE

57515007259 ULTIMED INC ULTIGUARD 29GX0.5 ML SYRINGE

57515007315 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

57515007319 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

57515007319 ULTIMED INC ULTIGUARD 30GX1 ML SYRINGE

57515007335 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

57515007339 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

57515007339 ULTIMED INC ULTIGUARD 30GX0.3 ML SYRINGE

57515007355 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

57515007359 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

57515007359 ULTIMED INC ULTIGUARD 30GX0.5 ML SYRINGE

57515007419 ULTIMED INC ULTIGUARD 31GX1 ML SYRINGE

57515007439 ULTIMED INC ULTIGUARD 31GX0.3 ML SYRINGE

57515007459 ULTIMED INC ULTIGUARD 31GX0.5 ML SYRINGE

57515008218 ULTIMED INC ULTICARE INS SYR 1 ML 28GX1/2"

57515008258 ULTIMED INC ULTICARE SYRIN 0.5 ML 28GX1/2"

57515008259 ULTIMED INC INS SYR U100 0.5 ML 29GX1/2"

57515009219 ULTIMED INC ULTICARE INS SYR 1 ML 29GX1/2"

57515009239 ULTIMED INC ULTICARE SYRIN 0.3 ML 29GX1/2"

57515009259 ULTIMED INC ULTICARE U100 0.5 ML 29GX1/2"

57515009315 ULTIMED INC ULTICARE INSULIN SYR U100 1 ML

57515009319 ULTIMED INC CAREONE INS SYR 1 ML 30GX5/16"

57515009335 ULTIMED INC ULTICARE INSUL SYR U100 0.3 ML

57515009339 ULTIMED INC ULTICARE U100 0.3 ML 30GX5/16"

57515009355 ULTIMED INC ULTICARE INSUL SYR U100 0.5 ML

57515009359 ULTIMED INC ULTICARE SYR 0.5 ML 30GX5/16"

57515009419 ULTIMED INC ULTCARE INS SYR 1 ML 31GX5/16"

57515009439 ULTIMED INC ULTICARE SYR 0.3 ML 31GX5/16"

57515009459 ULTIMED INC ULTICARE SYR 0.5 ML 31GX5/16"

57515059259 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML

57515059319 ULTIMED INC ORSINI INSUL SYR U100 1 ML

57515059359 ULTIMED INC ORSINI INSUL SYR U100 0.5 ML

Page 35 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:

NDC Code Labeler Name Label Name Desc

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.

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:

NDC Code Labeler Name Label Name Desc

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.

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

Oregon Health Authority

Division of Medical Assistance Programs

Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011

For billing guidelines and examples:

NDC Code Labeler Name Label Name Desc

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.

60171097001 ENTRA HEALTH SYSTEM MYGLUCOHEALTH MONITORING KIT

60171097003 ENTRA HEALTH SYSTEM MYGLUCOHEALTH TEST STRIPS

61059000419 OWEN MUMFORD US UNILET GP LANCET

61059000751 OWEN MUMFORD US UNISTIK 2 NORMAL 0.81MM DEVICE

61059000751 OWEN MUMFORD US UNISTIK 2 NORMAL 0.81MM DEVICE

61059000851 OWEN MUMFORD US UNISTIK 2 EXTRA 0.81 MM DEVICE

61059000851 OWEN MUMFORD US UNISTIK 2 EXTRA 0.81 MM DEVICE

61059000914 OWEN MUMFORD US UNILET GP LANCET

61059001119 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

61059001515 OWEN MUMFORD US UNILET GP LANCET SUPERLITE

61059002116 OWEN MUMFORD US UNILET LANCET

61059003113 OWEN MUMFORD US UNILET LANCET SUPERLITE

61059003519 OWEN MUMFORD US UNILET LANCET SUPERLITE

61059005301 OWEN MUMFORD US UNILET EXCELITE II LANCET

61059005351 OWEN MUMFORD US UNILET EXCELITE II LANCET

61059005711 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE

61059005711 OWEN MUMFORD US UNISTIK 2.4 MM DEVICE

61059006718 OWEN MUMFORD US UNISTIK 3 MM DEVICE

61059006718 OWEN MUMFORD US UNISTIK 3 MM DEVICE

61059007517 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

61059007517 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

61059007715 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

61059007715 OWEN MUMFORD US UNISTIK 2 2.4 MM DEVICE

61059008514 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059008514 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059008712 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059008712 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059009511 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059009511 OWEN MUMFORD US UNISTIK-2 3 MM DEVICE

61059010111 OWEN MUMFORD US AUTOLET MKII CLINISAFE DEVICE

61059012313 OWEN MUMFORD US AUTOLET LITE CLINISAFE DEV

61059015714 OWEN MUMFORD US DR LANCET

61059025714 OWEN MUMFORD US ULTRA THIN LANCETS

61059025735 OWEN MUMFORD US ULTRA THIN 28G LANCETS

61059025736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET

61059026013 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

61059026013 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

61059026518 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

61059026518 OWEN MUMFORD US AUTOLET MINI LANCING DEVICE

61059027010 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV

61059027119 OWEN MUMFORD US AUTOLET IMPRESSION LANCING DEV

61059035714 OWEN MUMFORD US DR ULTRA THIN LANCET

61059035726 OWEN MUMFORD US LIVE BETTER ULTRA THIN LANCET

61059043514 OWEN MUMFORD US ALTERNATE SITE LANCETS

61059046011 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

61059046516 OWEN MUMFORD US UNILET COMFORTOUCH LANCET

61059051015 OWEN MUMFORD US UNILET EXCELITE LANCET

61059051510 OWEN MUMFORD US UNILET EXCELITE LANCET

61059065711 OWEN MUMFORD US COMFORT LANCETS

61059065714 OWEN MUMFORD US SUPER THIN LANCETS

61059065726 OWEN MUMFORD US LIVE BETTER SUPER THIN LANCET

61059065735 OWEN MUMFORD US SUPER THIN 30G LANCETS

Page 38 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:

NDC Code Labeler Name Label Name Desc

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.

61059065736 OWEN MUMFORD US 1ST TIER COMFORTOUCH LANCET

61059070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING

61059070726 OWEN MUMFORD US LIVE BETTER ADVANCED LANCING

61059074212 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE

61059074212 OWEN MUMFORD US UNISTIK 2 1.8 MM DEVICE

61059076216 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

61059076216 OWEN MUMFORD US UNISTIK 2 NEONATAL DEVICE

61059100219 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

61059100219 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

61059104217 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

61059104217 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

61059106211 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

61059106211 OWEN MUMFORD US UNISTIK 3 1.8 MM LANCING DEVIC

63323090490 APP PHARMACEUTICALS, LLC. FLOW-EZE VENTED NEEDLE

63706001110 MEDTRONIC MINIM MINILET THIN LANCETS

65702010110 ROCHE DIAGNOSTI ACCU-CHEK AVIVA MONITORING KIT

65702010210 ROCHE DIAGNOSTI ACCU-CHEK AVIVA METER

65702010310 ROCHE DIAGNOSTI ACCU-CHEK AVIVA TEST STRIPS

65702010410 ROCHE DIAGNOSTI ACCU-CHEK AVIVA TEST STRIPS

65702010610 ROCHE DIAGNOSTI ACCU-CHEK AVIVA TEST STRIPS

65702010710 ROCHE DIAGNOSTI ACCU-CHEK AVIVA SOLUTION

65702010710 ROCHE DIAGNOSTI ACCU-CHEK AVIVA SOLUTION

65702012410 ROCHE DIAGNOSTI ACCU-CHEK SOFTCLIX LANCETS

65702015610 ROCHE DIAGNOSTI ACCU-CHEK SOFTCLIX LANCETS

65702021210 ROCHE DIAGNOSTI ACCU-CHEK AVIVA TEST STRIPS

65702021510 ROCHE DIAGNOSTI ACCU-CHEK COMFORT CURVE STRIP

65702022310 ROCHE DIAGNOSTI ACCU-CHEK COMPACT STRIPS

65702027410 ROCHE DIAGNOSTI ACCUTREND GLUCOSE TEST STRIP

65702027510 ROCHE DIAGNOSTI ACCUTREND GLUCOSE CONTROL

65702027510 ROCHE DIAGNOSTI ACCUTREND GLUCOSE CONTROL

65702036910 ROCHE DIAGNOSTI ACCU-CHEK COMPACT BLUE CONTROL

65702036910 ROCHE DIAGNOSTI ACCU-CHEK COMPACT BLUE CONTROL

65702040010 ROCHE DIAGNOSTI ACCU-CHECK SOFTCLIX LANCET KIT

65702040010 ROCHE DIAGNOSTI ACCU-CHECK SOFTCLIX LANCET KIT

66004005501 SOLARTEK PROD.I ULTIMA MONITOR KIT

66004012104 SOLARTEK PROD.I ULTIMA TEST STRIPS

66004012205 SOLARTEK PROD.I ULTIMA TEST STRIPS

66004085004 SOLARTEK PROD.I BLOOD GLUCOSE TEST STRIPS

66004085105 SOLARTEK PROD.I BLOOD GLUCOSE TEST STRIPS

66004097309 SOLARTEK PROD.I RELION ULTIMA TEST STRIPS

66852000490 AMIRA MEDICAL AT-LAST BLOOD GLUCOSE SYSTM

66852000539 AMIRA MEDICAL AT-LAST LANCETS

66852000547 AMIRA MEDICAL AT-LAST TEST STRIPS

66852001171 AMIRA MEDICAL AT-LAST TEST STRIPS

68016001670 CHAIN DRUG CONSORTIUM, LLC PV LANCING DEVICE

68016001676 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYSTEM

68016001677 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYS STRIPS

68016001678 CHAIN DRUG CONSORTIUM, LLC PV TRUETRACK SMART SYS STRIPS

68016030554 CHAIN DRUG CONSORTIUM, LLC PV ULTRA THIN LANCETS

68016030754 CHAIN DRUG CONSORTIUM, LLC PV ULTRA THIN LANCETS

68016051054 CHAIN DRUG CONSORTIUM, LLC PV LANCING DEVICE

68016065035 CHAIN DRUG CONSORTIUM, LLC PV INSUL SYR 0.3 ML 31GX5/16"

Page 39 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:

NDC Code Labeler Name Label Name Desc

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.

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:

NDC Code Labeler Name Label Name Desc

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.

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

Oregon Health Authority

Division of Medical Assistance Programs

Allowable NDCs for Diabetic Supply Billing - Effective 8/1/2011

For billing guidelines and examples:

NDC Code Labeler Name Label Name Desc

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.

86227062035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE

86227062055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE

86227062105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE

86227065035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE

86227065045 ALLISON MEDICAL SURE COMFORT 0.3 ML SYRINGE

86227065055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE

86227065105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE

86227070035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE

86227070055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE

86227070105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE

86227080055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE

86227080105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE

86227090035 ALLISON MEDICAL SURE COMFORT 3/10 ML SYRINGE

86227090055 ALLISON MEDICAL SURE COMFORT 0.5 ML SYRINGE

86227090105 ALLISON MEDICAL SURE COMFORT 1 ML SYRINGE

86227921625 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 30GX1/2"

86227921635 ALLISON MEDICAL PUB INSUL SYR 0.3 ML 31GX5/16"

86227921645 ALLISON MEDICAL PUB INSUL SYR 0.5 ML 31GX5/16"

86227921655 ALLISON MEDICAL PUB INSULIN SYR 1 ML 31GX5/16"

87701033674 BRITE LIFE BL TEST STRIPS

87701039908 BRITE LIFE GNP SUPER THIN LANCETS

87701039972 BRITE LIFE GNP INSUL SYR 0.5 ML 31GX5/16"

87701039973 BRITE LIFE GNP INSULIN SYR 1 ML 31GX5/16"

87701039974 BRITE LIFE GNP INSUL SYR 0.3 ML 31GX5/16"

87701044288 BRITE LIFE BL INSULIN 0.3 ML SYRINGE

87701044671 BRITE LIFE GNP THIN LANCETS

87701052620 BRITE LIFE GNP LANCING SYSTEM DEVICE

87701057044 BRITE LIFE GNP LANCETS

87701057046 BRITE LIFE GNP LANCETS

87701057048 BRITE LIFE BL LANCETS

87701065329 BRITE LIFE BL INSULIN 1 ML SYRINGE

87701065340 BRITE LIFE BL INSULIN 0.5 ML SYRINGE

87701065343 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE

87701065352 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR

87701065354 BRITE LIFE GNP ULTRA COMFORT 3/10 ML SYR

87701066838 BRITE LIFE BL REAGENT STRIPS

87701066840 BRITE LIFE BL REAGENT STRIPS

87701074702 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR

87701074723 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE

87701074725 BRITE LIFE GNP ULTRA COMFORT 3/10 ML SYR

87701074728 BRITE LIFE GNP ULTRA COMFORT 0.5 ML SYR

87701074745 BRITE LIFE GNP ULTRA COMFORT 1 ML SYRINGE

87701083729 BRITE LIFE BL THIN LANCETS

87701088246 BRITE LIFE GNP COLOR LANCETS

87701095986 BRITE LIFE GNP THIN LANCETS

89105200001 MPA-DIABETIC CHOICEDM CLARUS TEST STRIPS

89105200002 MPA-DIABETIC CHOICEDM CLARUS CONTROL SOLN

89105200008 MPA-DIABETIC CHOICEDM CLARUS MONITOR SYSTEM

89123700113 HOME AIDE DIAGN EASY CHECK CONTROL SOLN HIGH

89123700114 HOME AIDE DIAGN EASY CHECK CONTROL SOLN LOW

89123700118 HOME AIDE DIAGN EASY STEP BLOOD GLUCOSE METER

89123700121 HOME AIDE DIAGN EASY STEP GLUCOSE SYSTEM KIT

Page 42 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:

NDC Code Labeler Name Label Name Desc

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.

89123700141 HOME AIDE DIAGN EASY TRAK BLOOD GLUCOSE METER

89123700142 HOME AIDE DIAGN EASY TRAK GLUCOSE TEST STRIP

89123700143 HOME AIDE DIAGN EASY TRAK CONTROL SOLN NORMAL

89123700144 HOME AIDE DIAGN EASY TRAK GLUCOSE SYSTEM KIT

89123700145 HOME AIDE DIAGN EASY TRAK CONTROL SOLN HIGH

89123700146 HOME AIDE DIAGN EASY TRAK CONTROL SOLN LOW

89123700147 HOME AIDE DIAGN EASY TALK BLOOD GLUCOSE METER

89123700148 HOME AIDE DIAGN EASY TALK GLUCOSE TEST STRIP

89123700149 HOME AIDE DIAGN EASY TALK CONTROL SOLN LOW

89123700151 HOME AIDE DIAGN EASY TALK GLUCOSE SYSTEM KIT

89123700152 HOME AIDE DIAGN EASY TALK HIGH CONTROL SOLN

90166005015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 30GX1/2"

90166005035 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 30GX1/2"

90166005055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 30GX1/2"

90166005615 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 30GX5/16"

90166005635 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 30GX5/16"

90166005655 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 30GX5/16"

90166012102 GLOBAL DIABETIC E-Z PULL & CLICK LANCING DEV

90166012804 GLOBAL DIABETIC INJECT EASE 28G LANCETS

90166013004 GLOBAL DIABETIC INJECT EASE 30G LANCETS

90166015615 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 31GX5/16"

90166015635 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 31GX5/16"

90166015655 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 31GX5/16"

90166085015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 28GX1/2"

90166085055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 28GX1/2"

90166095015 GLOBAL DIABETIC INSULIN SYRINGE 1 ML 29GX1/2"

90166095035 GLOBAL DIABETIC INSULIN SYRIN 0.3 ML 29GX1/2"

90166095055 GLOBAL DIABETIC INSULIN SYRIN 0.5 ML 29GX1/2"

91237000100 HOME AIDE DIAGN EASY CHECK GLUCOSE METER

91237000101 HOME AIDE DIAGN EASY CHECK GLUCOSE TEST STRIP

91237000102 HOME AIDE DIAGN EASY CHECK GLUCOSE CNTRL SOLN

91237000104 HOME AIDE DIAGN EASY TOUCH LANCETS

91237000105 HOME AIDE DIAGN EASY CLICK LANCING DEVICE

91237000108 HOME AIDE DIAGN EASY COMFORT INSULIN 1 ML SYR

91237000109 HOME AIDE DIAGN EASY COMFORT 0.5 ML SYRINGE

91237000110 HOME AIDE DIAGN EASY COMFORT 0.3 ML SYRINGE

91237000112 HOME AIDE DIAGN EASY CHECK BLOOD GLUCOSE SYS

91237000113 HOME AIDE DIAGN EASY CHECK CONTROL SOLN HIGH

91237000114 HOME AIDE DIAGN EASY CHECK CONTROL SOLN LOW

91237000115 HOME AIDE DIAGN EASY TOUCH LANCETS

91237000116 HOME AIDE DIAGN EASY TOUCH LANCETS

91237000118 HOME AIDE DIAGN EASY STEP BLOOD GLUCOSE METER

91237000121 HOME AIDE DIAGN EASY STEP GLUCOSE SYSTEM KIT

91899001884 MEDICINE SHOP MS E-ZJECT LANCETS

91899042912 MEDICINE SHOP MS INSUL SYR 0.3 ML 31GX5/16"

91899043012 MEDICINE SHOP MS INSUL SYR 0.5 ML 31GX5/16"

91899043112 MEDICINE SHOP MS INSULIN SYR 1 ML 31GX5/16"

91899060778 MEDICINE SHOP MS INS SYR 0.5 ML 29GX1/2"

91899060878 MEDICINE SHOP MS INS SYR 1 ML 29GX1/2"

91899060978 MEDICINE SHOP MS INSULIN SYR 0.3 ML 29GX1/2"

91899062178 MEDICINE SHOP MS LANCETS

91899062181 MEDICINE SHOP MS LANCETS

Page 43 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:

NDC Code Labeler Name Label Name Desc

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.

91899062678 MEDICINE SHOP MS INS SYRINGE 1 ML 30GX1/2"

91899062778 MEDICINE SHOP MS INSUL SYR 0.5 ML 30GX1/2"

91899062878 MEDICINE SHOP MS INSULIN SYRINGE 0.3 ML

91899063078 MEDICINE SHOP MS THIN LANCETS

91899063178 MEDICINE SHOP MS SUPER THIN LANCETS

92896000001 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 1 ML

92896000002 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 0.5 ML

92896000003 FIFTY50 PHARMAC FIFTY50 INSULIN SYRINGE 0.3 ML

92896000008 FIFTY50 PHARMAC FIFTY50 2.0 GLUCOSE METER

92896000009 FIFTY50 PHARMAC FIFTY50 GLUCOSE TEST STRIP

92896000016 FIFTY50 PHARMAC FIFTY50 GLUCOSE CONTROL SOLN

92896000019 FIFTY50 PHARMAC FIFTY50 SAFETY SEAL LANCETS

92896000800 FIFTY50 PHARMAC FIFTY50 LANCING DEVICE

92896000810 FIFTY50 PHARMAC FIFTY50 SAFETY SEAL LANCETS

93351012710 MED.PLASTIC DEV ADJUSTABLE LANCING DEVICE

93815070043 ABBOTT DIABETES MEDISENSE THIN LANCETS

93815070550 ABBOTT DIABETES MEDISENSE H-L CONTROL SOLUTION

93815070551 ABBOTT DIABETES MEDISENSE H-M-L CONTROL SOLN

93815070552 ABBOTT DIABETES MEDISENSE MID CONTROL SOLUTION

93815071041 ABBOTT DIABETES OPTIUM EZ TEST STRIP

93815071042 ABBOTT DIABETES OPTIUM EZ TEST STRIP

93815080063 ABBOTT DIABETES PRECISION PCX PLUS TEST STR

93815080116 ABBOTT DIABETES PRECISION POINT OF CARE STR

93815080138 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL

93815080139 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL

93815080312 ABBOTT DIABETES MEDISENSE GLUC-KET CONT SOL

93815080339 ABBOTT DIABETES PRECISION PCX PLUS TEST STR

93815097137 ABBOTT DIABETES ULTRATLC LANCETS

93815097138 ABBOTT DIABETES ULTRATLC LANCETS

93815097400 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815097401 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815097411 ABBOTT DIABETES PRECISION CONTROL SOLUTION

93815097432 ABBOTT DIABETES MEDISENSE CONTROL SOLUTION

93815098138 ABBOTT DIABETES ULTRATLC THIN LANCETS

93815098335 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815098336 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815098436 ABBOTT DIABETES PRECISION CONTROL SOLUTION

93815098546 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098547 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098548 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098549 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098550 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098681 ABBOTT DIABETES MEDISENSE THIN LANCETS

93815098682 ABBOTT DIABETES MEDISENSE THIN LANCETS

93815098732 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815098733 ABBOTT DIABETES PRECISION Q-I-D TEST STRIPS

93815098757 ABBOTT DIABETES PRECISION PCX TEST STRIPS

93815098814 ABBOTT DIABETES PRECISION XTRA MONITOR

93815098894 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098895 ABBOTT DIABETES PRECISION SURE DOSE SYRINGE

93815098929 ABBOTT DIABETES PRECISION LINK DIRECT MONIT

93815099121 ABBOTT DIABETES PRECISION CONTROL SOLUTION

Page 44 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:

NDC Code Labeler Name Label Name Desc

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.

93815099134 ABBOTT DIABETES OPTIUM TEST STRIP

93815099135 ABBOTT DIABETES OPTIUM TEST STRIP

93815099565 ABBOTT DIABETES PRECISION PCX TEST STRIPS

93815099694 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815099695 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815099728 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815099837 ABBOTT DIABETES PRECISION XTRA MONITOR

93815099838 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815099877 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815099878 ABBOTT DIABETES PRECISION XTRA TEST STRIPS

93815974116 ABBOTT DIABETES PRECISION CONTROL SOLUTION

94030000201 OMNIS HEALTH EMBRACE BLOOD GLUCOSE SYSTEM

94030000202 OMNIS HEALTH EMBRACE TEST STRIPS

94030000207 OMNIS HEALTH EMBRACE GLUC CONTROL SOLN LOW

94030000209 OMNIS HEALTH VICTORY BLOOD GLUCOSE MONITOR

94030000210 OMNIS HEALTH VICTORY GLUCOSE TEST STRIPS

94030000211 OMNIS HEALTH VICTORY HIGH-LOW CONTROL SOLN

94030000211 OMNIS HEALTH VICTORY HIGH-LOW CONTROL SOLN

94030201001 OMNIS HEALTH EMBRACE BLOOD GLUCOSE SYSTEM

94030201003 OMNIS HEALTH EMBRACE TEST STRIPS

94030201006 OMNIS HEALTH EMBRACE GLUC CONTROL SOLN LOW

94046000100 DIABETIC SUPPLY ADVOCATE TEST STRIP

94046000101 DIABETIC SUPPLY ADVOCATE CONTROL SOLUTION LOW

94046000102 DIABETIC SUPPLY ADVOCATE BLOOD GLUCOSE MONITOR

94046000103 DIABETIC SUPPLY ADVOCATE BLOOD GLUCOSE MONITOR

94046000104 DIABETIC SUPPLY ADVOCATE CONTROL SOLUTION HIGH

94046000105 DIABETIC SUPPLY ADVOCATE LANCING DEVICE

94046000106 DIABETIC SUPPLY ADVOCATE LANCET

94046000107 DIABETIC SUPPLY ADVOCATE BLOOD GLUCOSE MONITOR

94046000109 DIABETIC SUPPLY ADVOCATE LANCETS

94046000111 DIABETIC SUPPLY ADVOCATE REDI-CODE GLU MONITOR

94046000113 DIABETIC SUPPLY ADVOCATE REDI-CODE TEST STRIP

94046000118 DIABETIC SUPPLY ADVOCATE LANCETS

94046000124 DIABETIC SUPPLY ADVOCATE REDI-CODE TEST STRIP

94046000126 DIABETIC SUPPLY ADVOCATE REDI-CODE TEST STRIP

94046000133 DIABETIC SUPPLY ADVOCATE BLOOD GLUCOSE MONITOR

94046000134 DIABETIC SUPPLY ADVOCATE BLOOD GLUCOSE MONITOR

94046000135 DIABETIC SUPPLY ADVOCATE REDI-CODE GLU MONITOR

94046000136 DIABETIC SUPPLY ADVOCATE REDI-CODE GLU MONITOR

94046000139 DIABETIC SUPPLY ADVOCATE REDI-CODE TEST STRIP

94046000140 DIABETIC SUPPLY ADVOCATE CONTROL SOLUTION LOW

94046000141 DIABETIC SUPPLY ADVOCATE TEST STRIP

94441021545 SAV-ON SAV-ON LANCETS

94441021546 SAV-ON SAV-ON LANCETS

94441021547 SAV-ON SAV-ON LANCETS

96295010295 LEADER LEADER COLORED LANCETS

96295010494 LEADER LEADER INS SYR 0.5 ML 28GX1/2"

96295010495 LEADER LEADER INS SYR 1 ML 28GX1/2"

96295010496 LEADER LEADER INS SYR 0.5 ML 29GX1/2"

96295010497 LEADER LEADER INS SYR 1 ML 29GX1/2"

96295010498 LEADER LEADER INS SYR 0.3 ML 29GX1/2"

96295010629 LEADER LEADER INSULIN SYRINGE 0.3 ML

Page 45 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:

NDC Code Labeler Name Label Name Desc

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.

96295010643 LEADER LEADER INS SYR 0.5 ML 30GX1/2"

96295010645 LEADER LEADER INS SYR 1 ML 30GX1/2"

96295010677 LEADER LEADER THIN LANCETS

96295010841 LEADER LEADER THIN LANCETS

96295010948 LEADER LEADER STARTER KIT

96295011105 LEADER LEADER SUPER THIN LANCETS

96295011261 LEADER LEADER SYRING 0.5 ML 31GX5/16"

96295011262 LEADER LEADER INS SYR 1 ML 31GX5/16"

96295011263 LEADER LEADER SYRING 0.3 ML 31GX5/16"

96295011503 LEADER LEADER E-ZJECT LANCETS

96295011708 LEADER LANCING DEVICE

98302000100 SIMPLE DIAGNOST SIMPLE DIAGNSTIC LANCET DEVICE

98302000102 SIMPLE DIAGNOST CLEVER CHEK TEST STRIPS

98302000103 SIMPLE DIAGNOST CLEVER CHEK CONTROL SOLUTION

98302000104 SIMPLE DIAGNOST PHARMACIST CHOICE 30G LANCETS

98302000106 SIMPLE DIAGNOST PHARMACIST CHOICE 28G LANCETS

98302000107 SIMPLE DIAGNOST CLEVER CHEK BLOOD GLUCOSE SYST

98302000108 SIMPLE DIAGNOST CLEVER CHEK TEST STRIPS

98302000109 SIMPLE DIAGNOST CLEVER CHEK CONTROL SOLUTION

98302000110 SIMPLE DIAGNOST CLEVER CHEK CONTROL SOLUTION

98302000111 SIMPLE DIAGNOST CLEVER CHEK BLOOD GLUCOSE SYST

98302000112 SIMPLE DIAGNOST CLEVER CHEK BLOOD GLUCOSE SYST

98302000115 SIMPLE DIAGNOST CLEVER CHEK ULTRA THIN LANCETS

98302000116 SIMPLE DIAGNOST CLEVER CHEK BLOOD GLUCOSE SYST

98302000118 SIMPLE DIAGNOST CLEVER CHEK TEST STRIPS

98302000120 SIMPLE DIAGNOST CLEVER CHEK TEST STRIPS

98302000121 SIMPLE DIAGNOST CLEVER CHEK BLOOD GLUCOSE SYST

98302000125 SIMPLE DIAGNOST PHARMACIST CHOICE 30G LANCETS

98302000126 SIMPLE DIAGNOST PHARMACIST CHOICE 28G LANCETS

98302000127 SIMPLE DIAGNOST CLEVER CHEK 30G LANCETS

98302000128 SIMPLE DIAGNOST CLEVER CHOICE PRO TEST STRIP

98302000129 SIMPLE DIAGNOST CLEVER CHOICE PRO GLUCOSE MTR

98302000131 SIMPLE DIAGNOST CLEVER CHOICE GLUCOSE MONITOR

98302000132 SIMPLE DIAGNOST PHARMACIST CHOICE GLUCOSE SYS

98302000133 SIMPLE DIAGNOST PHARMACIST CHOICE TEST STRIPS

98302000160 SIMPLE DIAGNOST PHARMACIST CHOICE 31G LANCETS

98302000170 SIMPLE DIAGNOST CLEVER CHOICE MICRO TEST STRIP

98302000180 SIMPLE DIAGNOST CLEVER CHOICE MICRO MONITOR

98939000200 FOR A CARE INC. FORA D10 BLOOD GLUCOSE SYSTEM

98939000201 FOR A CARE INC. FORA D10 GLUCOSE TEST STRIPS

98939000204 FOR A CARE INC. FORA HIGH CONTROL SOLUTION

98939000205 FOR A CARE INC. FORA LOW CONTROL SOLUTION

98939000206 FOR A CARE INC. FORA NORMAL CONTROL SOLUTION

98939000207 FOR A CARE INC. FORA V12 BLOOD GLUCOSE SYSTEM

98939000209 FOR A CARE INC. FORA V10 BLOOD GLUCOSE SYSTEM

98939000210 FOR A CARE INC. FORA V10 GLUCOSE TEST STRIP

98939000212 FOR A CARE INC. FORA D15C GLUCOSE TEST STRIPS

98939000216 FOR A CARE INC. FORA D15Z GLUCOSE TEST STRIPS

98939000217 FOR A CARE INC. FORA V20 BLOOD GLUCOSE SYSTEM

98939000218 FOR A CARE INC. FORA V20 GLUCOSE TEST STRIPS

98939000219 FOR A CARE INC. FORA V22 BLOOD GLUCOSE SYSTEM

98939000220 FOR A CARE INC. FORA V22 GLUCOSE TEST STRIP

Page 46 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:

NDC Code Labeler Name Label Name Desc

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.

98939000226 FOR A CARE INC. FORA V12 BLOOD GLUCOSE SYSTEM

98939000227 FOR A CARE INC. FORA V12 GLUCOSE TEST STRIP

98939000229 FOR A CARE INC. FORA G30A BLOOD GLUCOSE SYSTEM

98939000231 FOR A CARE INC. FORA G30A GLUCOSE TEST STRIP

98939000233 FOR A CARE INC. FORA G20 BLOOD GLUCOSE SYSTEM

98939000234 FOR A CARE INC. FORA G20 GLUCOSE TEST STRIPS

98939000235 FOR A CARE INC. FORA V10 BLOOD GLUCOSE SYSTEM

98939000236 FOR A CARE INC. FORA V10 GLUCOSE TEST STRIP

98939000238 FOR A CARE INC. FORA D15G GLUCOSE TEST STRIPS

98939000244 FOR A CARE INC. FORA D20 BLOOD GLUCOSE SYSTEM

98939000245 FOR A CARE INC. FORA D20 GLUCOSE TEST STRIPS

98939000246 FOR A CARE INC. FORA G90 BLOOD GLUCOSE SYSTEM

98939000247 FOR A CARE INC. FORA G90 GLUCOSE TEST STRIP

98939000256 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM

98939000257 FOR A CARE INC. FORA G71A GLUCOSE TEST STRIPS

98939000258 FOR A CARE INC. FORA LANCING DEVICE

98939000259 FOR A CARE INC. FORA V30A BLOOD GLUCOSE SYSTEM

98939000260 FOR A CARE INC. FORA V30A GLUCOSE TEST STRIP

98939000261 FOR A CARE INC. FORA LANCETS

98939000265 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM

98939000266 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM

98939000267 FOR A CARE INC. FORA G71A BLOOD GLUCOSE SYSTEM

99073011001 ABBOTT DIABETES FREESTYLE SYSTEM KIT

99073011004 ABBOTT DIABETES FREESTYLE SYSTEM KIT

99073012050 ABBOTT DIABETES FREESTYLE TEST STRIPS

99073012051 ABBOTT DIABETES FREESTYLE SIDEKICK II VALPK

99073012101 ABBOTT DIABETES FREESTYLE TEST STRIPS

99073012301 ABBOTT DIABETES FREESTYLE TEST STRIPS

99073012401 ABBOTT DIABETES FREESTYLE TEST STRIPS NFRS

99073012450 ABBOTT DIABETES FREESTYLE TEST STRIPS NFRS

99073013001 ABBOTT DIABETES FREESTYLE LANCETS

99073014001 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073014002 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073014003 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073014003 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073017001 ABBOTT DIABETES FREESTYLE FLASH SYSTEM KIT

99073070428 ABBOTT DIABETES FREESTYLE UNISTIK 2 LANCETS

99073070432 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073070432 ABBOTT DIABETES FREESTYLE CONTROL SOLUTION

99073070683 ABBOTT DIABETES FREESTYLE NAVIGATOR SENSOR KIT

99073070792 ABBOTT DIABETES FREESTYLE TEST STRIPS

99073070804 ABBOTT DIABETES FREESTYLE LITE METER NFRS

99073070805 ABBOTT DIABETES FREESTYLE LITE METER

99073070819 ABBOTT DIABETES FREESTYLE LITE TEST STRIP NFRS

99073070822 ABBOTT DIABETES FREESTYLE LITE TEST STRIP

99073070823 ABBOTT DIABETES FREESTYLE LITE TEST STRIP NFRS

99073070827 ABBOTT DIABETES FREESTYLE LITE TEST STRIP

99073070847 ABBOTT DIABETES FREESTYLE FREEDOM KIT

99073070914 ABBOTT DIABETES FREESTYLE FREEDOM LITE METER

99073070920 ABBOTT DIABETES FREESTYLE FREEDOM LITE NFRS

99073071097 ABBOTT DIABETES FREESTYLE PREC 1 ML 30GX5/16"

99073071098 ABBOTT DIABETES FREESTYLE PREC 0.5 ML 30GX5/16

Page 47 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:

NDC Code Labeler Name Label Name Desc

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.

99073071099 ABBOTT DIABETES FREESTYLE PREC 0.5 ML 31GX5/16

99073071100 ABBOTT DIABETES FREESTYLE PREC 1 ML 31GX5/16"

Page 48 of 48