ACTIVE CLOTTING FACTOR PRODUCTS BY NATIONAL DRUG CODE (NDC)

Source: Medicaid Data Warehouse, extracted on 3/6/2017

NDC Product Name Medicaid Fee–for–Service Reimbursement
Amount/ Unit, for the Product Cost
00026378225 KOGENATE FS 250 UNIT VIAL 0.988
00026378335 KOGENATE FS 500 UNIT VIAL 0.988
00026378555 KOGENATE FS 1,000 UNITS VIAL 0.988
00026378665 KOGENATE FS 2,000 UNIT VIAL 0.988
00026378775 KOGENATE FS 3,000 UNITS VIAL 0.988
00026379220 KOGENATE FS 250 UNIT VL–BIOSET 0.988
00026379330 KOGENATE FS 500 UNIT VL–BIOSET 0.988
00026379550 KOGENATE FS 1,000 UNIT–BIOSET 0.988
00026379660 KOGENATE FS 2,000 UNIT–BIOSET 0.988
00026379770 KOGENATE FS 3,000 UNIT–BIOSET 0.988
00026382125 KOVALTRY 250 UNIT KIT 1.135
00026382225 KOVALTRY 500 UNIT KIT 1.135
00026382425 KOVALTRY 1,000 UNIT KIT 1.135
00026382650 KOVALTRY 2,000 UNIT KIT 1.135
00026382850 KOVALTRY 3,000 UNIT KIT 1.135
00053623302 MONONINE 1,000 UNITS KIT 1.165
00053763302 MONOCLATE–P 1,000 UNIT KIT 0.855
00053763402 MONOCLATE–P 1,500 UNIT KIT 0.855
00053813102 HELIXATE FS 250 UNIT VIAL 1.055
00053813202 HELIXATE FS 500 UNIT VIAL 1.055
00053813302 HELIXATE FS 1,000 UNIT VIAL 1.055
00053813402 HELIXATE FS 2,000 UNIT VIAL 1.055
00053813502 HELIXATE FS 3,000 UNITS VIAL 1.055
00169720101 NOVOSEVEN RT 1 MG VIAL 1.855
00169720201 NOVOSEVEN RT 2 MG VIAL 1.855
00169720501 NOVOSEVEN RT 5 MG VIAL 1.855
00169720801 NOVOSEVEN RT 8 MG VIAL 1.855
00169781001 NOVOEIGHT 1,000 UNIT VIAL 1.205
00169781501 NOVOEIGHT 1,500 UNIT VIAL 1.205
00169782001 NOVOEIGHT 2,000 UNIT VIAL 1.205
00169782501 NOVOEIGHT 250 UNIT VIAL 1.205
00169783001 NOVOEIGHT 3,000 UNIT VIAL 1.205
00169785001 NOVOEIGHT 500 UNIT VIAL 1.205
00944284110 RECOMBINATE 220–400 UNIT VIAL 1.215
00944284210 RECOMBINATE 401–800 UNIT VIAL 1.215
00944284310 RECOMBINATE 801–1,240 UNIT VL 1.215
00944284410 RECOMBINATE 1,241–1,800 UNIT V 1.215
00944284510 RECOMBINATE 1,801–2,400 UNIT V 1.215
00944302602 RIXUBIS 250 UNIT NOMINAL 1.205
00944302802 RIXUBIS 500 UNIT NOMINAL 1.205
00944303002 RIXUBIS 1,000 UNIT NOMINAL 1.205
00944303202 RIXUBIS 2,000 UNIT NOMINAL 1.205
00944303402 RIXUBIS 3,000 UNIT NOMINAL 1.205
00944304510 ADVATE 1,801–2,400 UNITS VIAL 1.215
00944304610 ADVATE 2,401–3,600 UNITS VIAL 1.215
00944304710 ADVATE 3,601–4,800 UNITS VIAL 1.215
00944305102 ADVATE 200–400 UNITS VIAL 1.215
00944305202 ADVATE 401–800 UNITS VIAL 1.215
00944305302 ADVATE 801–1,200 UNITS VIAL 1.215
00944305402 ADVATE 1,201–1,800 UNITS VIAL 1.215
00944394002 HEMOFIL M 250 UNIT NOMINAL 0.995
00944394202 HEMOFIL M 500 UNIT NOMINAL 0.995
00944394402 HEMOFIL M 1,000 UNIT NOMINAL 0.995
00944394602 HEMOFIL M 1,700 UNIT NOMINAL 0.995
00944425202 ADYNOVATE 200–400 UNIT VIAL 1.710
00944425402 ADYNOVATE 401–800 UNIT VIAL 1.710
00944425602 ADYNOVATE 801–1,250 UNIT VIAL 1.710
00944425802 ADYNOVATE 1,251–2,500 UNIT VL 1.710
00944462201 ADYNOVATE 200–400 UNIT VIAL 1.710
00944462301 ADYNOVATE 401–800 UNIT VIAL 1.710
00944462401 ADYNOVATE 801–1,250 UNIT VIAL 1.710
00944462501 ADYNOVATE 1,251–2,500 UNIT VL 1.710
00944755102 VONVENDI 650 UNIT VIAL 2.115
00944755302 VONVENDI 1,300 UNIT VIAL 2.115
53270027005 IXINITY 500 UNIT VIAL 1.315
53270027105 IXINITY 1,000 UNIT VIAL 1.315
53270027106 IXINITY 1,000 UNIT VIAL –2 VLS 1.315
53270027205 IXINITY 1,500 UNIT VIAL 1.315
53270027206 IXINITY 1,500 UNIT VIAL –2 VLS 1.315
58394001201 XYNTHA 250 UNIT KIT 1.715
58394001301 XYNTHA 500 UNIT KIT 1.715
58394001401 XYNTHA 1,000 UNIT KIT 1.715
58394001501 XYNTHA 2,000 UNIT KIT 1.715
58394001603 XYNTHA SOLOFUSE 3,000 UNIT KIT 1.715
58394002203 XYNTHA SOLOFUSE 250 UNIT KIT 1.715
58394002303 XYNTHA SOLOFUSE 500 UNIT KIT 1.715
58394002403 XYNTHA SOLOFUSE 1,000 UNIT KIT 1.715
58394002503 XYNTHA SOLOFUSE 2,000 UNIT KIT 1.715
58394063303 BENEFIX 250 UNIT KIT 1.505
58394063403 BENEFIX 500 UNIT KIT 1.505
58394063503 BENEFIX 1,000 UNIT KIT 1.505
58394063603 BENEFIX 2,000 UNIT KIT 1.505
58394063703 BENEFIX 3,000 UNIT KIT 1.505
63833051802 CORIFACT KIT 7.785
63833061502 HUMATE–P 600 UNIT VWF:RCO 0.975
63833061602 HUMATE–P 1,200 UNIT VWF:RCO 0.975
63833061702 HUMATE–P 2,400 UNIT VWF:RCO 0.975
64193042302 FEIBA NF 500 UNIT (NOMINAL) 1.795
64193042402 FEIBA NF 1,000 UNIT (NOMINAL) 1.795
64193042502 FEIBA NF 2,500 UNIT (NOMINAL) 1.795
64193044502 BEBULIN 200–1,200 UNITS VIAL 1.115
64208775201 COAGADEX 250 UNIT VIAL 5.065
64208775301 COAGADEX 500 UNIT VIAL 5.065
64406080101 ELOCTATE 250 UNIT NOMINAL 2.034
64406080201 ELOCTATE 500 UNIT NOMINAL 2.034
64406080301 ELOCTATE 750 UNIT NOMINAL 2.034
64406080401 ELOCTATE 1,000 UNIT NOMINAL 2.034
64406080501 ELOCTATE 1,500 UNIT NOMINAL 2.034
64406080601 ELOCTATE 2,000 UNIT NOMINAL 2.034
64406080701 ELOCTATE 3,000 UNIT NOMINAL 2.034
64406091101 ALPROLIX 500 UNIT NOMINAL 2.912
64406092201 ALPROLIX 1,000 UNIT NOMINAL 2.912
64406093301 ALPROLIX 2,000 UNIT NOMINAL 2.912
64406094401 ALPROLIX 3,000 UNIT NOMINAL 2.912
64406096601 ALPROLIX 250 UNIT NOMINAL 2.912
64406097701 ALPROLIX 4,000 UNIT NOMINAL 2.912
67467018201 WILATE 500–500 UNIT VIAL 0.935
67467018202 WILATE 1,000–1,000 UNIT VIAL 0.935
68516320101 PROFILNINE 500 UNITS VIAL 1.305
68516320202 PROFILNINE 1,000 UNITS VIAL 1.305
68516320302 PROFILNINE 1,500 UNITS VIAL 1.305
68516360102 ALPHANINE SD 500 UNITS VIAL 0.945
68516360202 ALPHANINE SD 1,000 UNITS VIAL 0.945
68516360302 ALPHANINE SD 1,500 UNITS VIAL 0.945
68516460101 ALPHANATE 250–100 UNIT VIAL 0.915
68516460201 ALPHANATE 500–200 UNIT VIAL 0.915
68516460302 ALPHANATE 1,000–400 UNIT VIAL 0.915
68516460402 ALPHANATE 1,500–600 UNIT VIAL 0.915
68516460902 ALPHANATE 2,000–800 UNIT VIAL 0.915
68982013901 NUWIQ 250 UNIT VIAL PACK 1.385
68982014101 NUWIQ 500 UNIT VIAL PACK 1.385
68982014301 NUWIQ 1,000 UNIT VIAL PACK 1.385
68982014501 NUWIQ 2,000 UNIT VIAL PACK 1.385
68982018201 WILATE 500–500 UNIT VIAL 0.935
68982018202 WILATE 1,000–1,000 UNIT VIAL 0.935
69911047402 AFSTYLA 250 UNIT VIAL 1.340
69911047502 AFSTYLA 500 UNIT VIAL 1.340
69911047602 AFSTYLA 1,000 UNIT VIAL 1.340
69911047702 AFSTYLA 2,000 UNIT VIAL 1.340
69911047802 AFSTYLA 3,000 UNIT VIAL 1.340
69911086402 IDELVION 250 UNIT VIAL 4.010
69911086502 IDELVION 500 UNIT VIAL 4.010
69911086602 IDELVION 1,000 UNIT VIAL 4.010
69911086702 IDELVION 2,000 UNIT VIAL 4.010
76125025020 KOATE–DVI 250 UNITS VIAL 0.895
76125025620 KOATE 250 UNIT VIAL 0.895
76125066730 KOATE–DVI 500 UNITS VIAL 0.895
76125066750 KOATE–DVI 1,000 UNITS VIAL 0.895
76125066830 KOATE 500 UNIT VIAL 0.895
76125067250 KOATE–DVI 1,000 UNITS VIAL 0.895
76125067650 KOATE 1,000 UNIT VIAL 0.895

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