peach state health plan preferred diabetic supplies ...€¦ · preferred diabetic supplies:...

Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message Based on Q1 2016 P&T of 22

Peach State Health Plan

Preferred Diabetic Supplies: Alcohol Pads and

Lancets

each State Health Plan routinely reviews the products available on the Preferred Drug List (PDL). Items are added, removed or modified periodically due to industry standards, market availability, and/or assessment of use. Below is a list of PDL products and the Non-PDL products which are being removed as of 06/01/2016.

ALCOHOL PREP PADS

Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ALLISON MEDICAL ALCOHOL PAD PREP:

86227000855 86227012205

ALCOHOL PREP PAD: 86227012305

AMERICAN SALES COMPANY ALCOHOL SWAB PAD: 41520080930

AMERISOURCE BERGEN DRUGS GNP ALCOHOL PAD SWABS: 46122004378

APPLIED DIABETES RESEARCH FIFTY50 PREP PAD PADS: 08521080100

BD DIABETES CARE BD SWAB BFLY PAD SNGL USE: 08290006893

BD SWAB REG PAD SNGL USE: 08290326895

BEIERSDORF-FUTURO CURITY SWABS PAD ALCOHOL: 08225233300

BERGEN BRUNSWIG GNP ALCOHOL PAD SWABS: 24385006578

BOCA MEDICAL PRODUCTS ALCOHOL SWAB PAD: 43820005020

CHAIN DRUG CONSORTIUM ALCOHOL PREP PAD: 40986001290

CHAIN DRUG MARKETING ASSOC QC ALCOHOL PAD SWABS: 63868098903

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Effective date: June 1, 2016

Preferred Diabetic Supplies: Alcohol Pads and Lancets

Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message

Based on Q1 2016 P&T of 22

Labeler Name PDL Product (NDC) Non-PDL Product (NDC) COVIDIEN MEDICAL SUPPLIES CURITY PREP PAD

ALCOHOL: 08080176818 08080503300

WEBCOL PREP PAD LARGE: 08080511000 08080515000

WEBCOL PREP PAD MEDIUM: 08080575000 08080681800

CVS PHARMACY HEALTHCARE SERV

ALCOHOL SWAB PAD: 50428047377 50428130344

PREP PADS PAD: 50428297584

GLOBAL MEDICAL PRODUCTS GLOBAL PREP PAD PADS: 90166011103 90166022203

GOOD NEIGHBOR PHARMACY GNP ALCOHOL PAD SWABS: 87701069817

ALCOHOL SWAB PAD: 30142001032 30142001033 30142001050

ALCOHOL PREP PAD: 00904624560

SM ALCOHOL PAD PREP: 49348007753 49348089610

ALCOHOL WIPE PAD: 49614062278

ALCOHOL SWAB PAD: 19283059475

ALCOHOL SWAB PAD EX-THICK: 41250004081 41250004082

REALITY SWAB PAD: 41250064279

HOME AIDE DIAGNOSTICS ALCOHOL PAD: 91237000128

SAPS CARE PAD ALCOHOL: 91237000176

MEDICORE ALCOHOL PREP PAD: 32671000701

MEDISCA ALCOH-GLOVE PAD CONTOURE: 38779754401

ALCOH-WIPE PAD 12"X12": 38779754501




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MHC MEDICAL PRODUCTS ALCOHOL PREP PAD MED

70%: 42423027001 42423027002 42423027101 42423027102 42423027103 42423027104

NEW HAVEN PHARMACEUTICALS SAV-ON ALCO MIS SWABS: 98302000105

ONE PHARMA & MEDICAL SUPPLY CO

ALCOHOL PREP PAD: 59707000120 59707000125 59707011101 59707022201

PERRIGO DIABETES CARE ALCOHOL SWAB PAD: 00113200078

PHOENIX HEALTHCARE SOLUTIONS ALCOHOL PREP PAD: 60913000601 60913000702 60913000801 60913000902 60913001702 60913001802

PRESCRIPTION SOLUTIONS, INC. ALCOHOL SWAB PAD: 62451999810

RELIAMED ALCOHOL PREP PAD: 42167000630

RITE AID CORPORATION RA ALCOHOL PAD: 11822033374

RA ALCOHOL PAD SWABS: 11822080004 11822253720 11822515660

RUGBY ALCOHOL PREP PAD: 00536750001

SELECT BRAND SB ALCOHOL PAD PREP: 15127000887

SHOPKO STORES OPERATING CO ALCOHOL SWAB PAD: 37012049930

SPECIALTY MEDICAL SUPPLIES ALCOHOL PREP PAD: 38415000011 68113011401 68113099601

TARGET ALCOHOL SWAB PAD: 11673060010

WALGREENS ALCOHOL PREP PAD: 11917003175

ALCOHOL SWAB PAD: 11917006104 11917007088 11917008216 11917012805 11917012807 11917014296 11917014455




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) WAL-MART ALCOHOL SWAB PAD:

81131006044 81306041113

LANCETS

Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ABBOTT DIABETES CARE THIN LANCETS MIS :

57599004305 57599868102 57599868205 57599868206

FREESTYLE MIS LANCETS : 99073013001 99073013022 99073070428 99073083003

FREESTYLE MIS UNISTICK : 57599874605

ACCESS DIABETIC SUPPLY LANCETS MIS 30G : 08540003001

ACON LABORATORIES ON CALL MIS LANCETS : 82607054105

ON CALL PLUS MIS LANCETS : 82607053551

AGAMATRIX AGAMATRIX MIS 33G : 08554197101

AIMSCO/DELTA HI-TECH AUTO LANCET MIS : 51709000729

ULTRA THIN MIS LANC 26G : 89134072902

ULTRA THIN MIS LANC 28G : 89134072602

ULTRA-THIN MIS 28G : 51709000726 51709000727 89134072702

ULTRA-THIN MIS 30G : 51709000728 89134072802

ALLISON MEDICAL LANCETS MIS 30G : 86227000955

SURE COMFORT MIS LANCETS : 86227028105 86227028205 86227030105 86227030205

AMBIMEDINC EZ-LETS 21G MIS LANCETS : 25294000810

EZ-LETS II MIS LANCETS : 25294094300

EZ-LETS 23G MIS LANCETS : 25294000806






Labeler Name PDL Product (NDC) Non-PDL Product (NDC) AMBIMEDINC (cont) EZ-LETS 30G MIS LANCETS

: 25294000825

AMIRA MEDICAL AT LAST MIS LANCETS : 08238053904

APPLIED DIABETES RESEARCH FIFTY50 SAFE MIS LANCETS : 08521081030 08521081032

ARKRAY USA TECHLITE MIS LANC 30G : 08317880130

ASSURE LANCE MIS 21G : 08317980121

TECHLITE MIS LANCETS : 08317880125 08317880128 08317880225 08317880228

ASSURE LANCE MIS LOW FLOW : 08317980125 08317980225

TECHLITE AST MIS LANCETS : 08317880300

ASSURE LANCE MIS MICRO : 08317980128 08317980228

ASSURE LANCE MIS SAFE 25G : 08317990125

ASSURE LANCE MIS SAFE 30G : 08317990130

ASSURE PLUS MIS HIGH 18G : 08317970118

ASSURE PLUS MIS LOW 25G : 08317970125

ASSURE PLUS MIS MCRO 28G : 08317970128

ASSURE PLUS MIS NORM 21G : 08317970121

ASSURE PLUS MIS PEDIATRI : 08317970112

HAEMOLANCE MIS HIGH FLO : 08317990800

HAEMOLANCE MIS LANCETS : 08317045050

HAEMOLANCE MIS LOW FLOW : 08317950000 08317955000 08317960000 08317965000

HAEMOLANCE MIS PLUS : 08317990200 08317990250 08317990700 08317990750

HAEMOLANCE MIS PLUS LOW : 08317990900 08317990950

HAEMOLANCE MIS PLUS MAX : 08317990600

HAEMOLANCE MIS PLUS PED : 08317990400




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ARKRAY USA (cont) HAEMOLANCE MIS RETRACT :

08317015001 08317035050

QUICKLANCE MIS SYSTEM : 08317915050

A-S MEDICATION SOLUTIONS ONE TOUCH MIS LANCETS : 54569519000

ASCENSIA DIABETES CARE AMES GLU SYS MIS : 00193550921

BAYER MICRLT MIS LANCETS : 00193654621

FINGERSTIX MIS LANCETS : 00193596531

MICROLET MIS LANCETS : 00193658621

SINGLE-LET MIS 23G : 00193656801 00193656831

BD DIABETES CARE BD LANCET UF MIS 30G : 08290325772 08290325773

BD GENIE MIS LANCETS : 08290366579

BD LANCET UF MIS 33G : 08290322057 08290322065

BD MICROTAIN MIS LANCETS : 08290366592 08290366593 08290366594

BD MEDICAL SURGICAL SYSTEMS BD GENIE MIS LANCET : 08290366583

MICROTAINER MIS LANCET : 08290365759 08290366356 08290366357 08290366359

BERGEN BRUNSWIG GNP LANCETS MIS : 87701057044 87701057046

GNP LANCETS MIS MICRO : 87701040655

GNP LANCETS MIS SUP THIN : 87701039908

GNP LANCETS MIS THIN : 87701044671

GNP LANCETS MIS THIN 26G : 87701095986

LANCETS THIN MIS : 24385065482

BIONIME USA CORPORATION RIGHTEST MIS GL300 : 08539060000




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) BIOSENSE MEDICAL DEVICES SOLUS V2 MIS LANC 28G :

08611504100

SOLUS V2 MIS LANC 30G : 08611504000

BOCA MEDICAL PRODUCTS ULTILET MIS 26G : 08326261001

LANCET MIS 2MM : 08326200001

LANCETS MIS 30G : 08326003001

ULTILET MIS 28G : 08326281001 08326281002

ULTILET MIS 30G : 08326300001 08326301001

ULTILET MIS 33G : 08326330001 08326331001

ULTILET MIS LANCETS : 08326280001 08326280002

ULTILET MIS SAFETY : 08326231001

BOCA PHARMACAL DIASTAR MIS LANCETS : 08385103001

DIASTAR EASY MIS LANCETS : 08385003001

CARDIOCOM GLUCOCOM MIS 28G : 08525010300

GLUCOCOM MIS 33G : 08525011300

GLUCOCOM MIS 30G : 08525011200

CHAIN DRUG CONSORTIUM LANCETS ULTR MIS THIN 30G : 40986001668 40986001669

UNILET LANCT MIS 33G : 40986003283

CLOSER HEALTHCARE LANCETS MIS : 08464010001

COVIDIEN MEDICAL SUPPLIES MONOLET MIS LANCETS : 08881602018 08881602034 08881602075 08881602125

MONOLET MIS LANCETS : 08881602141 08881602190

MONOLET OPD MIS LANCETS : 08080602422

MONOLETTOR MIS LANCETS : 08080602091




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) CVS PHARMACY HEALTHCARE SERV

CVS LANCETS MIS ORIGINAL : 50428001773 59779032304

CVS LANCETS MIS THIN 26G : 50428001771 50428001772

ULTRA THIN MIS LANCETS : 50428235155 50428235157

DIABETIC SUPPLY OF SUNCOAST ADVCATE SAFE MIS LANC 26G : 94046000192

ADVOCATE MIS LANC 30G : 94046000110

ADVOCATE MIS LANCETS : 94046000106 94046000109 94046000118

DISPENSEXPRESS LANCETS MIS : 68115073000

ENTRA HEALTH SYSTEMS MYGLUCOHEALT MIS LANC 30G : 50081000303

FACET TECHNOLOGIES CLEANLET 28G MIS LANCETS : 94542005830 94542005835

SURELITE MIS LANCETS : 94542005005 94542051150

FORA CARE FORA MIS LANCETS : 98939000261

FORA LANCETS MIS 30G : 16042001201

FUTURA MEDICAL CORPORATION GENTLE-LET MIS 26G : 55283030001 55283030003

SAFE-T-LANCE MIS 21G : 55283084901 55283085000

GENTLE-LET MIS 28G : 55283031003

SAFE-T-LANCE MIS 25G : 55283084903 55283085100

GENTLE-LET MIS LANCETS : 55283011800 55283012100 55283012200 55283012400 55283070900 55283079600 55283080000

SAFE-T-LANCE MIS HI FLOW : 55283084905

LANCETS MIS 28G : 55283086502

SAFE-T-LANCE MIS LOW FLOW : 55283084909

PSS SAFE LAN MIS : 55283020603

SAFE-T-LANCE MIS NOR FLOW : 55283084907

PSS SEL LANC MIS : 55283020503

SURGILANCE MIS LANCETS : 55283083401 55283083402 55283083403 55283083404

THINLETS GP MIS 26G : 55283086501




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) GLOBAL MEDICAL PRODUCTS GLOBAL 28G MIS LANCETS :

90166012804

GLOBAL 30G MIS LANCETS : 90166013004

LANCETS MIS 33G : 90166001334

GLUCO PERFECT PERFECT 30G MIS LANCETS : 08531010030

PERFECT 28G MIS LANCETS : 08531010028

H&H WHOLESALE INC EASYTEST MIS LANCETS : 08385022650

EASYTEST II MIS LANCETS : 08385110579

PRECISION MIS 28G : 08385086701

PRECISION MIS 28G(T) : 08385086601

THINLETS MIS 28G(T) : 08385086501

W&F LANCETS MIS 21G : 08385610001

W&F LANCETS MIS 26G : 08385850501

HEALTH ALLIANCE LANCETS MIS : 08347100010

HOME AIDE DIAGNOSTICS ACTIVE 1ST MIS LANC 30G : 91237000187

EASY COMFORT MIS 30G : 91237000104 91237000116

EASY COMFORT MIS LANC/30G : 91237000115 91237000129

SAPSCARE MIS TWIST : 91237000175

HTL-STREFA DROPLET LANC MIS 30G : 08489716130

ACTI-LANCE MIS LITE 28G : 08489715510 08638714120 08638715510 08638731125 08638732150

ACTI-LANCE MIS SPEC 17G : 08489715710 08638714320 08638715710 08638731325 08638732350




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) HTL-STREFA (cont) ACTI-LANCE MIS UNIV 23G :

08489715610 08638714220 08638715610 08638731225 08638732250

MEDLANCE MIS PLUS 30G : 08489724120 08489724210 08489727625 08489728650

MEDLANCE PLS MIS 0.8MM : 08489704620 08489724610 08489728025 08489729050

MEDLANCE PLS MIS EXTR 21G : 08489704520 08489724510 08489727925 08489728950

MEDLANCE PLS MIS LITE 25G : 08489704320 08489724310 08489727725 08489728750

MEDLANCE PLS MIS UNIV 21G : 08489704420 08489724410 08489727825 08489728850

HY-VEE LANCETS MIS ORIGINAL : 75450031195

LANCETS MIS THIN : 75450031095

INFOPIA USA LANCETS MIS 30G : 08522000082

VANTAGE LANC MIS UNIV 30G : 08522000052

INVACARE SUPPLY GROUP LANCETS MIS 30G : 08618003001

INVERNESS MEDICAL KROGER LANCE MIS : 36652030418

KROGER LANCE MIS THIN : 36652030118 36652030218

KROGER LANCE MIS THIN 30G : 36652030318

LEADER BRAND PRODUCTS LANCETS MIS : 37205011882

LIFESCAN INC ONETOUCH MIS LANCETS : 53885010207

LIFESCAN MIS UNISTIK2 : 53885040410

ONETOUCH MIS 30G : 53885059501

ONETOUCH MIS COMBO : 53885073102




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) LIFESCAN INC (cont) ONETOUCH MIS LANCETS :

53885004610 53885013610 53885014301

ONETOUCH FP MIS LANCETS : 53885071202

ONETOUCH US MIS LANCETS : 53885039310

UNISTIK 2 MIS NEONATAL : 53885019610

UNISTIK II MIS LANCETS : 53885063610

LINKS MEDICAL PRODUCTS ACTI-LANCE MIS 28G : 51028000128

MEDLANCE MIS 30G PLUS : 51028000133

MEDLANCE PLS MIS LITE 25G : 51028000103 51028000125

MEDLANCE PLS MIS UNIV 21G : 51028000102 51028000121

LIVONGO HEALTH IN TOUCH LAN MIS 30G : 53553000506

LOGIMEDIX LANCETS MIS : 08429111101

LONGS DRUG THIN LANCETS MIS ULTRA : 12333097541

MAJOR PHARMACEUTICALS MAJOR COMFOR MIS LANCETS : 00904437560

MALGAM ENTERPRISES INC. GLUCOSOURCE MIS LANCETS : 08278220011

MEDICAL PLASTIC DEVICES LANCETS THIN MIS : 08271033100 08271035100

FINE 30 MIS : 08271087100

LANCETS THIN MIS 23G : 28465000351

MEDLANCE MIS EXTR 21G : 08271138300

LANCETS ULTR MIS THIN : 08271036100 08271036200

MEDLANCE MIS LITE 25G : 08271138100

VITALET LANCETS : 28465000331

MEDLANCE MIS PLUS : 08271138400

MEDLANCE MIS UNV 21G : 08271138200

VITALET PRO MIS : 28465001212 28465001222

VITALET PRO MIS PLUS : 28465001340 28465001350




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MEDICINE SHOPPE LANCETS MIS :

49614062178 49614062181

LANCETS THIN MIS : 49614063078 49614063081

MEDICORE LITE TOUCH MIS LANCETS : 32671020133 32671020233

LITETOUCH MIS LANCETS : 32671020333

MEDLINE INDUS SAFETY 21G MIS LANCETS : 08327006729 08327006929

SAFETY 28G MIS LANCETS : 08327006829 08327007029

MEDTRONIC MINIMED MINILET LANC MIS THIN : 63706001110

MEIJER LANCETS MIS 21G : 41250088304

LANCETS MIS 26G : 41250088305 41250088306

MEIJER MIS LANCETS : 38396030320

MEIJER LANCE MIS COLOR : 13733021547

MEIJER LANCE MIS UNIV 21G : 41250088303

MEIJER LANCE MIS UNIV 30G : 41250003693

REALITY MIS LANCETS : 41250084211

REALITY TRIG MIS LANCETS : 41250066828

MHC MEDICAL PRODUCTS EASY TOUCH MIS LANC/26G : 08496261001 08496261201

EASY TOUCH MIS LANC/21G : 08496212201 08496212401




EASY TOUCH MIS LANC/26G : 08496260801 08496261801 08496265801


EASY TOUCH MIS LANC/28G : 08496280801 08496281801 08496285801




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MHC MEDICAL PRODUCTS (cont) EASY TOUCH MIS

LANC/33G : 08496331001 EASY TOUCH MIS LANC/30G : 08496300601 08496305801

EASY TOUCH MIS LANC/32G : 08496320601

NEW HAVEN PHARMACEUTICALS OSCO LANCETS MIS STANDARD : 41280021546

NOVA BIOMEDICAL SUREFLEX MIS LANCETS : 08548048738

NOVA SAFETY MIS LANC 23G : 08548050939

NOVA SAFETY MIS LANC 28G : 08548050938

NOVA SURE MIS LANCETS : 08548043421

OMNIS HEALTH EMBRACE LANC MIS THIN 30G : 94030000204

ONE PHARMA & MEDICAL SUPPLY CO

SURE-LANCE MIS LANCETS : 59707028101 59707030101

SURE-LANCE MIS 26G : 59707000108

SURE-LANCE MIS LANCETS : 59707000110 59707000112 59707000166

SURE-TOUCH MIS UNV LANC : 59707000165

OWEN MUMFORD 1ST CHOICE MIS LANCETS : 08517015722 08517030722 08517035722 08517065722

ADV TRAVEL MIS LANC 28G : 08214048715

AURORA LANCE MIS 30G : 08214065724

MEDICHOICE MIS LANCET : 08214500712 08214501712 08214502712 08214503712 08214504712 08214506712

AURORA LANCE MIS THIN 23G : 08214015724

ON-THE-GO MIS LANC 30G : 08214028739 08214028755

CAREONE LANC MIS 28G : 08214035721

SAFETY 21G MIS LANCETS : 08470101501

CAREONE LANC MIS THIN 23G : 08214015721

TRAVEL LANCE MIS 30G : 08214028715

COMFORT MIS LANCETS : 08214065711

UNISTIK 3 MIS GENT 30G : 08470102201 08470102401 08470102701 08470102801




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) COMFORTOUCH MIS

LANCET : 08214046001 08214046002 08214046501 08470043001 08470043501 08470046001 08470046501

UNISTIK SAFE MIS LANC 28G : 08470144201

HLTHY ACCNTS MIS LANC 30G : 08214065750

UNISTIK SAFE MIS LANC 30G : 08470142201

INCONTROL MIS LANC 28G : 08214025727



KINNEY MIS LANCETS : 08214018718

KINNEY THIN MIS LANCETS : 08214020718

LANCET ALTER MIS SITE 26G : 08214043514

LANCET SUPER MIS THIN 30G : 08214065714 08214065726 08214065735 08214465714

LANCET ULTRA MIS 28G : 08214025735

LANCET ULTRA MIS THIN 28G : 08214025714

LANCETS MIS 23G : 08214515714

LANCETS ULTR MIS THIN 28G : 08214535714

LB LANCET MIS 28G : 08214035726

PC LANCETS MIS 30G : 08214535716

PX LANCETS MIS ULT THIN : 08214035729

QC LANCETS MIS 28G : 08214053533

QC LANCETS MIS 30G : 08214046533

SUPER THIN MIS LANCETS : 08214065740




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) TARGET LANCE MIS THIN

28G : 08214037020

TGT LANCET MIS 23G : 08214015720

TGT LANCET MIS 28G : 08214025720 08214030720 08214035720

TGT LANCET MIS 30G : 08214046520 08214065720

TGT LANCET MIS ALTERNAT : 08214043520

ULTRA THIN MIS LANCETS : 08214020740 08214025740

UNILET MIS 21G : 08470040001

UNILET CMFR MIS TCH 28G : 08517025736

UNILET CMFR MIS TCH 30G : 08517065736

UNILET EX II MIS 28G : 08214053001 08214053501 08470053001 08470053501

UNILET EXCEL MIS 23G : 08214051001 08214051501 08470051001 08470051501

UNILET G.P MIS SUPR 23G : 08214045001 08214045501

UNILET G.P. MIS 21G : 08214041401 08214041801 08470041401 08470041801

UNILET GP 28 MIS ULT THIN : 08214092001 08214092501 08470092001 08470092501

UNILET LANCE MIS 21G : 08214040001

UNILET LANCE MIS 33G : 08214058733

UNILET LANCT MIS 28G : 08214025739 08214025748 08214025755 08214025757 08214056761 08470056501




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) UNILET LANCT MIS 30G :

08214057761 08214065739 08214065748 08214065755 08214065757 08470057501

UNILET LANCT MIS 33G : 08470058501

UNILET SUPER MIS 23G : 08214044001 08214044501 08470044001 08470044501

UNILET SUPER MIS G.P. 23G : 08470045001 08470045501

PERRIGO DIABETES CARE CVS LANCETS MIS 21G : 38396050275

FP LANCETS MIS THIN : 38396033477

CVS LANCETS MIS THIN 26G : 38396030175 38396050175 38396050375

LONGS LANCET MIS ULTRA TH : 38396033070

CVS LANCETS MIS THIN 30G : 38396030575 38396030775 38396052175 38396052275

RENEW ADV MIS REFILLS : 38396044455

CVS LANCETS MIS THIN 33G : 38396031775

EQL LANCETS MIS 21G COLR : 38396030740

EQL LANCETS MIS 33G COLR : 38396031640

EQL LANCETS MIS THIN 26G : 38396030140 38396030240

EQL LANCETS MIS THIN 30G : 38396030540 38396030640

E-Z JECT MIS 21G : 38396030400

E-Z JECT MIS 21G COLR : 38396030500 38396030600

E-Z JECT MIS 30G : 38396030800

E-Z JECT MIS 32G COLR : 38396030900

E-Z JECT MIS LANC 21G : 38396030300

E-Z JECT MIS THIN 26G : 38396030100 38396030200




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) E-ZJECT LANC MIS 33G :

38396031600 38396031614

GNP LANCETS MIS 21G : 38396034264 38396034364

GNP LANCETS MIS THIN 26G : 38396034464 38396034564

LANCET MICRO MIS THIN 33G : 38396031618 38396031664

LANCET STAND MIS 21G : 38396091825 38396091925

LANCET SUPER MIS THIN 30G : 38396032325 38396054764


LANCETS MIS 21G : 38396030418 38396050132

LANCETS MIS 21G COLR : 38396035506 38396036606

LANCETS MIS 30G : 38396030522

LANCETS MIS THIN 26G : 38396031506

LANCETS MIS THIN 30G : 38396031156

LANCETS THIN MIS 26G : 38396030118 38396030157 38396030218 38396031225 38396032225

LONGS LANCET MIS STANDARD : 38396032870

LONGS LANCET MIS THIN : 38396032970

MEIJER MIS LANCETS : 38396030120 38396030220 38396030420

MEIJER LANCE MIS UNIVERSA : 38396031620

MICRO THIN MIS LANC 33G : 38396031632

PHARMACY COU MIS LANCETS : 38396030505




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) RA E-ZJECT MIS 28G :

38396031114

RA E-ZJECT MIS THIN 26G : 38396030114

RA E-ZJECT MIS THIN 28G : 38396031214

RA E-ZJECT MIS ULT THIN : 38396030514

RELION LANCE MIS THIN 26G : 38396030102 38396044902

RELION LANCE MIS THIN 30G : 38396045102 38396045202 38396045302 38396045402

RELION ULTRA MIS THIN PLS : 38396031402 38396031702

SM LANCETS MIS 33G : 38396031739

SMART SENSE MIS LANC 21G : 38396030325

SMART SENSE MIS LANC 26G : 38396030125 38396030225



SUPER THIN MIS LANC 28G : 38396031132 38396045532





THIN LANCETS MIS 26G : 38396050232 38396050332

THIN LANCETS MIS 30G : 38396050432

UNIVERSAL 1 MIS LANC 26G : 38396030137




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) UNIVERSAL 1 MIS LANC

30G : 38396030537

PHILOSYS GMATE LANCET MIS 30G : 89157052101

PHOENIX HEALTHCARE SOLUTIONS ASSURE CMFRT MIS 28G : 60913000201

ASSURE CMFRT MIS 30G : 60913000101

PHYSICIANS TOTAL CARE BD ULT FINE MIS LANCETS : 54868580700

ONETOUCH US MIS LANCETS : 54868579800

SOFTCLIX MIS LANCETS : 54868493100

POLYMER TECHNOLOGY SYSTEMS LANCETS MIS ORANGE : 08193008912

PRODIGY DIABETES CARE PRODIGY MIS 28G : 08484990328

LANCETS MIS 28G : 08321081028 08321240128 08321240228

LANCETS MIS 30G : 08321081030 08321240110

PRODIGY MIS 21G : 08484082321 08484082341

PRODIGY MIS 26G : 08321000170 08484082026 08484082316

PRODIGY MIS 28G : 08484081028 08484990338

SAFE LANCETS MIS 21G : 08321240130

SAFE LANCETS MIS 26G : 08321240160

PROGRESSIVE HEALTH SUPPLY SMARTEST MIS LANCETS : 08524000403

RELIAMED LANCETS MIS 28G : 42167000552 42167000640

LANCET ULTRA MIS FINE : 42167003329

LANCETS MIS 30G : 42167000548


RITE AID CORPORATION RA E-ZJECT MIS 33G : 11822350540

RA LANCETS MIS : 11822039928 11822098941




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) RITE AID CORPORATION (cont) RA LANCETS MIS

COLORED : 11822087186

RA LANCETS MIS THIN : 11822098940

ROCHE DIAGNOSTICS ACCU-CHEK MIS MLTICLIX : 50924045001 50924098101

COAGUCHEK MIS LANCETS : 50924004301

FASTCLIX MIS LANCETS : 65702028810

SAFE-T-PRO MIS LANCETS : 50924095120

SAFE-T-PRO MIS PLUS : 50924007920

SOFT TOUCH MIS LANCETS : 50924058510

SOFTCLIX MIS LANCETS : 50924012410 50924013024 50924097110 50924098820 65702012410 65702015610

SELECT BRAND SB LANCETS MIS THIN : 15127099010 15127099020

SB LANCETS MIS ULTR THN : 15127099110 15127099120

SIMPLE DIAGNOSTICS CLEVER CHECK MIS : 98302000115

CLEVER CHECK MIS 30G : 98302000127

LANCETS ULTR MIS THIN : 98302000104

ULTRA THIN MIS 28G : 98302000126




ULTRA THIN MIS LANCETS : 98302000106




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) SPECIALTY MEDICAL SUPPLIES LANCETS MIS 21G :

38415010021 38415030021 ASSURE MIS LANCETS : 38415010029

LANCETS MIS 26G : 38415010026 38415030026

BULLSEYE MIS LANCETS : 38415000013 38415000015

LANCETS MIS 28G : 38415020028 38415030028

BULLSEYE MIS MINI LNC : 38415000021 38415000025 38415000028 38415002101 38415002501 38415002801

LANCETS MIS 30G : 38415030030

LANCETS MIS : 38415010028 38415060001

LANCETS MIS 28G : 38415040028

LANCETS MIS 30G : 38415010030

LANCETS MIS 31G : 38415010031

SAFETY LET MIS LANCETS : 38415010001

STERILANCE MEDICAL STERILANCE MIS TL 28G : 08565015915

STERILANCE MIS TL 30G : 08565016915

STERILANCE MIS TL 32G : 08565017915

TELCARE LANCET ULTRA MIS THIN 30G : 59519000202

TRIVIDIA HEALTH LANCETS MIS 28G : 56151024221

TRUPLUS LANC MIS 28G : 56151034001 56151034002 56151034025

TRUPLUS LANC MIS 26G : 56151014101


TRUPLUS LANC MIS 30G : 56151014401 56151014801


ULTIMED LANCETS THIN MIS 28G : 08222072085 57515007208

LANCETS THIN MIS 30G : 08222073015 57515007301




Labeler Name PDL Product (NDC) Non-PDL Product (NDC) US DIAGNOSTICS LANCETS MIS 28G :

08463701228 SAFETY MIS LANCETS : 08463803028

LANCETS MIS 30G : 08463702930

VIP INTERNATIONAL EZ SMART MIS LANCETS : 53459000073

WALGREENS COMFORT ASSU MIS LANC 28G : 11917011815 11917011816


COMFORT ASSU MIS LANC 33G : 11917011817

LANCETS MIS 28G : 11917013416

LANCETS MIS 28G : 11917013415

LANCETS MIS 30G : 11917013417


LANCETS MIS 33G : 11917013418

LANCETS MICR MIS THIN 33G : 11917015019

LANCETS SUPR MIS THIN 28G : 11917015021

WAL-MART RELION LANCE MIS STND 21G : 81306022114

RELION LANCE MIS THIN 26G : 81306021214

RELION LANCE MIS THIN 30G : 78742002644 78742002646 81131009885 81306021314 81306022314

RELION MICRO MIS THIN 33G : 78742002648

RELION ULTRA MIS THIN 32G : 81131025695

For the most current program description you may call Member Services at 1-800-704-1484 (TTY/TTD 1-800-255-0056) or visit the Peach State Health Plan website at www.pshp.com

http://www.pshp.com/

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