Prescription Refill List Insulin and Related Supplies
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- Victor Phillips
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1 Insulin and Related Supplies Name Date Local Pharamcy Name/Address : 30 day/ 5 refills 90 day/ 3 refills Mail Away Pharamacy Name/Address: 30 day/ 5 refills 90day / 3 refills *Check only those items that require a new prescription for refills * Insulin (Vials) B-D Insulin Syringe with Attached Needle Humalog Syringe with Ultra- Fine Needle (12.7mm 1/2 30G) Novolog 30 unit syringe 50 unit syringe 100 unit syringe Apidra Humalog 75/25 Syringe with Ultra- Fine Short Needle (8mm 5/16 31G) Novolog 70/30 30 unit syringe 50 unit syringe 100 unit syringe 30 unit syringe with ½ unit markings Humulin R Novulin R Syringe with Micro-fine IV Needle (12.7mm 1/2 28G) Humulin R U500* 30 unit syringe 50 unit syringe 100 unit syringe *Used with severe insulin resistance Humulin N (NPH) Humulin 70/30 (NPH/Regular) Novolin N (NPH) Novulin 70/30 (NPH/Regular) Lantus Levemir Other Syringe Insulin Prefilled Pens Insulin Pen Device/Cartridge Insulin Pen Needles Humalog Kwik Pen Luxura Device BD Ultrafine Humalog Original Pen Memoir Device Nano 4mm (5/32 x 32G) Novolog Flex Pen Humalog Cartridge Mini 5mm (3/16 x 31G) Apidra SoloStar Short 8mm (5/16 x 31G) NovoPen 3 Device Orig. 12.7mm (1/2 x 29G) Humalog 75/25 Kwik Pen NovoPen Jr. Device Humalog 75/25 Original Pen Novolog Cartridge Novofine Novolog 70/30 Flex Pen 31G 6mm Opticlik Device 30G 8mm Levemir Flex Pen Apidra Cartridge 30G 8mm Autocover Lantus SoloStar Lantus Cartridge (Autocover hides the needle from view) Other Injectables Symlin 60 mcg Symlin 120 mcg Byetta 5 mcg Byetta10 mcg Vicotza Pen 6 mg/ml 1
2 Meter and Related Supplies *Check only those items that require a new prescription for refills * Lancet Devices Lancets B-D B-D Ultra Fine 33G, 30G * One Touch Ultra Soft One Touch Ultra Soft * Ascensia Microlet (Contour) Ascensia Microlet * Abbott Freestyle Free Style * *(Generic to all devices EXCEPT Accu-Chek) Roche Accu-Chek Multiclix Device Accu-Chek Multiclix Drum (6 lancets/ drum) Use Only with Accu-Chek Multiclix Device Roche Accu-Chek Soft Clix Device Accu-ChekSoft Clix Use Only with Accu-Chek Soft Clix Device Other Other Blood Glucose Meters Blood Glucose Test Strips *Dispensed in a box of 50 strips Roche-Accu-Chek Roche-Accu-Chek Accu-Chek Aviva Accu-Chek Aviva * Accu-Chek Compact Plus Accu-Chek Compact Plus (17 strips per drum) Bayer Bayer Digit (Incentives for testing and Nintendo game included) Contour * Contour USB (USB connects directly to computer) Contour Contour TS (simple with LARGE display mail order only) Breeze 2 ( colors: tinked pink, purple fusion,classic blue) Breeze 2 disc (ten strips per disk- 100 per box) Abbott Abbott Freestyle Lite * Freestyle Lite * Freestyle Freedom Lite (simpler with larger display) Freestyle Flash Freestyle* Precision Xtra Precision Xtra* Precision Xtra Ketone Strips (10 strips per box) LifeScan One Touch Ultra 2 One Touch Ultra * One Touch Ultra Mini (small and simple) One Touch UltraSmart (MDI and testing: graphs and stats on meter screen) One Touch Ultra Link (works with Medtronic Insulin Pump) One Touch Ping Meter (works with the One Touch Ping Insulin Pump) Other 2 Other
3 Miscellaneous Control Solution for meter Glucose tablets bottle of 100 Glucose tablets carry roll of 10 Glucose gel GLUCAGON EMERGENCY KIT Urine Ketostix Alcohol pads Application for Juvenile Diabetes Research Foundation Application for American Diabetes Association Application for Diabetes Camp Application for ID Bracelet Oral Medication Refills 3
4 Insulin Pump Supplies Animas One Touch Ping Insulin Pump (90 Degree Insertion Angle Infusion Set with Inserter) Inset (6mm) Pink Inset (9mm) Blue Inset 30 (13mm) Green Gray (Infusion Set without Inserter) Comfort (17mm) Comfort (13mm) (Steel Needle Infusion Set) Contact Detach Infusion Set (6mm) Contact Detach Infusion Set (8mm) Insulet Omni Pod Insulin Pump (Tubless infusion Set) Pod PDM (Personal Data Manager) Medtronic Insulin Pumps (90 Degree Insertion Angle Infusino Set) Quick Set (6mm) 18 tubing Quick Set (9mm) Quick Serter Insertion Device (90 Degree Insertion Ange Infusion Set with Inserter) Mio Infusion Set Pink 18 tubing Clear Blue (20-45 Degree Insertion Angle Infusion Set) Silhouette 13mm 18 tubing (only available with 13mm) Silhouette 17mm Silhouette 13mm (no tubing) 4
5 Insulin Pump Supplies Medtronic Insulin Pumps (Steel Needle Infusion Set) Miscellaneous Insulin Pump Supplies Barrier Wipe (IV prep, Skin Prep, Bard) Sure T (6mm) 18 tubing Transparent Dressing (IV 3000) Adhesive Solution (Mastisol) Sure T (8mm) Adhesive Remover (Unisolve Wipes) Local Anesthetic (Emla cream, Elamax cream) Sure T (10mm) (6mm/27 gauge needle) Sure T Soft set (6mm) 24 tubing Soft Set (8mm) 42 tubing Soft-serter Insertion Device Accu-chek Spirit Insulin Pump (90 degree Insertion Angle Infusion Set) Accu-chek Flex Link Plus (6mm) Accu-chek Flex Link Plus (8mm) Accu-chek Flex Link Plus (10mm) Link Assist Plus Insertion Device 16 tubing 28 tubing 39 tubing (20-45 Degree Insertion Angle Infusion Set) Accu-chek Tender (13mm) Accu-chek Tender (17mm) (Steel Needle infusion Set) Accu-chek Rapid D (6mm) Accu-chek Rapid D (8mm) Accu-chek Rapid D (10mm) 24 tubing 24 tubing 5
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Frequently Used PINs for Billing Purposes November 2018
Diabetic Test Strips PIN Description 97799824 ACCU-CHEK ADVANTAGE STRIPS (100) 97799823 ACCU-CHEK ADVANTAGE STRIPS (50) 97799814 ACCU-CHEK AVIVA TEST STRIPS (100) 97799815 ACCU-CHEK AVIVA TEST STRIPS (50)
ACCU-CHEK AVIVA TEST STRIPS ACCU-CHEK COMPACT TEST STRIP ACCU-CHEK COMPACT TEST STRIP ACCU-CHEK FASTCLIX 6 LANCET DRUM (102S)
Appendix H Product Identification Number (PIN) DIN Code Brand Name Canadian Product Name 00999997 99 EXTEMPOR. CPDS - NFLD- 00977062 ACCU-CHEK ADVANTAGE TEST ACCU-CHEK ADVANTAGE TEST 00977124 ACCU-CHEK
Inpatient Glycemic Management:
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PIN List 909661 ABDOMINAL PAD 907622 ACCU-CHEK AVIVA BLOOD GLUCOSE TEST STRIPS 977999 ACCU-CHEK COMPACT BLOOD GLUCOSE TEST STRIPS 977993 ACCU-CHEK EASY BLOOD GLUCOSE TEST STRIPS 900418 ACCU-CHEK MOBILE
DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
Metformin DIABETES (1 of 5) Glucophage Glucophage XR ER $7 (500mg) $7 (500mg) $5 $5 500mg, 750mg only 500mg, 750mg only Sulfonylurea/Combinations Amaryl Glucotrol glimepiride glipizide $5 $5 Glucotrol
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