Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 1 of 5 PageID #: 1535
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 1 of 5 PageID #: 1535
`
`
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`
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`EXHIBIT A
`
`EXHIBIT A
`
`
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 1 of 5 PageID #: 1535
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`
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`
`
`EXHIBIT A
`
`EXHIBIT A
`
`
`
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 2 of 5 PageID #: 1536
`Case 1:18-cv-00303—RGAUFQnggiggit 65-1 Filed 11/14/18 Page 2 of 5 PagelD #: 1536
`Baxter
`
`Dexmedetomidine Hydrochloride 4 mcg/mL in 0.9% Sodium
`
`Chloride injection (200 meg/50 mL). Liquid Premix.
`
`I
`
`SKU: 2G3496
`
`
`
`,
`;_»_.2_-_--,_----- _
`
`_
`
`Product Characteristics
`
`Trademark:
`
`Container Type:
`Volume:
`
`Dosage Form:
`Diluent:
`
`Strength:
`
`Concentration:
`Shelf Life from manufacture:
`
`Contains Preservative:
`
`Storage Recommendations:
`
`Dexmedetomidine Hydrochloride in 0.9% Sodium Chloride injection, 200
`meg/5O mL (4 mcg/mL) in GALAXY Plastic Container. Liquid Premix. NDC
`0338-9555-24. Please referto full Prescribing Information
`
`Galaxy is a trademark of Baxter International Inc., or
`its subsidiaries.
`
`GALAXY
`50 ML
`
`Liquid
`Sodium Chloride
`
`200 meg/50 mL
`
`4 mcg/mL
`21 months
`
`No
`
`Store at 20° to 25°C (68° to 77°F)[See USP Controlled
`Room Temperature]. Discard unused portion.
`
`Rx Only:
`
`Yes
`
`Package Insert Link:
`
`baxterpi.comlpi-pdf/Dexme(..)
`
`Carton
`
`Length:
`Width:
`
`Height:
`Volume:
`
`Weight:
`Pack Factor:
`
`11.94 IN
`5.88 IN
`
`2.5 IN
`0.1 FC
`
`3.33 LB
`24
`
`Reimbursement Information
`NDC Outer
`
`HCPCS Code
`
`J3490
`A4216
`
`Medication Delivery
`Reimbursement Hotline
`
`Information Source: CMS
`
`0338955524
`
`HCPCS Descriptor
`
`Unclassified Drugs
`Sterile Water, Saline and/or Dextrose, Diluent/Flush,
`10mL
`
`888-338-0001
`
`Disclaimer: The coverage, coding, and payment information included in this guide has been compiled from various
`resources for informational use as a tool to assist providers with reimbursement issues. This information is current as
`of 3/31/2008; howeverthis information is subject to change and should not be construed as legal advice. Providers
`should exercise independent clinicaljudgment when selecting codes and submitting claims to accurately reflect
`services rendered to individual patients. Baxter Healthcare Corporation does not guarantee success in obtaining
`insurance payments. Providers are encouraged to contact third-party payors for specific information on their
`coverage, coding, and payment policies.
`
`
`
`
`
`
`Orderin .
`i -
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 3 of 5 PageID #: 1537
`af 5 PageID #: 1537
`Baxter Produc oe':
`
`UPN/GTIN CS Unit:
`50303389555242
`
`UPN/GTIN EA Unit:
`
`National Drug Code:
`Unit of Measure:
`
`00303389555247
`
`0338955524
`CA
`
`© 2018 Baxter. All rights reserved.
`
`
`
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 4 of 5 PageID #: 1538
`Case 1:18-cv-00303—RGAUFQnggiggit 65-1 Filed 11/14/18 Page 4 of 5 PagelD #: 1538
`Baxter
`
`Dexmedetomidine Hydrochloride 4 mcg/mL in 0.9% Sodium
`
`Chloride injection (4oo mcg/loo mL). Liquid Premix.
`
`
`
`:f‘f‘.
`
`I
`
`Product Characteristics
`
`Trademark:
`
`Container Type:
`Volume:
`
`Dosage Form:
`Diluent:
`
`Strength:
`
`Concentration:
`Shelf Life from manufacture:
`
`Contains Preservative:
`
`Storage Recommendations:
`
`SKU: 2G3497
`
`Dexmedetomidine Hydrochloride in 0.9% Sodium Chloride injection, 400
`mcg/1OO mL (4 mcg/mL) in GALAXY Plastic Container. Liquid Premix.
`NDC 0338-9557-12. Please referto full Prescribing Information
`
`Galaxy is a trademark of Baxter International Inc., or
`its subsidiaries.
`
`GALAXY
`100 ML
`
`Liquid
`Sodium Chloride
`
`400 meg/100 mL
`
`4 mcg/mL
`21 months
`
`No
`
`Store at 20° to 25°C (68° to 77°F)[See USP Controlled
`Room Temperature]. Discard unused portion.
`
`Rx Only:
`
`Yes
`
`Package Insert Link:
`
`baxterpi.comlpi-pdf/Dexme(..)
`
`Carton
`
`Length:
`Width:
`
`Height:
`Volume:
`
`Weight:
`Pack Factor:
`
`11.94 IN
`5.88 IN
`
`2.5 IN
`0.1 FC
`
`3.33 LB
`12
`
`Reimbursement Information
`NDC Outer
`
`HCPCS Code
`
`J3490
`A4216
`
`Medication Delivery
`Reimbursement Hotline
`
`Information Source: CMS
`
`0338955712
`
`HCPCS Descriptor
`
`Unclassified Drugs
`Sterile Water, 0.9% Sodium Chloride and/or Dextrose
`DiluentlFlush,10mL
`
`888-338-0001
`
`Disclaimer: The coverage, coding, and payment information included in this guide has been compiled from various
`resources for informational use as a tool to assist providers with reimbursement issues. This information is current as
`of 3/31/2008; howeverthis information is subject to change and should not be construed as legal advice. Providers
`should exercise independent clinicaljudgment when selecting codes and submitting claims to accurately reflect
`services rendered to individual patients. Baxter Healthcare Corporation does not guarantee success in obtaining
`insurance payments. Providers are encouraged to contact third-party payors for specific information on their
`coverage, coding, and payment policies.
`
`
`
`
`
`
`Orderin .
`i -
`Case 1:18-cv-00303-RGA Document 65-1 Filed 11/14/18 Page 5 of 5 PageID #: 1539
`7 af 5 PageID #: 1539
`Baxter Produc oe':
`
`UPN/GTIN CS Unit:
`50303389557123
`
`UPN/GTIN EA Unit:
`
`National Drug Code:
`Unit of Measure:
`
`00303389557128
`
`0338955712
`CA
`
`© 2018 Baxter. All rights reserved.
`
`
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