| | A | B |
|---|
| 1 | | |
|---|
| 2 | Product Description | Allowable Amount |
|---|
| 3 | | |
|---|
| 4 | Adhesive Liquids | 4 oz per month |
|---|
| 5 | Adhesive Removers | 8 oz per 3 months |
|---|
| 6 | Bedside Drainage Bottle | 1 each per 3 months |
|---|
| 7 | Bedside Drainage Bag | 2 per month |
|---|
| 8 | Belt, Ostomy | 1 each per month |
|---|
| 9 | Cleanser for appliance/16 ounces | 1 per month |
|---|
| 10 | Convex Inserts | 10 each per month |
|---|
| 11 | Deodorant Tab's, for use in pouch | based on physician order |
|---|
| 12 | Deodorant, liquid, for use in pouch | based on physician order |
|---|
| 13 | Faceplate, reusable plastic or rubber | 3 ea. Per 6 months |
|---|
| 14 | Gauze, non-sterile for use with continent stoma only | 60 each per month |
|---|
| 15 | Irrigation Bags | 1 each per 3 months |
|---|
| 16 | Irrigation Cone/ Catheter | 1 each per 3 months |
|---|
| 17 | Irrigation Lubricant | 4 oz. per month |
|---|
| 18 | Irrigation Sleeve | 4 ea. per month |
|---|
| 19 | Lubricant per ounce | 4 oz. per month |
|---|
| 20 | Ostomy Ring | 10 per month |
|---|
| 21 | Paste, Ostomy | 4 oz. per month |
|---|
| 22 | Pouch, Closed-End | 60 each per month |
|---|
| 23 | Pouch, Drainable or Urinary, for use on faceplate, rubber | reuseable for week to months |
|---|
| 24 | Pouch, Drainable or Urinary, for use on faceplate, plastic | 10 each per month |
|---|
| 25 | Pouch, Drainable or urinary with faceplate attached plastic or rubber | reuseable for week to months |
|---|
| 26 | Pouch, Drainable, one piece or two piece | 20 per month |
|---|
| 27 | Pouch, Drainable, extended wear, one piece or two piece | based on physician order |
|---|
| 28 | Pouch, Urostomy, one piece or two piece | 20 each per month |
|---|
| 29 | Pouch, Urostomy, extended wear, one piece or two piece | based on physician order |
|---|
| 30 | Powder, Ostomy | 10 oz. per 6 months |
|---|
| 31 | Skin Barrier, Extended Wear with or without convex with Flange | based on physician order |
|---|
| 32 | Skin Barrier with Flange | 20 each per month |
|---|
| 33 | Skin Barrier,Liquid Spray, Brush, etc. | 2 oz. per month |
|---|
| 34 | Skin Barrier Wipes, 50/box | 3 bxs per 6 months |
|---|
| 35 | Skin Barrier, Solid 4x4, 6x6, 8x8 | 20 per month |
|---|
| 36 | Skin Barrier, Solid w/built in convexity | based on physician order |
|---|
| 37 | Stoma Caps (plug for continent stoma) | 31 each per month |
|---|
| 38 | Tape (1" x 10 yards ONLY) - 2 rolls or 2x10-1 roll | 1 roll per month |
|---|
