Drug Benefit List

94:00 DEVICES

94:00.00 DEVICES

HYDROXYPROPYLCELLULOSE

5MG Ophthalmic Insert

00889970     LACRISERT LAMELLE     FRS     *

NEEDLE (NON-INSULIN)

Needle

99400528     NEEDLES (NON-INSULIN) DISPOSABLE     

SPACER DEVICE

Device

99400496     ACE ADAPTORS     AUC

99400497     ACE KIT     AUC

99400495     ACE MDI SPACER     AUC

99400500     ACE SPACER WITH LARGE MASK     AUC

99400499     ACE SPACER WITH MEDIUM MASK     AUC

99400498     ACE SPACER WITH SMALL MASK     AUC

96899994     AEROCHAMBER MAX VHC WITH ADULT MASK     TRU

96899995     AEROCHAMBER MAX VHC WITH CHILD MASK     TRU

96899996     AEROCHAMBER MAX VHC WITH INFANT MASK     TRU

96899997     AEROCHAMBER MAX VHC WITH MOUTHPIECE     TRU

99400487     AEROCHAMBER PLUS VHC ADULT     TRU

99400488     AEROCHAMBER PLUS VHC WITH ADULT MASK     TRU

99400490     AEROCHAMBER PLUS VHC WITH INFANT MASK     TRU

99400489     AEROCHAMBER PLUS VHC WITH PEDIATRIC MASK     TRU

99400507     E-Z SPACER     WEP

99400511     E-Z SPACER (MASK ONLY)     WEP

99400508     E-Z SPACER WITH SMALL MASK     WEP

99400501     OPTICHAMBER     AUC

99400504     OPTICHAMBER LARGE MASK     AUC

99400503     OPTICHAMBER MEDIUM MASK     AUC

99400502     OPTICHAMBER SMALL MASK     AUC

99400505     OPTIHALER     AUC

99400506     OPTIVENT IN-LINE MDI SPACER     AUC

99400787     POCKET CHAMBER     MCA

99400791     POCKET CHAMBER WITH ADULT MASK     MCA

99400788     POCKET CHAMBER WITH INFANT MASK     MCA

99400790     POCKET CHAMBER WITH MEDIUM MASK     MCA

99400789     POCKET CHAMBER WITH SMALL MASK     MCA

99400512     RONDO INHALATION CHAMBER     KIN

99400516     RONDO INHALATION CHAMBER-CHILD MASK     KIN

99400515     RONDO INHALATION CHAMBER-INFANT MASK     KIN

99400514     RONDO INHALATION CHAMBER-NEONATAL MASK     KIN

99400513     RONDO INHALATION CHAMBER-UNIVERSAL MASK     KIN

99400517     SPACE CHAMBER     AUC

99400521     SPACE CHAMBER ADULT LARGE MASK     AUC

99400520     SPACE CHAMBER ADULT REGULAR MASK     AUC

99400518     SPACE CHAMBER INFANT MASK     AUC

99400519     SPACE CHAMBER PEDIATRIC MASK     AUC

99400491     VENT 170 SPACER     NDE

99400493     VENT 170 SPACER AND MASK     NDE

99400492     VENT 170 SPACER DELUXE     NDE

99400494     VENTAHALER     GSK

Kit

99400777     ACE LARGE MASK ACCESSARY KIT     AUC

99400776     ACE MEDIUM MASK ACCESSARY KIT     AUC

99400775     ACE SMALL MASK ACCESSARY KIT     AUC

SYRINGE & NEEDLE (NON-INSULIN)

Syringe & Needle

99400534     NON-INSULIN 1CC     

99400536     NON-INSULIN 3CC     

99400537     NON-INSULIN 5CC     

99400538     NON-INSULIN 10CC     

SYRINGE (NON-INSULIN)

Syringe

99400530     LUER LOCK (DISP) 3CC     

99400535     LUER LOCK (DISP) 5CC     

99400539     LUER LOCK (DISP) 10CC     

99400548     LUER LOCK (DISP) 20CC     

99400823     LUER LOCK (DISP) 30CC     BTD

99400549     LUER LOCK (DISP) 60CC     

99400529     NON-INSULIN (DISP) 1CC     

99400531     NON-INSULIN (DISP) 3CC     

99400532     NON-INSULIN (DISP) 5CC     

99400533     NON-INSULIN (DISP) 10CC     

VENTODISK DISKHALER

Device

00905739     VENTODISK DISKHALER     GSK

94:01.00 DEVICES (DIABETIC)

GLUCOMETER

Device

99401060     ACCU-CHEK COMPACT     ROD

99401010     ACCUSOFT     ROD

99401046     ACCUTREND GC     ROD

97799934     ASCENSIA BREEZE     BAY

97799879     ASCENSIA CONTOUR     BAY

99401012     ASCENSIA ELITE     BAY

99401013     ASCENSIA ELITE XL     BAY

99401065     BD LATITUDE     BTD

99401011     DEX     BAY

99401061     FREESTYLE     THS

97799819     FREESTYLE MINI     THS

99401070     INDUO     LIF

99401006     ONE TOUCH FASTTAKE     JAJ

99401007     ONE TOUCH SURESTEP     AUC

99401058     ONE TOUCH ULTRA     JAJ

99401069     ONE TOUCH ULTRASMART     LIF

99401001     PRECISION QID     AUC

99401004     PRECISION QID COLOR W/O ELECTRODES BLUE     AUC

99401003     PRECISION QID COLOR W/O ELECTRODES RED     AUC

99401005     PRECISION QID PEN     AUC

99401002     PRECISION QID W/O ELECTRODES     AUC

99401059     PRECISION XTRA     AUC

99401064     PRESTIGE SMART SYSTEM     THR

GLUCOMETER BATTERIES

Device

99401030     BATTERIES - 1.5 VOLT     

99401031     BATTERIES - 3 VOLT     

99401029     BATTERIES - AAA     

99401056     BATTERIES - LITHIUM     

99401032     BATTERIES - SIZE J 6V     

INSULIN PUMP SUPPLIES

Device

99401049     ADAPTOR     AUC

99401052     ADHESIVE PAD WITH COTTON     AUC

99401053     ADHESIVE PAD WITHOUT COTTON     AUC

99401050     INFUSION SETS     AUC

99401038     INSULIN PUMP BATTERY     AUC

99401047     INSULIN PUMP CARTRIDGES     AUC

99401048     PISTON ROD     AUC

99401051     TUBING     AUC

ISOPROPYL ALCOHOL

70% Swab

00480452     ALCOHOL PREP SWAB     PFD

02247809     ALCOHOL SWAB     TIP

02240759     B-D ALCOHOL SWAB     BTD

99438102     MONOJECT ALCOHOL WIPES     SHM

00795232     WEBCOL ALCOHOL PREP     JAJ

LANCET

Lancet

97799817     ACCU-CHEK MULTICLIX     ROD

99401068     BD LATITUDE     BTD

00900834     FINGERSTIX     BAY

00995965     FINGERSTIX     BAY

00977839     FREESTYLE     THS     *

99401063     FREESTYLE     THS

00977853     LIFESCAN FINE POINT     JAJ

00901555     LIFESCAN REGULAR     JAJ

00906190     MEDISENSE     AUC

00906239     MICROLET     BAY

00977493     MICROLET     BAY

00977543     MONOLET ORIGINAL     SHM

99401055     MONOLET THIN     SHM

97799810     MPD THIN (100)     MPD

97799811     MPD THIN (200)     MPD

97799807     MPD ULTRA THIN (100)     MPD

97799808     MPD ULTRA THIN (200)     MPD

00901359     ONE TOUCH ULTRA SOFT     JAJ

00905917     SOFT TOUCH     ROD

00977952     SOFT TOUCH     ROD

99493957     SOFT TOUCH     ROD

00000165     SOFTCLIX     BOE

00902144     SOFTCLIX SELECT     BOE

00977373     SOFTCLIX SELECT     BOE

00977659     ULTRA-FINE II     BTD

00900141     ULTRA-FINE II     BTD

00977051     UNILET COMFORT TOUCH     BAY

00977896     UNILET COMFORT TOUCH     BAY

00984167     UNILET COMFORT TOUCH     BAY

LANCING DEVICE

Device

99401025     B-D LANCET     BTD

99401020     GLUCOLET     BAY

99401021     GLUCOLET 2     BAY

99401014     MEDISENSE TLC     AUC

99401017     MICROLET     BAY

99401015     MONOJECTOR     SHM

99401016     PENLET PLUS     JAJ

99401022     REGULAR ENDCAPS FOR GLUCOLET     BAY

99401018     REGULAR ENDCAPS FOR MICROLET     BAY

99401024     SOFTTOUCH     ROD

99401023     SUPER ENDCAPS FOR GLUCOLET     BAY

99401019     SUPER ENDCAPS FOR MICROLET     BAY

MAGNIFIER

Magnifier

99400550     SYRINGE SCALE MAGNIFIER     

NEEDLE

Insulin Injection Device Needles

00977756     NOVOFINE     NOO

Needle

00908452     B-D PEN     BTD

22G Needle

00977616     B-D DISPOSABLE 1 INCH 5155     BTD

00977624     B-D DISPOSABLE 1½ INCH 5156     BTD

25G Needle

00977071     B-D DISPOSABLE 5/8 INCH 5122     BTD

00977063     B-D DISPOSABLE 1½ INCH 5127     BTD

27G Needle

00977012     B-D DISPOSABLE ½ INCH 5109     BTD

28G Needle

99221028     NOVOFINE INSULIN PEN 28G     NOO

29G Needle

00977101     B-D ULTRA-FINE PEN     BTD

00900513     OWEN MUMFORD UNIFINE PENTIPS 1/2 INCH     AUC

00908185     ULTRAFINE PEN ULTRA-FINE 29G     BTD

30G Needle

00921114     NOVOFINE     NOO

00908169     NOVOFINE 30G     NOO

99117796     NOVOFINE INSULIN PEN 30G     NOO

31G Needle

00977011     B-D ULTRA-FINE PEN III     BTD

00900511     OWEN MUMFORD UNIFINE PENTIPS 1/4 INCH     AUC

00900512     OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH     AUC

32G Needle

97799821     NOVOFINE 32G 6MM     NOO

SHARPS CONTAINER

Device

99401026     B-D SHARPS CONTAINER 1.4L     BTD

99401027     B-D SHARPS CONTAINER 3.1L     BTD

99401028     B-D SHARPS CONTAINER 3.8L     SHM

SYRINGE

0.3CC Syringe

00977961     B-D MICRO-FINE     BTD

00977977     B-D ULTRA-FINE / ULTRA-FINE II     BTD

00920169     MICRO-FINE     BTD

00977951     MONOJECT     SHM

99254011     MONOJECT DISP 3/10CC (100)     SHM

99253047     MONOJECT DISP 3/10CC (30)     SHM

00920053     SYRN MONOJECT     SHM

00900506     ULTICARE 29G     AUC

00964018     ULTICARE 29G     AUC

00900503     ULTICARE 30G     AUC

00964174     ULTICARE 30G     AUC

00920193     ULTRA-FINE     BTD

0.5CC Syringe

00977985     B-D ULTRA-FINE II     BTD

00920177     MICRO-FINE     BTD

00920355     MONOJECT     SHM

99432799     MONOJECT (100)     SHM

99432633     MONOJECT (30)     SHM

00900505     ULTICARE 29G     AUC

00963941     ULTICARE 29G     AUC

00900502     ULTICARE 30G     AUC

00964115     ULTICARE 30G     AUC

00920207     ULTRA-FINE     BTD

1CC Syringe

99328369     B-D ULTRA-FINE     BTD

00920045     MONOJECT     SHM     *

99433383     MONOJECT (100)     SHM

99432914     MONOJECT (30)     SHM

00900504     ULTICARE 29G     AUC

00963895     ULTICARE 29G     AUC

00900501     ULTICARE 30G     AUC

00964069     ULTICARE 30G     AUC

00920215     ULTRA-FINE     BTD

00909238     ULTRA-FINE II 30G     BTD

SYRINGE & NEEDLE

0.3CC Syringe and Needle

99328419     B-D INSULIN 1/3CC 29G UF 1     BTD

99639286     B-D MICRO-FINE 1/3CC     BTD

00909092     SYRN INS U-II 3/10CC 30G     BTD

00905690     SYRN INSULIN MICRO 3/10CC 28G     BTD

00906786     SYRN INSULIN ULTRA 3/10CC 29G     BTD

0.5CC Syringe and Needle

99328377     B-D INSULIN 50U 29G     BTD

99221044     B-D MICRO-FINE INSULIN 50U     BTD

00983004     INSULIN LO DOSE MICRO 28G     BTD

00909084     SYRN INSULIN U-II 30G     BTD

00906727     SYRN INSULIN ULTRA 29G     BTD

1CC Syringe and Needle

99262295     B-D INJECT-EASE WITH MICRO-FINE     BTD

99767467     B-D MICRO-FINE INSULIN 100U     BTD

00901911     B-D MICRO-FINE INSULIN 28G     BTD

00906816     SYRN INSULIN ULTRA 29G     BTD

SYRINGE CASE

Syringe Case

99400552     MYHEALTH SYRINGE CASE-7     AUC

99400551     MYHEALTH SYRINGE CASE-SINGLE     AUC