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
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