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