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x

x

Evelopes Bottles Evelopes Dressing Evelopes Dressing

x x x x x x

x x x x x x

Evelopes Bottles

x x

x x

Roll Roll

x x

x x

Pads Pads Pads Pads Napkins/ Tampons

x x x x xCI

x x x R R

Sponges Sponges Sponges

x x x

x x x

Pumps

x

x

Condoms Condoms Gm Gm Gm Suppository

x x x x x x

x x x x x x

Strips

x

x

Strips Strips Dispenser Strips Strips/Tabs Lancets Each Each Tubes

x x x x x x x x x PA x x

x x x x x x x x x PA x x

Cushion Gms

Gms Each

x x

x x

Syringe Syringe

x x

x x

Containers Discs

x x x

x x x

Notes

Excludes Common household adhesive strips Restricted to use in postpartum bleeding/ drainage hermorrhoidal bleeding and wound bledding/ drainage

MAIC

ONE TOUCH PREFERRED

Patient age over 5 years old only

Mechanical or Electrical, See DME coverage

Description Therapeutic Class

Medical Supplies ALCOHOL, ISOPROPYL BANDAGES DRESSING-NON MEDICATED ADAPTIC NU-GAUZE KENDALL OP-SITE PETROLATUM GAUZE VIGILON DRESSING-MEDICATED BISMUTH TRIBROMOPHENATE NU-GAUZE IODOFORM GAUZE KLING KERLIX PAD TYPE ABDOMINAL EYE GAUZE ADHESIVE SANITARY NAPKINS/ TAMPON

CHP/HEALTHY FAMILIES MEDICAL SUPPLY LIST

Form

Mcal

CHP

SPONGE GAUZE COVER DRESSING TOPPER GAUZE SUPER SPONGES BREAST PUMP BULB TYPE CONDOMS MALE FEMALE CONTRACEPTIVE CREAM CONTRACEPTIVE FOAM CONTRACEPTIVE JELLY CONTRACEPTIVE SUPPOSITORY DIABETIC TESTS GLUCOSE BOLLD TEST STRIPS GLUCOSE URINE TEST STRIPS CLINISTIX DIASTIX TEST TAPE GLUCOSE-KETONES, URINE TEST KETONES TESTS LANCETS DIAPHRAGM KIT FEEDING TUBE INCONTINENCE SUPPLIES INVALID CUSHION KARAYA GUM POWDER LUBRICATING JELLY SURGILUBE NEBULIZER, BULB TYPE NEEDLES, HYPODERMIC DISPOSABLE REUSABLE OSTOMY SUPPLIES ADHESIVE (non tape) ADHESIVE DISCS ADHESIVE REMOVER

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