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Therapeutic Class

CHP/HEALTHY FAMILIES MEDICAL SUPPLY LIST

Description

BAGS BARD GREER HOLLISTER KAYS NUHOPE SHIELD SQUIBB UNITED IRRIGATION KITS IRRIGATION SLEEVES SKIN PROTECTANTS BARRIER FILMS KARAYA WAFERS PERISTOMAL COVERINGS STOMAHESIVE PASTE TINCTURE OF BENZOIN SUSPENSORY SWABSTICK, SATURATED

SYRINGE, BULB TYPE BULB SYRINGE CATHETER TIP GLASS EAR AND ULCER SYRINGE INFANT NASAL ASPIRATOR SYRINGE WITH NEEDLE DISPOSABLE SYRINGE WITH NEEDLE THERMOMETER ORAL BASAL URINARY DRAINAGE/ IRRIGATION SUPPLIES BOTTLES, EXPANDABLE CATHETERS URINARY DRAINAGE COLLECTION UNITS VAPORIZER UNLISTED MEDICAL SUPPLIES

Form

Bags Bags Bags Bags Bags Bags

Each Each

Wafers

Each Each

Syringe Syringe Aspirator

Thermometer Thermometer

Each

Each Each

Mcal

CHP

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

R

Notes

Restricted to catheter cleansing at exit site during dressing changes and IV starts

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

PA

PA

MAIC- Mechanical or Electrical, See DME Coverage

KEY: MAIC- Maximum Allowed Ingredient Cost DME- Durable Medical Equipment

2

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