| Effective 01/01/2003 |
Quantity Limitations |
BLN Assignment? |
| Adhesives and Adhesive Removers |
|
| Adhesive (Cement), Liquid Or Equal, Any Type, Per Oz (A4364) |
4 oz per month |
Assignment on Formulary Products Only |
| Adhesive Remover Or Solvent (For Tape, Cement Or Other Adhesive), Per Ounce (A4455) |
8 oz per 3 months
16 oz per 6 months |
Assignment on Formulary Products Only |
| Adhesive Or Non-Adhesive; Disk Or Foam Pad (A5126) |
20 per month |
Assignment on Formulary Products Only |
| Pouches |
|
| Ostomy Pouch, Closed (A5051, A5052, A5053, A5054) |
Up to 60 |
needs documentation |
| Ostomy Pouch, Drainable - 2 piece (A5063) |
Up to 20 |
Assignment on Formulary Products Only |
| Ostomy Pouch, Drainable - 1 piece (A5062, K0567, K0568) |
Up to 20 |
Assignment on Formulary Products Only |
| Ostomy Pouch, Urinary, For Use On Faceplate, Plastic, Each (A4381) |
10 per month |
Assignment on Formulary Products Only |
| Ostomy Pouch, Urinary - 2 piece (A5073) |
20 per month |
Assignment on Formulary Products Only |
| Ostomy Pouch, Urinary - 1 piece (A5071, A5072) |
20 per month |
Assignment on Formulary Products Only |
| Wafers/Flanges |
|
Assignment on Formulary Products Only |
| Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion) (K0570, K0571, A4414, A4415) |
20 per month |
Assignment on Formulary Products Only |
| Skin Barrier; Solid, 4"x4", 6"x6", or 8"x8" (A4362, A5121, A5122) |
20 per month |
Assignment on Formulary Products Only |
| Skin Barriers |
|
| Ostomy Skin Barrier, Liquid (Spray, Brush, Etc), Per Oz (A4369) |
2 oz per month |
Assignment on Formulary Products Only |
| Ostomy Skin Barrier, Paste, Per Ounce (K0561, K0562, A4405, A4406) |
4 oz per month |
No Assignment |
| Ostomy Skin Barrier, Powder, Per Oz (A4371) |
5 oz per 3 months
10 oz per 6 months |
Assignment on Formulary Products Only |
| Other |
|
|
| Appliance Cleaner, Incontinence And Ostomy Appliances, Per 16 Oz. (A5131) |
16 oz per month |
Assignment on Formulary Products Only |
| Bedside Drainage Bag, Day Or Night, With Or Without Anti-Reflux Device, With or Without Tube, Each (A4357) |
2 ea per month |
Assignment on Formulary Products Only |
| Bedside Drainage Bottle With Or Without Tubing, Rigid Or Expandable, Each (A5102) |
1 ea every 3 months
2 ea every 6 months |
No Assignment |
| Belt, Ostomy (A4367) |
1 ea every 3 months
2 ea every 6 months |
No Assignment |
| Belt, Ostomy (A4367) |
1 ea per month |
Assignment on Formulary Products Only |
| Continent Device; Catheter For Continent Stoma (A5082) |
1 per month |
Assignment on Formulary Products Only |
| Continent Device; Plug For Continent Stoma (A5081) |
31 per month |
Assignment on Formulary Products Only |
| Gauze, Non-Impregnated, Non-Sterile, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing (A6216) |
60 per month |
Assignment on Formulary Products Only |
| Irrigation Supply; Sleeve, Each (A4397) |
4 per month |
Assignment on Formulary Products Only |
| Lubricant, Per Ounce (A4402) |
4 oz per month |
Assignment on Formulary Products Only |
| Ostomy Accessory; Convex Insert (A5093) |
10 per month |
Assignment on Formulary Products Only |
| Ostomy Faceplate, Each (A4361) |
3 per 6 months |
Assignment on Formulary Products Only |
| Ostomy Irrigation Supply; Bag, Each (A4398) |
2 per 6 months |
Assignment on Formulary Products Only |
| Ostomy Ring, Each (A4404) |
10 per month |
Assignment on Formulary Products Only |
| Stoma Cap (A5055) |
31 per month |
Assignment on Formulary Products Only |
| Tape, per 18 Square Inches (A4450, A4452) |
Varies by region.
Approx. 2 rolls of 1" tape per month |
No Assignment |
NON-COVERED ITEMS Pouch covers
Liquid barriers and wipes in the same month
Stoma caps, plugs, or gauze, not all three
A urinary bag or bottle for the night, not both
Quantities in excess of the guidelines unless accompanied by a doctor's letter explaining the necessity for additional supplies.
|
*Please note that Medicare will pay for a
3-month supply of Ostomy products at one time.
|
Better living Now, Inc. assumes no responsibility in regards to Medicare coverage and has interpreted Medicare Rules for the benefit and understanding of the patient. For detailed information regarding Medicare coverage please visit their web site at: www.cms.gov. For Coverage Information for Ostomy Supplies go to: http://www.tricenturion.com/content/dmerc/0602_16_10_ostomy_supplies.cfm
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