X

Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply.

Alcohol, rubbing

X

Over-the-counter supply.

Alcohol, swabs (diabetic)

X

Over-the-counter supply not covered, unless RX provided at time of dispensing.

Alcohol, swabs

X

Covered only when received with IV therapy or central line kits/supplies.

Ana Kit Epinephrine

X

A self-injection kit used by patients highly allergic to bee stings.

Arm Sling

X

Dispensed as part of office visit.

Attends (Diapers)

X

Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan

Bandages

X

Basal Thermometer

X

Over-the-counter supply.

Batteries – initial

X

For covered DME items

Batteries – replacement

X

For covered DME when replacement is necessary due to normal use.

Betadine

X

See IV therapy supplies.

Books

X

Clinitest

X

For monitoring of diabetes.

Colostomy Bags

See Ostomy Supplies.

Communication Devices

X

Contraceptive Jelly

X

Over-the-counter supply. Contraceptives are not covered under the plan.

Cranial Head Mold

X

Diabetic Supplies

X

Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips.

Diapers/Incontinent Briefs/Chux

X

Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan

Diaphragm

X

Contraceptives are not covered under the plan.

Diastix

X

For monitoring diabetes.

Diet, Special

X

Distilled Water

X

Dressing Supplies/Central Line

X

Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape.  Many times these items are dispensed in a kit when includes all necessary items for one dressing site change.

Dressing Supplies/Decubitus

X

Eligible for coverage only if receiving covered home care for wound care.

Dressing Supplies/Peripheral IV Therapy

X

Eligible for coverage only if receiving home IV therapy.

Dressing Supplies/Other

X

Dust Mask

X

Ear Molds

X

Custom made, post inner or middle ear surgery

Electrodes

X

Eligible for coverage when used with a covered DME.

Enema Supplies

X

Over-the-counter supply.

Enteral Nutrition Supplies

X

Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage.  Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease

Eye Patches

X

Covered for patients with amblyopia.

Formula

X

Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.)  Physician documentation to justify prescription of formula must include:

• Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product

Does not include formula:

• For members who could be sustained on an age-appropriate diet.
• Traditionally used for infant feeding
• In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product)
• For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met.

Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally.

Gloves

X

Hydrogen Peroxide

X

Over-the-counter supply.

Hygiene Items

X

Incontinent Pads

X

Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan

Insulin Pump (External) Supplies

X

Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item.

Irrigation Sets, Wound Care

X

Eligible for coverage when used during covered home care for wound care.

Irrigation Sets, Urinary

X

Eligible for coverage for individual with an indwelling urinary catheter.

IV Therapy Supplies

X

Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.

K-Y Jelly

X

Over-the-counter supply.

Lancet Device

X

Limited to one device only.

Lancets

X

Eligible for individuals with diabetes.

Med Ejector

X

Needles and Syringes/Diabetic

See Diabetic Supplies

Needles and Syringes/IV and Central Line

See IV Therapy and Dressing Supplies/Central Line.

Needles and Syringes/Other

X

Eligible for coverage if a covered IM or SubQ medication is being administered at home.

Normal Saline

See Saline, Normal

Novopen

X