mc sup prod ost onedr
Medical Supply Products: Ostomy – One-Piece Drainable Pouches1
This section lists the billing codes, manufacturer codes and units for ostomy one-piece drainable pouch medical supplies. In this section, “UPN” refers to the Universal Product Number and “MAC” refers to the maximum acquisition cost. For additional help, refer to the Medical Supplies section in this manual. HCPCS codes are for reference only.
ONE-PIECE OSTOMY PRODUCTS *Description /
UPN / HCPCS(reference only) /
Billing
Code /
MAC /
Unit of
Measure
ONE-PIECE DRAINABLE OSTOMY POUCHES
ONE-PIECE DRAINABLE POUCH WITH ATTACHED EXTENDED WEAR BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)
Coloplast – JN
Assura - 1-Pc. Non-Convex Extra-Extended Wear Drainable Pouch, Cut-to-fit, Opaque / 11 1/4" (28 cm), 3/8" - 2 3/4"
(10-70 mm) / 0762123031971 / A4388 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Extra-Extended Wear Drainable Pouch, Cut-to-fit, Transparent / 11 1/4" (28 cm), 3/8" - 2 3/4"
(10-70 mm) / 0762123031995 / A4388 / 9907TJN / $4.30 / each
Assura - 1-Pc. EasiClose WIDE - Extra-Extended Wear,
Non-Convex, Transparent, Cut-to-fit, 10-77 mm / 0762123049716 / A4388 / 9907TJN / $4.30 / each
Assura - 1-Pc. EasiClose WIDE - Extra-Extended Wear,
Non-Convex, Opaque, Cut-to-fit, 10-77 mm / 0762123049730 / A4388 / 9907TJN / $4.30 / each
* All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
mc sup prod ost onedr
Medical Supply Products: Ostomy – One-Piece Drainable Pouches1
ONE-PIECE DRAINABLE POUCH WITH ATTACHED EXTENDED WEAR BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Cymed – CD
9" one-piece colostomy pouch, clear, plain barrier style, No washer, cut-to-fit for stomas up to 1 3/4 inches (45 mm) / (01)00383950411004 / A4388 / 9907TCD / $4.30 / each
9" one-piece colostomy pouch, opaque, plain barrier style, No washer, cut-to-fit for stomas up to 1 3/4 inches (45 mm) / (01)00383950411011 / A4388 / 9907TCD / $4.30 / each
11" one-piece colostomy pouch, clear, plain barrier style, No washer, cut-to-fit for stomas up to 1 3/4 inches (45 mm) / (01)00383950811002 / A4388 / 9907TCD / $4.30 / each
11" one-piece colostomy pouch, opaque, plain barrier style, No washer, cut-to-fit for stomas up to 1 3/4 inches (45 mm) / (01)00383950811019 / A4388 / 9907TCD / $4.30 / each
Hollister – HS
Premier Flat CTF Transp Drn Lnr (64 mm) / 10610075085313 / A4388 / 9907THS / $4.30 / each
Premier Flat Transp Drn Lnr (25 mm) 1" / 10610075085320 / A4388 / 9907THS / $4.30 / each
Premier Flat Transp Drn Lnr (38 mm) 1 1/2" / 10610075085337 / A4388 / 9907THS / $4.30 / each
Premier Flat Transp Drn Lnr (32 mm) 1 1/4" / 10610075085382 / A4388 / 9907THS / $4.30 / each
Premier Flat Transp Drn Lnr (44 mm) 1 3 /4" / 10610075085399 / A4388 / 9907THS / $4.30 / each
Premier Flat CTF Beige Drn Lnr (64 mm) 2 1/2" / 10610075085511 / A4388 / 9907THS / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCH WITH ATTACHED EXTENDED WEAR BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Hollister – HS
Premier Flat Beige Drn Lnr (25 mm) 1" / 10610075085528 / A4388 / 9907THS / $4.30 / each
Premier Flat Beige Drn Lnr (38 mm) 1 1/2" / 10610075085535 / A4388 / 9907THS / $4.30 / each
Premier Flat Beige Drn Lnr (32 mm) 1 1/4" / 10610075085580 / A4388 / 9907THS / $4.30 / each
Premier Flat Beige Drn Lnr (44 mm) 1 3/4" / 10610075085597 / A4388 / 9907THS / $4.30 / each
Premier Drn Pch Ctf 2 1/2" / 10610075086310 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 1" / 10610075086327 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 1 1/2" / 10610075086334 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 2" / 10610075086341 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 2 1/2" / 10610075086358 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 3/4" / 10610075086372 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 1 1/4" / 10610075086389 / A4388 / 9907THS / $4.30 / each
Premier Ps Drn Pch 1 3/4" / 10610075086396 / A4388 / 9907THS / $4.30 / each
Premier Drn Ctf Trn Mini (64 mm) / 10610075086419 / A4388 / 9907THS / $4.30 / each
Premier Drn Ps Opq Mini (25 mm) / 10610075086426 / A4388 / 9907THS / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCH WITH ATTACHED EXTENDED WEAR BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Hollister – HS
Premier DRN PS Opq Mini (38 mm) / 10610075086433 / A4388 / 9907THS / $4.30 / each
Premier DRN PS Opq Mini (51 mm) / 10610075086440 / A4388 / 9907THS / $4.30 / each
Premier DRN PS Opq Mini (19 mm) / 10610075086471 / A4388 / 9907THS / $4.30 / each
Premier DRN PS Opq Mini (32 mm) / 10610075086488 / A4388 / 9907THS / $4.30 / each
Premier DRN PS Opq Mini (44 mm) / 10610075086495 / A4388 / 9907THS / $4.30 / each
Premier FT DRN Clamp Ctf 2-1/2" (64 mm) / 10610075117274 / A4388 / 9907THS / $4.30 / each
ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER, WITH FILTER (Limited to no more than 90 pouches in 81 days without authorization.)
Coloplast – JN
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Cut-To-Fit, Opaque / 11 1/2" (29 cm), 655 ml 3/8" - 2 3/4"
(10-70 mm) / 0762123046302 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Pre-Cut, Opaque / 11 1/2" (29 cm), 655 ml 1" (25 mm) / 0762123046388 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Pre-Cut, Opaque / 11 1/2" (29 cm), 655 ml 1 3/16" (30 mm) / 0762123046401 / A4424 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER, WITH FILTER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Pre-Cut, Opaque / 11 1/2" (29 cm), 655 ml 1 3/8" (35 mm) / 0762123046425 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Cut-To-Fit, Transparent / 11 1/2" (29 cm), 655 ml 3/8" - 2 3/4"
(10-70 mm) / 0762123046289 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Cut-To-Fit, Maxi Soft Front, Opaque / 11 1/4" (28 cm), 600 ml
3/8" - 2 3/4" (10-70 mm) / 0762123032268 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Maxi Soft Front, Opaque / 11 1/4" (28 cm), 600 ml 1"
(25 mm) / 0762123032169 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Maxi Soft Front, Opaque / 11 1/4" (28 cm), 600 ml
1 3/16" (30 mm) / 0762123032183 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Maxi Soft Front, Opaque / 11 1/4" (28 cm), 600 ml
1 3/8" (35 mm) / 0762123032206 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Cut-To-Fit, Maxi Transparent / 11 1/4" (28 cm), 600 ml 3/8" -
2 3/4" (10-70 mm) / 0762123032244 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Cut-To-Fit, Midi Soft Front Graphic / 10 1/4" (26 cm), 470 ml
3/8" - 2 1/8" (10-55 mm) / 0762123032220 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Midi Soft Front, Opaque / 10 1/4" (26 cm), 470 ml 1"
(25 mm) / 0762123032107 / A4424 / 9907TJN / $4.30 / each
One-piece ostomy products are effective March 1, 2008, unless otherwise noted.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesAugust 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER, WITH FILTER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Midi Soft Front, Opaque / 10 1/4" (26 cm), 470 ml
1 3/16" (30 mm) / 0762123032121 / A4424 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ Drainable Pouch,
Pre-Cut, Midi Soft Front, Opaque / 10 1/4" (26 cm), 470 ml
1 3/8" (35 mm) / 0762123032145 / A4424 / 9907TJN / $4.30 / each
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear Non-Convex, Maxi, Transparent, Cut-To-Fit, 3/8" - 3" / 1170193001 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Transparent, Pre-Cut, 1" / 1170193002 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Transparent, Pre-Cut, 1 1/4" / 1170193003 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Transparent, Pre-Cut, 1 3/8" / 1170193004 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Opaque, Cut-to-fit, 3/8" - 3" / 1170193005 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Opaque, Pre-Cut, 1" / 1170193006 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Standard Wear, Non-Convex, Maxi, Opaque, Pre-Cut, 1 1/4" / 1170193007 / A4424 / 9907TJN / $4.30 / each †
SenSura, 1-Pc. EasiClose WIDE Outlet, Non-Convex, Maxi, Opaque, Pre-Cut, 1 3/8" / 1170193008 / A4424 / 9907TJN / $4.30 / each †
†Effective September 1, 2008
One-piece ostomy products are effective March 1, 2008, unless otherwise noted.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesAugust 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER, WITH FILTER (Limited to no more than 90 pouches in 81 days without authorization.)Hollister – HS
Premier CTF Beige Drn Flt (55 mm) 1 15/16" / 10610075106452 / A4424 / 9907THS / $4.30 / each
Premier PS Beige Drn Flt (25 mm) 1" / 10610075106469 / A4424 / 9907THS / $4.30 / each
Premier PS Beige Drn Flt (30 mm) 1 3/16" / 10610075106476 / A4424 / 9907THS / $4.30 / each
Premier PS Beige Drn Flt (35 mm) 1 3/8" / 10610075106483 / A4424 / 9907THS / $4.30 / each
Premier PS Beige Drn Flt (40 mm) 1 9/16" / 10610075106490 / A4424 / 9907THS / $4.30 / each
Premier Ctf Transparent Drn Flt (55 mm) 1 15/16" / 10610075106506 / A4424 / 9907THS / $4.30 / each
Premier PS Transparent Drn Flt (25 mm) 1" / 10610075106513 / A4424 / 9907THS / $4.30 / each
Premier PS Transparent Drn Flt (30 mm) 1 3/16" / 10610075106520 / A4424 / 9907THS / $4.30 / each
Premier PS Transparent Drn Flt (35 mm) 1 3/8" / 10610075106537 / A4424 / 9907THS / $4.30 / each
Premier PS Transparent Drn Flt (40 mm) 1 9/16" / 10610075106544 / A4424 / 9907THS / $4.30 / each
Premier Mini Beige Drain Lnr Fltr Ctf (15-55 mm) / 15390166080148 / A4424 / 9907THS / $4.30 / each
Premier Mini Beige Drain Lnr Fltr (25 mm) 1" / 15390166080162 / A4424 / 9907THS / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER, WITH FILTER (Limited to no more than 90 pouches in 81 days without authorization.)Hollister – HS
Premier Mini Beige Drain Lnr Fltr 1 3/16" (30 mm) / 15390166080186 / A4424 / 9907THS / $4.30 / each
Premier Mini Beige Drain Lnr Fltr 1 3/8" (35 mm) / 15390166080209 / A4424 / 9907THS / $4.30 / each
Premier Mini Beige Drain Lnr Fltr 1 3/8" (35 mm) / 15390166080223 / A4424 / 9907THS / $4.30 / each
Premier Mini Transparent Drain Lnr Fltr Ctf (15-55 mm) / 15390166080124 / A4424 / 9907THS / $4.30 / each
Premier Mini Transparent Drain Lnr Fltr 1" (25 mm) / 15390166080247 / A4424 / 9907THS / $4.30 / each
Premier Mini Transparent Drain Lnr Fltr 1 3/16" (30 mm) / 15390166080261 / A4424 / 9907THS / $4.30 / each
Premier Mini Transparent Drain Lnr Fltr 1 3/8" (35 mm) / 15390166080285 / A4424 / 9907THS / $4.30 / each
Premier Mini Transparent Drain Lnr Fltr 1 9/16" (40 mm) / 15390166080308 / A4424 / 9907THS / $4.30 / each
ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)
Coloplast – JN
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Non-Filter, Cut-To-Fit, Transparent / 11 1/2" (29 cm), 655 ml
3/8" - 2 3/4" (10-70 mm) / 0762123048153 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Easiclose™ WIDE Outlet - Maxi, Non-Filter, Cut-To-Fit, Opaque / 11 1/2" (29 cm), 655 ml
3/8" - 2 3/4" (10-70 mm) / 0762123048177 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Cut-To-Fit, Opaque / 12" (30 cm) 3/8" - 2 3/4 (10-70 mm) / 0762123019092 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Opaque / 12" (30 cm) 1" (25 mm) / 0762123019351 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Opaque / 12" (30 cm) 1 3/16" (30 mm) / 0762123019399 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Opaque / 12" (30 cm) 1 3/8" (35 mm) / 0762123019412 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Opaque / 12" (30 cm) 1 9/16" (40 mm) / 0762123019436 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Cut-To-Fit, Transparent / 12" (30 cm) 3/8" - 2 3/4" (10-70 mm) / 0762123019115 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Transparent / 12" (30 cm) 1" (25 mm) / 0762123019450 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Transparent / 12" (30 cm) 1 3/16" (30 mm) / 0762123019474 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Transparent / 12" (30 cm) 1 3/8" (35 mm) / 0762123019481 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Drainable Pouch, Pre-Cut, Transparent / 12" (30 cm) 1 9/16" (40 mm) / 0762123019504 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Cut-To-Fit, Opaque / 10" (25 cm) 3/8" - 2 1/8"
(10-55 mm) / 0762123019054 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Opaque / 10" (25 cm) 1" (25 mm) / 0762123019153 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Opaque / 10" (25 cm) 1 3/16" (30 mm) / 0762123019177 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Opaque / 10" (25 cm) 1 3/8" (35 mm) / 0762123019191 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Opaque / 10" (25 cm) 1 9/16" (40 mm) / 0762123019214 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Cut-To-Fit, Transparent / 10" (25 cm) 3/8" - 2 1/8"
(10-55 mm) / 0762123019078 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 1" (25 mm) / 0762123019238 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 1 3/16" (30 mm) / 0762123019252 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 1 3/8" (35 mm) / 0762123019276 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 1 9/16" (40 mm) / 0762123019290 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 1 3/4" (45 mm) / 0762123019313 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Non-Convex Standard Wear Small Drainable Pouch, Pre-Cut, Transparent / 10" (25 cm) 2" (50 mm) / 0762123019337 / A5061 / 9907TJN / $4.30 / each
Assura - 1-Pc. Pediatric Drainable Pouch, Cut-To-Fit, Transparent / 8 1/2" (21 cm) 3/8" - 1 3/8" (10-35 mm) / 0762123019139 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Cut-To-Fit, Opaque / Standard 11" (28 cm) 5/8 - 2 3/8"
(15-60 mm) Curagard / 0762123000267 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Cut-To-Fit, Opaque / Standard 11" (28 cm) 5/8 - 2 3/8"
(15-60 mm) SecureLife / 0762123000274 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 13/16" (20 mm) - SecureLife / 0762123000281 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 1" (25 mm) - SecureLife / 0762123000298 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 1 3/16" (30 mm) - SecureLife / 0762123000304 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 1 3/8" (35 mm) - SecureLife / 0762123000311 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 1 9/16" (40 mm) - SecureLife / 0762123000328 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 1 3/4" (45 mm) - SecureLife / 0762123000335 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 2" (50 mm) - SecureLife / 0762123000342 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Opaque / Standard 11" (28 cm) 2 3/8" (60 mm) - SecureLife / 0762123000366 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Cut-To-Fit, Transparent / Standard 11" (28 cm) 5/8 - 2 3/8"
(15-60 mm) - Curagard / 0762123000151 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Cut-To-Fit, Transparent / Standard 11" (28 cm) 5/8 - 2 3/8"
(15-60 mm) - SecureLife / 0762123000168 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 13/16" (20 mm) - SecureLife / 0762123000175 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 1" (25 mm) - SecureLife / 0762123000182 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 1 3/16" (30 mm) - SecureLife / 0762123000199 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 1 3/8" (35 mm) - SecureLife / 0762123000205 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
mc sup prod ost onedr
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 1 9/16" (40 mm) - SecureLife / 0762123000212 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 1 3/4" (45 mm) - SecureLife / 0762123000229 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 2" (50 mm) - SecureLife / 0762123000236 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Standard Drainable Pouch,
Pre-Cut, Transparent / Standard 11" (28 cm) 2 3/8" (60 mm) - SecureLife / 0762123000250 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch,
Cut-To-Fit, Opaque / Small 10" (25 cm) 5/8 - 1 9/16"
(15-40 mm) - Curagard / 0762123000014 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch,
Cut-To-Fit, Opaque / Small 10" (25 cm) 5/8 - 1 9/16"
(15-40 mm) - SecureLife / 0762123000021 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Opaque / Small 10" (25 cm) 13/16" (20 mm) - SecureLife / 0762123000038 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Opaque / Small 10" (25 cm) 1" (25 mm) - SecureLife / 0762123000045 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
mc sup prod ost onedr
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Opaque / Small 10" (25 cm) 1 3/16" (30 mm) - SecureLife / 0762123000052 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Opaque / Small 10" (25 cm) 1 3/8" (35 mm) - SecureLife / 0762123000069 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Opaque / Small 10" (25 cm) 1 9/16" (40 mm) - SecureLife / 0762123000076 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch,
Cut-To-Fit, Transparent / Small 10" (25 cm) 5/8 - 1 9/16"
(15-40 mm) - Curagard / 0762123000083 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch,
Cut-To-Fit, Transparent / Small 10" (25 cm) 5/8 - 1 9/16"
(15-40 mm) - SecureLife / 0762123000090 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Transparent / Small 10" (25 cm) 13/16" (20 mm) - SecureLife / 0762123000106 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Transparent / Small 10" (25 cm) 1" (25 mm) - SecureLife / 0762123000113 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Transparent / Small 10" (25 cm) 1 3/16" (30 mm) - SecureLife / 0762123000120 / A5061 / 9907TJN / $4.30 / each
All one-piece ostomy products are effective March 1, 2008.
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesJanuary 2008
mc sup prod ost onedr
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Coloplast – JN
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Transparent / Small 10" (25 cm) 1 3/8" (35 mm) - SecureLife / 0762123000137 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Small Drainable Pouch, Pre-Cut, Transparent / Small 10" (25 cm) 1 9/16" (40 mm) - SecureLife / 0762123000144 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Post Op And Wound Management Drainable Pouch, Transparent/13" 3/8" - 3 1/8" (10-80 mm) - Curagard / 0762123000373 / A5061 / 9907TJN / $4.30 / each
Coloplast - 1-Pc. Non-Convex Post Op And Wound Management Drainable Pouch, Transparent/13" 3/8" - 3 1/8" (10-80 mm) - SecureLife / 0762123000380 / A5061 / 9907TJN / $4.30 / each
SenSura, 1-Pc., Maxi, Drainable, Standard Wear,
Non-Convex, Non-Filter, Transparent, Cut-To-Fit, 3/8" - 3" / 1170193080 / A5061 /
9907TJN
/ $4.30 / each ††Effective September 1, 2008
One-piece ostomy products are effective March 1, 2008, unless otherwise noted..
2 – Medical Supply Products: Ostomy – One-Piece Drainable PouchesAugust 2008
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ONE-PIECE DRAINABLE POUCHES WITH ATTACHED BARRIER (Limited to no more than 90 pouches in 81 days without authorization.)Convatec – SQ
ActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w/1 sided comfort panel w/tape 10" Opaque, 3/4" (19 mm) / 30003022750 / A5061 / 9907TSQ / $4.30 / each
ActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w1 sided comfort panel w/tape, 10" Opaque, 1 " (25 mm) / 30003022751 /
A5061
/ 9907TSQ / $4.30 / eachActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w/1 sided comfort panel w/tape, 10" Opaque, 1 1/4" (32 mm) / 30003022752 / A5061 / 9907TSQ / $4.30 / each
ActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w/1 sided comfort panel w/tape, 10" Opaque, 1 1/2" (38 mm) / 30003022753 /
A5061
/ 9907TSQ / $4.30 / eachActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w1 sided comfort panel w/tape, 10" Opaque, 1 3/4" (45 mm) / 30003022754 / A5061 / 9907TSQ / $4.30 / each
ActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w1 sided comfort panel w/tape, 10" Opaque, 2" (50 mm) / 30003022755 / A5061 / 9907TSQ / $4.30 / each
ActiveLife® One-Piece Pre-Cut Drainable Pouch with Stomahesive® Skin Barrier, w1 sided comfort panel w/tape, 10" Opaque, 2 1/2" (64 mm) / 30003022756 / A5061 / 9907TSQ / $4.30 / each
ActiveLife® One-Piece Drainable Pre-Cut Pouch with Stomahesive® Skin Barrier, w/1-sided comfort panel w/tape, 12" Trans, 3/4" (19 mm) / 30003022757 / A5061 / 9907TSQ / $4.30 / each
One-piece ostomy products are effective March 1, 2008, unless otherwise noted.