SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE - UPDATED JANUARY 1, 2016
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1 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. Enteral Medical Supplies B4087 Gastrostomy Tubes Standard Stoma Length 0.8 cm thru Stoma Length 5.0 Various B4088 Gastrostomy Tubes LowProfile Stoma Length 0.8 cm thru Stoma Length 5.0 Various /18/ :26 AM Page 1
2 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. Enteral Formulae Boost Kids Essentials 1.0 Choc / 8 fl.oz briks/case 27 ( ) Boost Kids Essentials 1.0 Sberry / 8 fl.oz briks/case 27 ( ) Boost Kids Essentials 1.0 Van / 8 fl.oz briks/case 27 ( ) Boost Kids Essentials 1.5 w/ Fiber / 8 fl.oz briks/case 27 ( ) Boost Kids Essentials 1.5 Choc / 8 fl.oz briks/case 27 ( ) Boost Kids Essentials 1.5 SBerry / 8 fl.oz briks/case 27( ) Boost Kids Essentials 1.5 Van / 8 fl.oz briks/case 27 ( ) Nutren Junior ( ) Nutren Junior w/fiber ( ) Pediasure 1.0 Enteral Formula ( ) Enteral Formulas for Pediatrics PediaSure 1.5 Cal ( ) PediaSure 1.5 Cal with fiber ( ) PediaSure Enteral Formula 1.0 Cal (Fiber) ( ) PediaSure Shake Banana / 8floz (237mL) can / 24 ct ( ) PediaSure Shake Choc / 8floz (237mL) can / 24 ct ( ) PediaSure Shake Straw / 8floz (237mL) can / 24 ct ( ) PediaSure W Fiber Vanilla / 8floz (xxxml) can / 24 ct ( ) B4161 Elecare DHA/ARA Infant ( ) B4161 Elecare Jr. Unflavored ( ) B4161 Elecare Jr. Vanilla ( ) B4161 Neocate Infant DHA&ARA ( ) B4161 Neocate Jr Unflavored ( ) B4161 Neocate Jr with Probiotics Unflavored ( ) B4161 PediaSure Peptide Vanilla ( ) B4161 PediaSure Peptide Strawberry ( ) B4161 PediaSure Peptide Unflavored ( ) Enteral Formulas for Pediatrics B4161 Pediasure Peptide 1.5 CAL ( ) B4161 Peptamen Junior Strawberry 24 x 250 ( ) B4161 Peptamen Junior Vanilla 24 x 250 ( ) B4161 Peptamen Junior Unflavored 24x250 ( ) B4161 B4161 Peptamen Junior Fiber ( ) B4161 Peptamen JR w/ Prebio Vanilla 24 x 250 ml TP ( ) B4161 Vivonex Pediatric ( ) /18/ :26 AM Page 2
3 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. Durable Medical Equipment E0240 ACTIVE AID TILT IN SPACE PLUS PEDIATRIC SHOWER COMMODE 282 1, E1399 ACTIVE AID BACK HARDWARE TO ADJUST SEAT DEPTH AND ANGLE OPTION D E1399 ACTIVE AID HEAD SUPPORT OPTION D E1399 ACTIVE AID SAFETY STRAP CHEST OPTION F CHEST E1399 ACTIVE AID TRUNK/THORACIC LATERAL SUPPORTS OPTION D E1399 ALTIMATE MEDICAL STANDER 5 PT KNOB PNG E1399 ALTIMATE MEDICAL STANDER ACCESSORIES BRACKET PNG E1399 ALTIMATE MEDICAL STANDER BACK/UPPER BODY STYLE PNG E1399 ALTIMATE MEDICAL STANDER BACK/UPPER BODY STYLE PNG E1399 ALTIMATE MEDICAL STANDER CHEST STRAP SMALL PNG E1399 ALTIMATE MEDICAL STANDER FRAME STYLE PNG E1399 ALTIMATE MEDICAL STANDER FRAME STYLE PNG E1399 ALTIMATE MEDICAL STANDER HEAD SUPPORT PNG E1399 ALTIMATE MEDICAL STANDER HIGH MOUNT VEST BRACKET PNG E1399 ALTIMATE MEDICAL STANDER HIP SUPPORTS PNG E1399 ALTIMATE MEDICAL STANDER KNEE PAD STYLE PNG E1399 ALTIMATE MEDICAL STANDER LATERAL SUPPORTS PNG E1399 ALTIMATE MEDICAL STANDER MOBILE NG , E1399 ALTIMATE MEDICAL STANDER MOBILE SELF PROPELLED PNG , E1399 ALTIMATE MEDICAL STANDER ROTATING SEAT PNG E1399 ALTIMATE MEDICAL STANDER ROTATING SEAT PNG E1399 ALTIMATE MEDICAL STANDER SECURE FOOT STRAPS PNG E1399 ALTIMATE MEDICAL STANDER SECURE FOOT STRAPS PNG E1399 ALTIMATE MEDICAL STANDER SHADOW TRAY PNG E1399 ALTIMATE MEDICAL STANDER SHADOW TRAY PNG E1399 ALTIMATE MEDICAL STANDER SHORT MULTIADJUSTABLE FOOTPLATES PNG E1399 ALTIMATE MEDICAL STANDER VELCRO HIP BELT PNG E1399 ALTIMATE MEDICAL STANDER VEST PNG E0240 CLARKE HEALTH CARE PRODUCTS AQUATEC BATH WITH RECLINING BACK, 300 LB CAPACITY A , E1399 CLARKE HEALTH CARE PRODUCTS AQUATEC CHEST BELT A E1399 CLARKE HEALTH CARE PRODUCTS AQUATEC PELVIC/SEAT BELT A E1399 COLUMBIA DETACHABLE ROLLING BASE BATH CHAIR E1399 COLUMBIA FIXED TRANSFER FRAME WITH SHUTTLE BATH CHAIR , E0240 COLUMBIA LARGE ULTIMA STAINLESS STEEL BATH CHAIR 8720B E1399 COLUMBIA LATERAL PADS FOR ALL BATH CHAIRS 8830B E0240 COLUMBIA MEDIUM ELITEVERSE FULL MESH BATH/SHOWER CHAIR , E0240 COLUMBIA OMNI BATH CHAIR , E1399 COLUMBIA OMNI BATH CHAIR ANTITIPPERS E1399 COLUMBIA OMNI BATH CHAIR FOLDING FRAME , E1399 COLUMBIA OMNI BATH CHAIR HEAD PAD 8875B /18/ :26 AM Page 3
4 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. E1399 COLUMBIA OMNI BATH CHAIR PELVIC POSITIONING BELT E0240 COLUMBIA OMNI BATH CHAIR WITH COMMODE , E1399 COLUMBIA ROOSEVELT STANDARD CAR SEAT 1000RSG E1399 COLUMBIA SPIRIT CARSEAT 2400B 1, E1399 COLUMBIA SPIRIT CARSEAT ABDUCTOR 2419B E1399 COLUMBIA SPIRIT CARSEAT DEPTH EXTENDER 4" E1399 COLUMBIA SPIRIT CARSEAT HIP SUPPORT 2471HB E1399 COLUMBIA SPIRIT CARSEAT SUPPORT PAD MEDIUM SIZE 2482M E1399 COLUMBIA SPIRIT CARSEAT SUPPORT PAD SMALL SIZE 2481S E1399 COLUMBIA SPIRIT CARSEAT SWING AWAY TRUNK SUPPORT 2472TB E1399 COLUMBIA SPIRIT CARSEAT SWING AWAY TRUNK SUPPORT 2474TB E1399 COLUMBIA SPIRIT CARSEAT TETHER STRAP ASSY # P E0240 COLUMBIA VERSA SHOWER COMMODE , E1399 COLUMBIA VERSA SHOWER COMMODE FOOTRESTS E1399 CONVAID PRODUCTS CARROT3 CAR SEAT CT , E0240 NUPRODX INC BATH CHAIR PEDIATRIC MULTICHAIR 6000 TILT MC6000TILTP 3, E1399 NUPRODX INC BODYPOINT POSITIONING BELT CHEST J1BPM E1399 NUPRODX INC BODYPOINT POSITIONING BELT SEAT J4BPM E1399 NUPRODX INC LATERALS H19R E1399 NUPRODX INC SPLASH GUARD/ABDUCTOR H18R E0240 OTTOBOCK LECKY BATH CHAIR 414B80 414B E0240 OTTOBOCK LECKY BATH CHAIR 415A80 415A E1399 OTTOBOCK ABDUCTION BELT 415J80 SK E1399 OTTOBOCK CHEST BELT 415K80 SK E1399 OTTOBOCK EASY SEAT COMPLETE 414C85 1, E1399 OTTOBOCK HEAD SUPPORT 415L80 SK E1399 OTTOBOCK HIP BELT 415A80 SK E1399 OTTOBOCK LECKY BATH CHAIR COVER 415A80 SK E1399 OTTOBOCK PIVOT CHASSIS 415A E1399 PACIFIC REHAB MEYWALK , E1399 PACIFIC REHAB MEYWALK LEG GUIDES E1399 PACIFIC REHAB MEYWALK LEG DIVIDER E1399 PACIFIC REHAB MEYWALK MKJ NON REVERSE BRAKE E1399 PACIFIC REHAB MEYWALK REVERSE BRAKE E1399 PATTERSON MEDICAL TROTTER FOOT/ANKLE POSITIONER E1399 PATTERSON MEDICAL TROTTER HEADREST EXTENSION E1399 PATTERSON MEDICAL TROTTER MOBILE POS CHAIR 12" , E1399 PATTERSON MEDICAL TROTTER TORSO VEST E1399 PATTERSON MEDICAL TROTTER TRAY E1399 POSEY FULL SIDE RAIL COVERS /18/ :26 AM Page 4
5 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. E1399 PRIME ENGINEERING FOLDING BASE ASSEMBLY NL E1399 PRIME ENGINEERING HLT HEADREST ASSEMBLY NOT LISTED E1399 PRIME ENGINEERING HLT HIP LATERAL SUPPORTS NOT LISTED E1399 PRIME ENGINEERING HLT LATERAL CHEST SUPPORTS NOT LISTED E1399 PRIME ENGINEERING HLT MULTIPOSITION FOOT SYSTEM NOT LISTED E1399 PRIME ENGINEERING HLT OPAQUE TRAY NOT LISTED E1399 PRIME ENGINEERING HLT PADDED CHEST BELT NOT LISTED E1399 PRIME ENGINEERING HLT SOFT HIP SUPPORT NOT LISTED E1399 PRIME ENGINEERING KIDWALK 1 Kidwalk1 2, E1399 PRIME ENGINEERING KIDWALK 2 Kidwalk 2 2, E1399 PRIME ENGINEERING KW ANTI ROLLBACK DEVICE NOT LISTED E1399 PRIME ENGINEERING KW DIRECTIONAL LOCKS NOT LISTED E1399 PRIME ENGINEERING KW HEAD PAD NOT LISTED E1399 PRIME ENGINEERING KW LAT CHEST NOT LISTED E1399 PRIME ENGINEERING SYM FOOT STRAPS NOT LISTED E1399 PRIME ENGINEERING SYM INDEPENDENT ADJ KNEE SUPPORTS NOT LISTED E1399 PRIME ENGINEERING SYM PADDED CHEST BELT NOT LISTED E1399 PRIME ENGINEERING SYM ROHO KNEE PADS NOT LISTED E1399 PRIME ENGINEERING SYM TWO PIECE PUMP HANDLE NOT LISTED E1399 PRIME ENGINEERING SYMEXTENDED BACK ASSEMBLY NOT LISTED E1399 PRIME ENGINEERING SYMHEADREST ASSEMBLY NOT LISTED E1399 PRIME ENGINEERING SYMHIPGUIDES NOT LISTED E1399 PRIME ENGINEERING SYMLATERAL CHEST SUPPORTS NOT LISTED E1399 PRIME ENGINEERING SYMLOWBACK ASSEMBLY NOT LISTED E1399 PRIME ENGINEERING SYMSEATBELT NOT LISTED E1399 PRIME ENGINEERING SYMSWSEAT NOT LISTED E1399 RIFTON STANDER COMMUNICATION TRAY K E1399 RIFTON STANDER MOUNTING BRACKET SMALL K E1399 RIFTON STANDER SMALL DYNAMIC K103 1, E1399 RIFTON STANDER WHEELS PAIR K E0240 SNUG SEAT MANATEE SZ E1399 SNUG SEAT CROCODILE ANTITIP LEVERS E1399 SNUG SEAT CROCODILE LATERAL PAD KIT E1399 SNUG SEAT CROCODILE PELVIC PAD KIT E1399 SNUG SEAT CROCODILE PELVIC STRAP E1399 SNUG SEAT CROCODILE SLING SEAT SZ E1399 SNUG SEAT CUSTOM CAR SEAT E1399 SNUG SEAT MANATEE SZ 1 HEADREST/LATERAL E1399 SNUG SEAT MUSTANG ARMREST WITH HANDLES E1399 SNUG SEAT MUSTANG CHEST SUPPORT * COVER E1399 SNUG SEAT MUSTANG CONNECTING ROD E1399 SNUG SEAT MUSTANG HEADREST E1399 SNUG SEAT MUSTANG HIP SUPPORTS SIZE E1399 SNUG SEAT MUSTANG SEAT SIZE E1399 SNUG SEAT MUSTANG TURTLE BRACKET /18/ :26 AM Page 5
6 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. E1399 SNUG SEAT PILOT BOOSTER CARSEAT E1399 SNUG SEAT TRAVELER PLUS EL 7009EL E1399 SNUG SEAT TRAVELER PLUS EL TETHER ANCHOR HARDWARE KIT E8000 SNUG SEAT CROCODILE GAIT TRAINER E8000 SNUG SEAT GAIT TRAINER E8002 SNUG SEAT MUSTANG SIZE , E8002 SNUG SEAT MUSTANG SIZE , E2599 VARIOUS TABLET, SOFTWARE, CARRYING CASE SPEECH GENERATING DEVICE Various /18/ :26 AM Page 6
7 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. Wheelchair and Wheelchair Accessories K0108 ADAPTIVE SWITCH LAB MICRO EXTREMITY CONTROL LSST ASL129 2, K0108 ATR DRB ASSEMBLY QUICKIE / ZIPPIE TYPE , K0108 COMFORT COMPANY COMFORT FOOT BC K0108 CONCEPTS IN MOTION RECLINE REMOVAL KIT KIT K0108 DALTON MOTOR AND GEAR BOX PCMO3CM K0108 FALCON PWR SWING AWAY KIT FOR SINGLE SWITCH TA0204 2, K0108 FRANKLIN MOBILITY SYSTEMS ERGONOMIC CONTROL SYSTEM , K0108 INNOVATION IN MOTION NEW BUG SEAT MNBS 1, K0108 PERMOBIL BACK REST FRAME K0108 PERMOBIL POWER ARTICULATING CENTER MOUNT ELEVATING LEG RESTS , K0108 PERMOBIL POWER CONTROL LEGREST K0108 PRIDE CONTROLLER MB4549 1, K0108 PRIDE HIBACK SEAT ASSEMBLY K0108 STEALTH HEAD POSITIONING CONTROL SYSTEM K0108 SUNRISE 16 DP 80D K0108 SUNRISE 18 DP 80D K0108 SUNRISE CNTR CTR FIRST KIT K0108 SUNRISE KIT TILT K0108 SUNRISE PWC CENTER ELEVATING LEG RESTS 172H125 1, K0108 SUNRISE RECLINE REMOVAL KIT K0108 SUNRISE RNET OMNI INPUT CONTROL 1720N K0108 SUNRISE MEDICAL 4 POINT TRANSIT SYSTEM 172T /18/ :26 AM Page 7
8 V3 FAIR MARKET VALUE LIST UPDATED JANUARY 2016 SELECTED DMEPOS ITEMS PRICED AT FAIR MARKET PRICE UPDATED JANUARY 1, 2016 MATCHES THIS LIST EXACTLY IF AN ITEM CLASSIFIED AS "MANUALLY PRICED" IS NOT ON THIS LIST; IT WILL BE PROCESSED USING THE LESSER OF MSRP 30% OR COST +30% ACCORDING TO OHCA POLICY 317: DATED SEPTEMBER 12, 2014 UPDATES TO THIS LIST WILL BE PROCESSED ANNUALLY UNLESS OTHERWISE NOTED ITEMS ON THIS LIST ARE DESIGNED TO IMPROVE MEMBER ACCESS. PRODUCT INCLUSION ON THIS DOCUMENT DOES NOT IMPLY THAT OHCA ENDORSES THESE PRODUCTS THEY ARE LISTED FOR PRICING AND CLAIMS PROCESSING ONLY. Hearing Services V5254 DIGITAL MONAURAL CIC V5255 DIGITAL MONAURAL ITC V5256 DIGITAL MONAURAL ITE V5257 DIGITAL MONAURAL BTE HEARING AIDS FOR FLAT OR GENTLY SLOPING HEARING LOSS ADJUSTED BY V5258 DIGITAL BINAURAL CIC THE 7.75% BUDGET REDUCTION OF SFY '15 1, V5259 DIGITAL BINAURAL ITC 1, V5260 DIGITAL BINAURAL ITE 1, V5261 DIGITAL BINAURAL BTE 1, Various V5254 DIGITAL MONAURAL CIC V5255 DIGITAL MONAURAL ITC V5256 DIGITAL MONAURAL ITE V5257 DIGITAL MONAURAL BTE HEARING AIDS FOR PRECIPITOUS HEARING LOSS ADJUSTED BY THE 7.75% V5258 DIGITAL BINAURAL CIC BUDGET REDUCTION OF SFY '15 1, V5259 DIGITAL BINAURAL ITC 1, V5260 DIGITAL BINAURAL ITE 1, V5261 DIGITAL BINAURAL BTE 1, NOTE CIC COMPLETELY IN CANAL ITC IN THE CANAL ITE IN THE EAR BTE BEHIND THE EAR 12/18/ :26 AM Page 8
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