Peach State Provider Office Manual - Peach State Health Plan ...

Common Brand Name(s) Product Description Covered Brand Product Limitations/RestrictionsInsulin Syringe/Needle U-100 1/2 ML 30 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1/2 ML 30 x1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 25 x 5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 25 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 26 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 27 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 27 x 5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 28 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 28 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 G x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x 1/2"INS SYRINGE, INSULINSYRG, MAGELLAN INS Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 29 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 30 x 1/2"INS SYRINGE, INSULINSYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 1 ML 31 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 31 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 2 ML 27.5 x5/8" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 2 ML 29 x 1/2" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x7/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x5/16" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 29 x 1" INSULIN SYRG Max Qty=150/30 daysInsulin Syringe/Needle U-100 0.3 ML 30 x 1" INSULIN SYRG Max Qty=150/30 days*Insulin Pen Needle*** ULTILET PEN Max Qty=150/30 daysInsulin Pen Needle 29 G X 12 MM Max Qty=150/30 daysInsulin Pen Needle 30 G X 8 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 5 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 6 MM Max Qty=150/30 daysInsulin Pen Needle 31 G X 8 MM Max Qty=150/30 days*Respiratory Therapy Supplies - Misc** ADULT MASK Max Qty=1/360 days*Respiratory Therapy Supplies -Mouthpieces**ALL FLOW67 of 70