Private Health Insurance (Prostheses) Rules 2012 (No. 1) (Cth)

Private Health Insurance (Prostheses) Rules 2012 (No. 1)

As amended

Made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.

This compilation was prepared on 15 May 2012 taking into account amendments up to the Private Health Insurance (Prostheses) Amendment Rules 2012 (No. 1).

Prepared by the Department of Health and Ageing, Canberra

Contents

Part 1 Preliminary 3

1.Name of Rules 3

2.Commencement 3

3.Revocation 3

4.Definitions 3

Part 2 Benefit requirements 5

5.Listing of, and benefits for, prostheses 5

5A.Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable 6

5B.Conditions in relation to provision of listed prostheses 6

6.Benefits for prostheses provided as part of hospital treatment 6

7.Benefits for prostheses provided as part of hospital-substitute treatment 7

Part 3 Other 8

8.Timing of applications to have a prosthesis listed 8

9.Minister may have regard to recommendations and advice 8

10.Listing criteria for prostheses to be listed on Part C of the Schedule 8

Part 1 Preliminary

Name of Rules

These Rules are the Private Health Insurance (Prostheses) Rules 2012 (No. 1).

Commencement

These Rules commence on 3 March 2012.

Revocation

These Rules revoke the Private Health Insurance (Prostheses) Rules 2011 (No. 2) as amended by the Private Health Insurance (Prostheses) Amendment Rules 2011 (No. 2) and the Private Health Insurance (Prostheses) Amendment Rules 2011 (No. 3).

Definitions

Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003. These terms include:

complying health insurance policy
hospital-substitute treatment
hospital treatment
medicare benefit

In these Rules:

accredited podiatrist means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.

Note: The registration requirements for an accredited podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules.

Act means the Private Health Insurance Act 2007.

certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

consultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

gap permitted prosthesis means a prosthesis of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.

implantable cardiac event recorder includes a component of an implantable cardiac event recorder.

insulin infusion pump includes a component of an insulin infusion pump.

listed prosthesis means a kind of prosthesis listed in the Schedule to these Rules.

listing application has the same meaning as in subsection 72-10(6) of the Act.

listing criteria has the same meaning as in subsection 72-10(6) of the Act.

National Law means:

(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or

(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.

Note: The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.

no gap prosthesis means a prosthesis of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.

private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

professional attendance has the same meaning as in clause 1.2.3 of the General Medical Services Table being the table prescribed under section 4 of the Health Insurance Act 1973.

professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

public hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

Schedule means the Schedule in these Rules.

Part 2 Benefit requirements

5. Listing of, and benefits for, prostheses

For item 4 of the table in subsection 72-1 (2) of the Act:

(a)the Schedule lists the kinds of prostheses:

(i)in relation to which the Minister has granted an application for listing under subsection 72-10 (5) of the Act; or

(ii)which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and

Note: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.

(aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 5A; and

(ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 5B; and

(b)rule 6 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis; and

(c)rule 7 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis.

5A. Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable

For the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:

(a) the provision of a listed prosthesis which is associated with podiatric treatment by an accredited podiatrist.

Note: Paragraph (c) of Item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.

5B. Conditions in relation to the provision of listed prostheses

For the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:

(a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in the Schedule under the listing for that kind of prosthesis, that requirement; and

(b) in relation to a listed prosthesis that is an insulin infusion pump, also:

(i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and

(ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and

(iii) the insulin infusion pump must be provided for the purpose of administering insulin.

Note: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.

6. Benefits for prostheses provided as part of hospital treatment

(1)For a no gap prosthesis provided as part of an episode of hospital treatment by a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(2)For a gap permitted prosthesis provided as part of an episode of hospital treatment by a private hospital:

(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

(b)the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

(3)For a no gap prosthesis provided as part of an episode of hospital treatment by a public hospital:

(a)the minimum benefit is the lesser of the following amounts:

(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and

(b)the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit'.

(4)For a gap permitted prosthesis provided as part of an episode of hospital treatment by a public hospital:

(a)the minimum benefit is the lesser of the following amounts:

(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and

(b)the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.

Note: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.

7. Benefits for prostheses provided as part of hospital-substitute treatment

(1)For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(2)For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:

(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

(b)the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

Note 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10 (3) (a) of the Act.

Note 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.

Part 3 Other

8. Timing of applications to have a prosthesis listed

As a matter of normal administrative practice, applications made under subsection 72-10 (2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in the Schedule the next time the Minister makes or varies the Rules.

Note 1: Under subsection 72-10 (5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.

Note 2: Under subsection 72-15 (3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.

9. Minister may have regard to recommendations and advice

In making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.

10. Listing criteria for prostheses to be listed in Part C of the Schedule

For a listing application to be granted to list a kind of prosthesis in Part C of the Schedule, the listing criterion is that the kind of prosthesis is an:

(i) insulin infusion pump; or

(ii) implantable cardiac event recorder.

Note: 1. The power to make listing criteria is in subsection 72-10(6) of the Act.

2. Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.

3. Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.

Part A - Prostheses List February 2012

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.1.1 - Aphakic

1.1.1.1 - Rigid

Alcon Laboratories (Aust.) Pty Ltd

AL003 MTA2UO - MTA6UO PMMA +5 to +30 D $156.00

Bausch & Lomb (Australia) Pty Ltd

BL005 Storz (Coburn) Intraocular Lens PMMA Anterior Chamber Intraocular lens 13.75mm length. 6.0mm optic $156.00

121UV; L122UV PMMA Anterior 1 piece size, diopter range 3-30d.

Chamber Lens L122UV: 6.0mm optic,

13.75mm length, power range;
5.0 to 30.0 Diopters

Emagin Pty Ltd

EG009 Artisan Anterior Chamber Intraocular Aphakia ModelComposition: PMMA 5.00mm Optic Diameter x 8.5 $156.00

Lens in overall length

ifc

AMO Australia Pty Ltd

AO019 Verisyse AC IOL Aphakic Model 5mm Optic Diameter x 8.5 $250.00

overall length

m

AMO Australia Pty Ltd

AO001 Intraocular Lens: Model AC 51L Duralens PMMA, Anterior Chamber IOL 6.00 mm Optic Diameter x $198.00

13.0mm in overall length

1.1.2 - Phakic

1.1.2.1 - Rigid

AMO Australia Pty Ltd

AO016 Verisyse AC IOL Phakic Intraocular Lens: Model Myopia. 5mm Optic Diameter x 8.5 $680.00

Composition: PMMA overall length; 6mm Optic

Diameter x 8.5 overall length

AO017 Verisyse AC IOL Phakic Intraocular Lens: Model 5mm Optic Diameter x 8.5 $680.00

Hyperopia. Composition: PMMA overall length

Prostheses List by Category, Groups and Sponsor Page 1 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Emagin Pty Ltd

EG012 Artisan Anterior Chamber IOL Phakic Intraocular Lens Myopic / 5.00mm Optic Diameter x 8.5 $680.00

Hyperopic in overall length;

t1

AMO Australia Pty Ltd

AO030 Verisyse Toric (Custom) Phakic intraocular lens: Model toric 5mm Optic Diameter x 7.5mm $1,056.00

overall length

Emagin Pty Ltd

EG008 Artisan Anterior Chamber Intraocular Phakic Intraocular Lens: Model Toric 5.00mm Optic Diameter x 7.5 $1,056.00

Lens Composition: PMMA in overall length

t2

AMO Australia Pty Ltd

AO029 Verisyse Toric (Custom) Phakic intraocular lens: Model toric 5mm Optic Diameter x 7.5mm $1,358.00

overall length

1.1.2.2 - Foldable

Alcon Laboratories (Aust.) Pty Ltd

AL034 AcrySof Cachet Phakic Lens Anterior chamber foldable, acrylic, single -6.0 to -16.5 diopters, in 0.5 $723.00

piece phakic lens diopter increments

AMO Australia Pty Ltd

AO025 VeriFlex Foldable Phakic IOL Anterior chamber foldable phakic silicone -2 to -14.5d in 0.5d $723.00

intraocular lens increments. Overall diameter

8.5mm. Optic 6.0mm

Emagin Pty Ltd

EG010 Artiflex Anterior Chamber Intraocular Optic: Hydrophobic Polysiloxane. Haptic: 6mm optic diameter x 8.5 in $723.00

Lens PMMA overall length

1.2.1 - Rigid

Alcon Laboratories (Aust.) Pty Ltd

AL002 Models MZ60BD, MC50BD, CZ70BD Other:PMMA Range of Powers:-10 to +34 D $156.00

Prostheses List by Category, Groups and Sponsor Page 2 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Bausch & Lomb (Australia) Pty Ltd

BL006 Posterior chamber IOLS model P359 PMMA Posterior Chamber lens 1 piece; 12.25mm to 13.75mm length. $156.00

UV, P399 UV, 68 UV, 95 BUV, or 5.5mm to 7mm optic size,

lolab PC One Piece, model 6741B, diopter range -4.5 - 45d to 10

8591B, 8191B; Model EZE-Fit 65 - 34d; EZE-Fit 65: 6.5mm

optic, 13.35mm length, Power
range: 10.0 to 30.0 Diopter

1.2.2 - Foldable

1.2.2.1 - Microincision

Carl Zeiss Pty Ltd

CZ016 CT ASPHINA 409M ZEISS Micro Incision Aaspheric 6mm optic, 11mm overall $364.00

(aberration neutral) IOL: Foldable, square-           diameter. Diopter range 0.0 to
edged, single piece IOL for capsular bag             +32.0D (0.5D steps from 10.0
fixation  to 30.0D, 1.0D outside this

range)

CZ017 CT ASPHINA 509M ZEISS Micro Incision Aspheric 6mm Optic, 11mm overall $364.00

(aberration correcting) IOL: Foldable,                  diameter. Diopter range 0.0 to
square-edged, single piece IOL for   +32.0D (0.5D steps from 10.0
capsular bag fixation  to 30.0D, 1.0D outside this

range)

at, pl

Bausch & Lomb (Australia) Pty Ltd

BL026 Akreos AO Micro Incision Lens Micro Incision, posterior chamber, 6mm optic overall diameter $374.00

foldable acrylic, aphakic, anterior &   11.0mm(10D-15D), 10.7mm
posterior edge modification, preloaded,                (15.50-22D), 10.5mm (22.50-
with aberration contro, intraocular lens                30D)

Carl Zeiss Pty Ltd

CZ028 CT ASPHINA 409MP Preloaded, micro incision, aspheric Diopter range: 0.0 to 32.0D; $374.00

(aberration neutral), foldable square-edged Optic size: 6.0mm; Overall
single piece inraocular lens for capsular length: 11.0mm
bag fixation.

Prostheses List by Category, Groups and Sponsor Page 3 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

at, pl, t1

Carl Zeiss Pty Ltd

CZ031 AT TORBI 709MP (Standard Range) Bitoric, preloaded, micro incision, aspheric Diopter range: Sph -10.0 to $760.00

(aberration neutral), foldable, square-                 32.0, Cyl +1.0 to 6.5
edged, single-piece IOL for capsular bag             Optic size: 6.0mm, Overall
fixation  length: 11.0mm

at, pl, t2

Carl Zeiss Pty Ltd

CZ032 AT TORBI 709MP (high cyl) Bitoric, preloaded, micro incision, aspheric Diopter range: Sph -10.0 to $1,061.00

(aberration neutral), foldable, square-                 32.0, Cyl +7.0 to 12.0, Optic
edged, single-piece IOL for capsular bag             size: 6.0mm. Overall Length
fixation  11.0mm

t1

Carl Zeiss Pty Ltd

CZ020 AT TORBI 709M STANDARD RANGE BITORIC - 6mm optic, 11mm overall $740.00

ZEISS Micro Incision Aspheric   diameter. Diopter range: Sph
(abberation neutral) IOL: Foldable,   +6.0 to +32.0D, Cyl +1.0 to
square-edged, single piece IOL for   6.5D (all 0.5D steps)
capsular bag fixation

CZ026 AT TORBI™709M LOW SPHERE BITORIC - ZEISS Micro 6mm optic, 11mm overall $740.00

Incision Aspheric (aberration neutral)                 diameter. Diopter range: Sph -
IOL: Foldable, square-edged, single piece            10.0 to +5.5D, Cyl +1.0 to
IOL for capsular bag fixation  6.5D (all 0.5D steps)

t2, at

Carl Zeiss Pty Ltd

CZ027 AT TORBI 709M HIGH CYLINDER BITORIC - ZEISS 6mm optic, 11mm overall $1,041.00

Micro Incision Aspheric (aberration   diameter. Diopter range: Sph -
neutral) IOL: Foldable square edged,                    10.0 to +32.0D, +7.0 to 12.0D
single piece IOL for capsular bag fixation             (all 0.5D steps)

1.2.2.2 - No edge modification

Ellex Australia Pty Ltd

XE002 Staar foldable silicone intraocular lens: Polyimide haptics 6.3mm optic - low 14.0mm length $281.00

Model AQ 5010V diopters

Prostheses List by Category, Groups and Sponsor Page 4 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

t1

Ellex Australia Pty Ltd

XE001 Staar Toric foldable silicone intraocular Plate haptics 6.0mm optic 10.8mm - 11.2mm length $579.00

lens: Model AA4203TF; Model

AA4203TL

1.2.2.3 - Edge modification

Alcon Laboratories (Aust.) Pty Ltd

AL004 Acrysof Multipiece Models MA50BM, Foldable Acrylic Multi-piece Lens -5 D to +30 D $322.00

MA60AC

AL011 Acrysof Model SA60AT Foldable Acrylic Single-piece Lens, Range of Powers: +6 to +40 D $322.00

asymmetric optic/consistent edge

AMO Australia Pty Ltd

AO002 Sensar AR40 Monofocal Acrylic IOL, Soft Acrylic, Foldable, UV Absorbing, 6 mm Optic Diameter x 13mm $322.00

Sensar OptiEdge AR40e Foldable Posterior in overall length.

Acrylic IOL

AO006 Clariflex, Model CLRFLXB Posterior Foldable Silicone IOL with OptiEdge One size only $322.00

Chamber Intraocular Lens design

Bausch & Lomb (Australia) Pty Ltd

BL020 Akreos Adapt acrylic foldable posterior Composition: Hydrophilic acrylic polymer. 10.0 to 15.0 Diopter in 1.0 $322.00

chamber intraocular lens Packaged in lens folding device in a sterile Diopter increments15.0 to

vial. Four haptic design 25.0 Diopter in 0.5 Diopter

increments25.0 to 30.0
Diopter in 1.0 Diopter
increments

BL021 SoflexSE, Intraocular lenses, Posterior Composition: silicone, Lenses - foldable, Range of powers: 5.0 to 30.0 $322.00

Chamber posterior chamber intraocular lenses Diopter - Optic diameter

6.0mm; 13.0mm length

Carl Zeiss Pty Ltd

CZ003 Intraocular Lens: Model Bigbag Hydrophilic acrylic, foldable, PC, single 6.5mm optic diameter x 10.35 $322.00

piece, Tri-haptic, square edge design, UV overall diameter
blocker

CZ029 CT 53N Foldable, 3-piece, monofocal, square- Diopter range: 0.0 to 40.0, $322.00

edged, hydrophilic acrylic (with Optic size: 6.0mm, Overall
hydrophobic surface properties) length: 13.0mm
intraocular lens for capsular bag or sulcus
fixation.

Prostheses List by Category, Groups and Sponsor Page 5 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Ellex Australia Pty Ltd

XE003 Staar foldable silicone IOLs: Models Plate haptics 6.0mm; Polymide haptics 5.5 10.8mm 0 13.5mm length $322.00

AQ2010V, AQ2017V and AO2003V or 6.3mm optic;

Kevin Grundy (IBD) Pty Ltd

KG001 Rayner C-Flex Hydrophilic HEMA-MMA copolymer, 5.75mm dia optic, 12.00mm $322.00

foldable with injector dia overall

KG002 Superflex Hydrophilic HEMA-MMA copolymer, 6.25mm dia optic, 12.5mm dia $322.00

foldable with injector overall

at

AMO Australia Pty Ltd

AO014 TECNIS™ Intraocular Lens (Z9002 & Foldable Intraocular Lenses - Ultraviolet 5-10 dioptre in 1.0 dioptre $364.00

ZA9003) light absorbing posterior chamber increments; 10.5 - 30 dioptre in

intraocular lenses, Silicone/Acrylic 0.5 increments

AO024 Tecnis™ One Piece (ZCB00) One piece intraocular lens with edge +6 diopters to +30 diopters in $364.00

modification and 360 degree square edge 0.5d increments

Bausch & Lomb (Australia) Pty Ltd

BL022 SofPort Advanced Optic (AO) Posterior chamber, foldable silicone IOL 0 D to 30.0 D $364.00

with anterior optic-haptic square edge,
posteriof optic-haptic square edge, 360-
degree optic square edge and asperic optic
for aberration control

BL023 Akreos Advanced Optic Posterior chamber, foldable acrylic IOL, 0 D to 30.0 D $364.00

with anterior optic-haptic square edge,
posterior optic-haptic square edge, 360
degree optic square edge and aspheric
optic for aberration control

BL030 enVista The enVista, Model MX60, is an ultra- Overall diameter 12.5mm, optic $364.00

violet-absorbing, posterior chamber,   body diameter 6.0mm in
hydrophobic acrylic one-piece intraocular            dioptric powers ranging from
lens (IOL) Has an aspheric lens optic,                 +0.0 to +34D
square posterior edge, modified C haptics            0.0D to 10.0D in 1 Diopter
and available in dioptric powers ranging              increments
from +0.0 to +34.0D.  11.0D to 30.0D in 0.5 Diopter

increments
31.0D to 34.0D in 1 Diopter
increments

Prostheses List by Category, Groups and Sponsor Page 6 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Carl Zeiss Pty Ltd

CZ030 CT ASPHINA 404 Small incision, foldable, single piece, Diopter range: -10.0 to 42.0, $364.00

monofocal, aspheric (aberration neutral), Optic size: 6.0mm, Overall
square-edged, hydrophilic acrylic (with length: 11.0mm
hydrophobic surface properties)
intraocular lens for capsular bag fixation.
(Monofocal lens for powers outside
standard 409MP MICS range).

IQ Medical

IQ004 Softec Acrylic, single piece, foldable intraocular Available in dioptric powers $364.00

lens with anterior and posterior optic-                   from -5.0 to +36.0, 1D steps: -
haptic square edge, 360 degree optic                    5.0 to +10.0 and +31.0 to
square edge design, precision power                    +36.0; 0.5D steps: +10.5 to
calculation and aberration technology                   +18.0 and +25.0 to +29.5;

0.25D steps: +18.0 to +25.0

IQ010 PreciSAL 302AC Acrylic, single piece, foldable intraocular Available in dioptric powers $364.00

lens with anterior and posterior optic-                   from 0.0 to +30.0. 1D steps:
haptic square edge, 360 degree optic                    0.0 to +10.0; 0.5D steps:
square edge design, precision power                    +10.5 to + 17.5 and +28.5 to
calculation, aberration technology and UV          +30.0; 0.25D steps: +18.0 to
light filter.  +28.0

Kevin Grundy (IBD) Pty Ltd

KG012 Rayner "C-Flex" and Superflex" Aspheric Intra Ocular Lenses with Amon- C-Flex -970C + 22.5D to $364.00

Aspheric IOL Apple enhanced 360 Degree square edge, +34D Superflex-920H - 10D

Anti-vaulting Haptics to +22D

at, pl

Carl Zeiss Pty Ltd

CZ011 CT ASPHINA 603P Aspheric, pre-loaded, hydrophilic acrylic, 6.0mm Optic x 10.5mm Overall $374.00

single piece, trihaptic IOL with square Diameter
edge design, for use with SkyJet injector

Ellex Australia Pty Ltd

XE004 Preloaded Aspheric Intraocular Lens Silicone intraocular lens 6.0mm $374.00

Prostheses List by Category, Groups and Sponsor Page 7 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

at, pl, t1, vblf

Design for Vision Pty Ltd

DV253 HOYA AF-1 351 Toric T3/T4/T5 Preloaded injector system, correct corneal IOL Power: + 6.0D to 30.0D $800.00

astigmatism micro-incision, ashperic, blue- (0.5 steps), IOL Cylinder
blocker, single piece hydophobic. power: 1.50D (T3), 2.25D

(T4), 3.00D (T5).

at, pl, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL024 AcrySert model SN60WS Foldable Acrylic Single-piece Lens with +6 to +30 D $405.00

Blue light protection and aspheric
correction, in cartridge.

AL031 AcrySert C Model SN6CWS Posterior chamber, UV absorbing, +6.0 to +30.0 D $405.00

foldable, acrylic, single piece lens with blue
light protection and aspheric correction, in
cartridge

Design for Vision Pty Ltd

DV250 Hoya-PS AF-1 (UY) PY-60AD Preloaded in cartridge, Aspheric, Blue +6.0D to +30.0D (0.5D steps) $405.00

blocker, Foldable, Single-Piece,
Hydrophobic Acrylic

DV252 HOYA iSert® 251 Preloaded injector system, Micro-incision, +6.0D to 30.0D (5 steps) $405.00

Aspheric, Blue-Blocker, Single Piece,
Hydrophobic

at, t1

AMO Australia Pty Ltd

AO031 TECNIS® Toric 1-Piece IOL 1-piece IOL Posterior chamber +5.0 to +34.0 diopter powers $740.00

Intraocular lens, incorporates a proprietary           in 0.5 diopter increments.
wavefront designed toric aspheric optic              Cylinder power: 1.00 diopter,
with a squared posterior optic edge   1.50 diopter, 2.25 diopter,
designed to provide a 360 degree barrier.             3.00 diopter and 4.00 diopter
The edge of the optic has a frosted design            (as measured at the IOL plane).
to reduce potential edge glare effects.                    Overall diameter 13mm, Optic

size 6mm.

at, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL021 Alcon AcrySof SN60WF Foldable Acrylic Single-piece Lens with + 6.0 D to +30.0 D $385.00

Blue Light Protection and Aspheric
Correction

Prostheses List by Category, Groups and Sponsor Page 8 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Bausch & Lomb (Australia) Pty Ltd

BL025 SofPort Advanced Optic (AO) Violet Posterior chamber, aphakic, foldable 6mm optic 13mm overall length $385.00

Shield silicone, anterior & posterior edge Modified C 5 degree

modification intraocular lens with angulation 0-30D, 0.5D steps
aberration technology, a violet light

Design for Vision Pty Ltd

DV247 HOYA AF-1 iMics1 NY-60 Mini Incision, Aspheric, Blue-blocker, +6.0D to 30.0D (0.5 steps) $385.00

Single-piece, Hydrophobic

IQ Medical

IQ009 Softec HDY Acrylic, single piece, foldable intraocular Available in dioptric powers $385.00

lens with anterior and posterior optic-                   from -5.0 to + 36.0, 1D steps:
haptic square edge, 360 degree optic                    -5.0 to +10.0 and +31.0 to
square edge design, precision power                    +36.0; 0.5D steps: +10.5 to
calculation, aberration technology and blue           +18.0 and +25.0 to 29.5;
light filter  0.25D steps: + 18.0 to +25.0

IQ011 PreciSAL 302A Acrylic, single piece, foldable intraocular Available in dioptric powers $385.00

lens with anterior and posterior optic-                   from 0.0 to +30.0. 1D steps:
haptic square edge, 360 degree optic                    0.0 to +10.0; 0.5D steps:
square edge design, precision power                    +10.5 to +17.5 and +28.5 to
calculation, aberration technology and blue           +30.0; 0.25D steps: +18.0 to
light filter.  +28.0

pl

Ellex Australia Pty Ltd

XE005 Staar KS-Xs Preloaded Acrylic Preloaded acrylic lens with anterior and Optic diameter 6.0mm, overall $332.00

Intraocular Lens posterior edge modification length 12.5mm, diopter range

+10 to +28.0

t1

Bausch & Lomb (Australia) Pty Ltd

BL028 Akreos Toric Astigmatism- Correcting Single piece, foldable, acrylic intraocular The overall diameter is 11 $698.00

Lens lens with a toric optic on the posterior millimetres for the entire lens

surface and axis marks on the posterior power range (spherical
optic's flat meridian. equivalent powers from +10.0

to +30.0 diopters in 0.5 diopter
steps and cylinder powers of
+1.25, +2.00 & +2.75
diopters).

Prostheses List by Category, Groups and Sponsor Page 9 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Kevin Grundy (IBD) Pty Ltd

KG003 Rayner Standard Toric C-Flex Hydrophilic HEMA-MMA copolymer, 5.00mm dia optic, 12.00mm $698.00

foldable with injector dia overall, cyls 2.0D to 6.0D in

2D increments

t1, at, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL032 AcrySof IQ Toric IOL Posterior chamber, UV absorbing, +6 to +30 D spherical; 1.00 to $780.00

foldable, acrylic, toric, single piece lens 6.00 D cylinder.
with blue light protection and aspheric
correction

Design for Vision Pty Ltd

DV251 HOYA AF - 1 311 Toric T3/T4/T5 Correct Corneal Astigmatism, Micro- lOL Power: 6.0D to 30.0D $780.00

incision,Aspheric, Blue-Blocker, Single (0.5 steps)lOL Cylinder
Piece, Hydrophobic Power: 1.50D (311T3), 2.25D

(311T4), 3.00D (311T5)

t1, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL023 Alcon AcrySof Toric PC IOL Models Posterior chamber, UV absorbing, +6 to +34 D spherical; 1.50 to $740.00

foldable, acrylic, toric, single piece lens 6.00 D cylinder
with blue light protection

t2

Kevin Grundy (IBD) Pty Ltd

KG004 Rayner Premium Toric C-Flex HEMA-MMA copolymer, foldable with 5.75mm dia optic, 12.00mm $1,000.00

injector dia overall, cyls 1.5D to 11.0D

in 0.5D increments

KG013 Rayner Super Premium Toric I.O.L. Acrylic foldable toric single piece I.O.L -10.0D to 0.00D Sphere: 1D to $1,000.00

11.00D Cylinder in 0.25 steps
+31.00D to +35.00 Spit:
1D to 11.00D Cylinder in
0.25steps

vblf

Alcon Laboratories (Aust.) Pty Ltd

AL016 Alcon Acrysof Natural Model SN60AT Foldable Acrylic Single-piece Lens, +6 to +40D $364.00

asymmetric optic/consistent edge, with
blue light protection

Prostheses List by Category, Groups and Sponsor Page 10 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

AL025 AcrySof Multipiece Models MN60MA, Foldable Acrylic multi-piece Lens with - 5 D to + 30 D $364.00

MN60AC Blue light Protection

1.2.2.4 - Multifocal or bifocal

AMO Australia Pty Ltd

AO020 ReZoom Acrylic Multifocal Intraocular Acrylic, foldable, posterior chamber, 6.0mm Optic Diameter x $780.00

Lens intraocular lens 13.0mm overall length

AO023 TECNIS™ Multifocal Intraocular Lens Tecnis Multifocal foldable Posterior +5.0 Diopter to 34.0 Diopter in $780.00

(ZM900) Chamber Diffractive Intraocular Lens 0.5 diopter increments

Model ZM900. Posterior Chamber lens
with UV light-absorbing, foldable, silicone,
3 piece with a diffractive posterior optic
and a Modified Prolate Anterior Surface
Technology

at

AMO Australia Pty Ltd

AO026 TECNIS™ Multifocal Intraocular Lens Posterior chamber lens with UV light- +5 diopters to +34 diopters in $822.00

(ZMA00) absorbing, foldable acrylic, 3-piece with a 0.5d increments

diffractive posterior optic and a modified
anterior surface technology with edge
modification and 360 degree square edge.

AO027 Tecnis Multifocal 1-Piece Lens, Model A multifocal posterior chamber lens with 6.0mm Optic Diameter x $822.00

ZMB00 UV-blocking, foldable acrylic, 1-piece 13.0mm in overall length. +5.0

with a diffractive posterior optic and a Diopter to +34.0 Diopter in 0.5
modified anterior surface technology with Diopter increments.
edge modification and a 360 degree
square edge.

Carl Zeiss Pty Ltd

CZ015 AT LISA 809M ZEISS micro incision, aspheric multifocal 6mm optic, 11mm diameter. $822.00

IOL. Diffractive bifocal anterior surface Diopter range 0.0D to +32.0D
with asymmetric light distribution (65% (0.5D steps)
distance / 35% near), 3.75D addition for
near focus.

Prostheses List by Category, Groups and Sponsor Page 11 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Kevin Grundy (IBD) Pty Ltd

KG009 Rayner "M-Flex" Mulitfocal Foldable IOL Acrylic, Foldable, Single piece multi-zoned 6.5mm Optic-Overall diameter $822.00

refractive aspheric multifocal with Amon-           12.5mm: +3D or + 4D
Apple 360 Degree Square edge, Anti                  Addition: +14D to +25D in
Vaulting Haptics  1.0D increments: +8.5D to

+23.5D in 0.5D increments

at, pl

Carl Zeiss Pty Ltd

CZ033 AT LISA 809MP Preloaded, micro incision, aspherical Diopter range: 0.0 to 32.0 $842.00

bifocal, square edged, single-piece IOL for Optic size: 6.0mm. Overall
capsular bag fixation. The anterior length: 11.0mm
aspheric bifocal surface has an asymmetric
light distribution 65/35 for distance/near
vision, and 3.75D add for the near focus.

at, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL028 AcrySof IQ ReSTOR SN6AD3 Posterior Chamber, UV absorbing, +6 D to + 34 D $864.00

foldable, acrylic, single piece lens with
apodised diffractive optic and blue light
protection

AL030 AcrySof IQ ReSTOR SN6AD1 and Posterior Chamber, UV absorbing, +6 D to + 34 D $864.00

MN6AD1 foldable, acrylic, single and multiple lenses

with apodised diffractive optic and blue
light protection

Design for Vision Pty Ltd

DV248 HOYA PY-60MV Preloaded in cartridge, Multifocal, +14.0D to 27.0D (0.5 steps) $864.00

Aspheric, Blue-blocker, Single Piece,
Hydrophobic

t1, at

Carl Zeiss Pty Ltd

CZ025 AT LISA toric 909M ZEISS micro incision, multifocal toric IOL 6mm optic, 11mm diameter. $1,198.00

(standard cyl range). Aspheric toric   Diopter range: Sph -10.0D to
anterior surface, diffractive bifocal   +32.0D, Cyl +1.0 to 6.5D (all
posterior surface with asymmetric light                0.5D steps)
distribution (65% distance / 35% near),
3.75D addition for near focus.

Prostheses List by Category, Groups and Sponsor Page 12 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Kevin Grundy (IBD) Pty Ltd

KG010 Rayner M-Flex Toric (Standard) Acrylic, Foldable, Single Piece, Multi- 5.75mm / 12.0mm: 6.25mm / $1,198.00

zoned Refractive Aspheric Toric Mulitfocal         12.5mm +3.00D or +4.00D
with Amon-Apple enhanced 360 degree             Addition FAR: +14.0D to
Square edge, Anti Vaulting Haptics  +32.00D in 0.5 STEPS:

+2.00D +3.00D +4.00D
Cylinder. NEAR: +14.0D to
27.0D in 0.5 STEPS: +2.00D
+3.00D +4.00D Cylinder

KG011 Rayner "M-Flex" Toric (Non Standard) Acrylic, Foldable, Single Piece, Muli- 5.75/12.0mm: 6.25/12.5mm $1,198.00

Zoned Refractive, Toric Multifocal with              +3.00D to +4.00D Addition
Amon-Apple enhanced 360 Degree   FAR: +14.0D to +32.0D in
square edge, Anti-vaulting Haptics, Patient         0.5D Increments: NEAR:
Specific.  +14.0D to +27.0D in 0.50D

Increments Cylinder: 1.0D to
1.5D and 2.5D to 6.00D in 0.5
increments

t1, at, vblf

Alcon Laboratories (Aust.) Pty Ltd

AL033 AcrySof IQ ReSTOR multifocal toric IOL Posterior chamber UV absorbing foldable, +6 to +34 D spherical; 1.00 to $1,240.00

acrylic, aspheric, toric single piece lense 3.00 D cylinder
with apodised diffractive optic and blue
light protection.

t2, at

Carl Zeiss Pty Ltd

CZ024 AT LISA toric 909M ZEISS micro incision, multifocal toric IOL 6mm optic, 11mm diameter. $1,500.00

(standard cyl range). Aspheric toric   Diopter range: Sph -10.0D to
anterior surface, diffractive bifocal   +32.0D, Cyl +7.0 to 12.0D (all
posterior surface with asymmetric light                 0.5D steps)
distribution (65% distance / 35% near),
3.75D addition for near focus.

Prostheses List by Category, Groups and Sponsor Page 13 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.2.2.5 - Accommodative

pa

Bausch & Lomb (Australia) Pty Ltd

BL027 Crystalens HD Accommodating lens with > 3 Dioptres of 10.0 to 33.0 Dioptres in .05 $780.00

accommodation with dual mechanism of Dioptre steps
action: (1) forward axial movement of lens
and (2) accommodative arching of optic.
Posterior chamber, polyspheric optics, 3-
piece, plate haptic, foldable UV light
filtering, bic

IQ Medical

IQ003 Tetraflex Acrylic single piece, foldable Available in dioptric powers $780.00

accommodating intraocular lens with sqare          from +5.0 to +36.0, 1D steps:
edge design, custom control precision and            +31.0 to +36.0; 0.5D steps:
closed loop haptic design  +5.0 to +18.0 and +25.0 to

+30.0; 0.2D steps; +18.0 to
+25.0

pa, at

Bausch & Lomb (Australia) Pty Ltd

BL029 Crystalens AO Accommodating lens designed to provide 10.0 to 33.0 D in 0.50 Diopter $822.00

> 3 Diopters of accommodation with dual            steps. 10.0 - 16.5 Diopters
mechanism of action: (1) forward axial                (12mm length) and 17.0 - 33.0
movement of lens and (2) accommodative            Diopters (11.5mm length).
arching of optic. Posterior chamber,
aspheric, aberration free optics, 3-piece,
plate haptic, fol

pa, pl

AMO Australia Pty Ltd

AO028 Synchrony Accommodating IOL Synchrony Dual Optic Accommodating 5.50mm Anterior Optic, $800.00

Posterior Chamber IOL 6.00mm Interior Optic,

9.80mm Overall Length,
Diopter Range: +16.00 to
+28.00 in 0.5D Increments

Prostheses List by Category, Groups and Sponsor Page 14 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.2.3 - Pseudo-phakic, piggy-back

1.2.3.1 - Monofocal

Design for Vision Pty Ltd

DV246 Rayner Sulcoflex Ashperic (Premium) Pseudophakic Supplementary I.O.L.O.L. -10.0D to -5.50D in 0.5D $323.00

I.O.L. increments. +5.50D

to 10.00D in 0.5D increments

at

Kevin Grundy (IBD) Pty Ltd

KG008 Rayner "Sulcoflex" Pseudophakic I.O.L. Sulcoflex Aspheric Pseudophakic I.O.L -5D to +5D $365.00

t1, at

Kevin Grundy (IBD) Pty Ltd

KG005 Rayner Sulcoflex Aspheric Toric Acrylic, Aspheric, Toric Pseudophakic SE -3 to +3 in 0.5 D steps $698.00

Pseudophakic Secondary I.O.L - Secondary IOL : Sulcus fixated with Cyl +1 to +3 in 1D steps

Standard undulating Haptics and Posterior Haptic

Angulation (Standard)

KG007 Rayner Sulcoflex Aspheric Toric Acrylic, Aspheric, Toric Pseudophakic SE -6.00 to +6.00 in 0.5 D $698.00

Pseudophakic Secondary IOL (Premium) Secondary IOL: Sulcus fixated with steps Syl +1.00 to +6.00 in

undulating Haptics and Posterior Haptic 0.5D steps
Angulation (Premium)

1.2.3.2 - Multi-focal

at

Kevin Grundy (IBD) Pty Ltd

KG006 Rayner "Sulcoflex" Aspheric Multi-focal Acrylic, Aspheric Multi-focal 6.5mm / 13.5mm - $822.00

Pseudophakic Secondary IOL Pseudophakic Secondary IOL: Sulcus- 5.00D+5.00D sphere with +

Fixated with Undulating Haptics and 3.00 Addition
Posterior Haptic Angulation

1.3.1 - Viscoelastic

Alcon Laboratories (Aust.) Pty Ltd

AL006 PROVISC VISCOELASTIC PROVISC contains sodium hyaluronate 0.85mL pack $80.00

SOLUTION

Prostheses List by Category, Groups and Sponsor Page 15 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

AL007 VISCOAT Viscoelastic Fluid Chondroitin sulfate and sodium hyaluronate 0.75mL $80.00

AL015 Cellugel viscoelastic fluid Hypromellose 2% . $80.00

AL029 DisCoVisc Ophthalmic Viscosurgical Sodium hyaluronate 17 mg/mL and 0.5 mL and 1.0 mL $80.00

Device chondroitin sulfate 40mg/mL

AMO Australia Pty Ltd

AO008 Healon, Intraocular Viscoelastic Fluid Sodium Hyaluronate 10mg/ml Healon 0.4ml, 0.55ml & 0.85ml $80.00

Bausch & Lomb (Australia) Pty Ltd

BL008 Ocucoat Intraocular Fluid 20mg/mL hydroxypropylmethyl cellulose 1mL sterile $80.00

for intraocular use

BL015 Amvisc Plus injection 15mg/mL Sodium Hyaluronate for 0.5mL and 0.8mL $80.00

intraocular use

Carl Zeiss Pty Ltd

CZ022 VISTHESIA 1.5% VISCOANAESTHETIC syringe contains 0.8ml syringe & 2x0.3ml $80.00

sodium hyaluronate (NaHA, 1.5%) and ampoules
lidocaine hydrochloride (1%). Also
contains two topical ampoules with NaHA
(0.3%) and lidocaine (2%)

IQ Medical

IQ002 Ocuvis and Ocumax 2% 20mg/mL hydroxypropylmethyl cellulose 2mL sterile $80.00

Hydroxypropylmethylcellulose for intraocular use. Pre-loaded in a sterile

syringe with one cannula for injection, in a
sterile Tyvek pouch

hmw

AMO Australia Pty Ltd

AO009 Healon 5, Intraocular Viscoelastic Fluid HEALON5- Sodium hyaluronate 23mg/ml 0.6ml $85.00

.

AO010 Healon GV Intraocular Viscoelastic Fluid Sodium Hyaluronate 14mg/mL 0.5mm and 0.85ml $85.00

Carl Zeiss Pty Ltd

CZ012 Z-HYALIN Viscoelastic Cohesive Viscoelastic Solution - sodium Volume 1.0ml $85.00

hyaluronate 10mg/ml. (previously called
Ophthalin)

Prostheses List by Category, Groups and Sponsor Page 16 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

CZ013 Z-HYALIN Plus Viscoelastic Cohesive Viscoelastic Solution - sodium Volume 1.0ml $85.00

hyaluronate 15mg/ml. (previously called
Opthalin Plus)

1.3.1.1 - Dual Fluids

Alcon Laboratories (Aust.) Pty Ltd

AL005 DUOVISC VISCOELASTIC PROVISC contains sodium hyaluronate, Small & large packs $110.00

SYSTEM VISCOAT contains chondroitin sulfate

and sodium hyaluronate

Carl Zeiss Pty Ltd

CZ019 TWINVISC Viscoelastic TWINVISC includes a cohesive and a Total volume 1.4 ml $110.00

dispersive viscoelastic in one syringe,
separated by a valve. Dispersive: sodium
hyaluronate (2.2%). Cohesive: sodium
hyaluronate (1%)

1.3.2 - Non Viscous

Design for Vision Pty Ltd

DV231 Vision Blue Trypan blue dye for ophthalmic applications 0.5ml syringe $48.00

1.4.1 - Simple

Alcon Laboratories (Aust.) Pty Ltd

AL001 Capsular Tension Rings - 10.0 - 12.0 compressed, 12.3 $159.00

- 14.5 uncompressed

AMO Australia Pty Ltd

AO021 Stabileyes Capsular Tension Ring Polymethylmethacrylate (PMMA) Implant 12mm ring, and 13mm ring $159.00

Carl Zeiss Pty Ltd

CZ002 Tensiobag: Capsular Tension Ring PMMA Diameter 10 - 14mm $159.00

Prostheses List by Category, Groups and Sponsor Page 17 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Design for Vision Pty Ltd

DV009 Morcher Capsular Tension Ring PMMA Implant 14, 14A, 14C $159.00

Emagin Pty Ltd

EG001 Capsular Tension Rings Clear PMMA Implant 10/08, 12/10, 13/11mm $159.00

pl

Design for Vision Pty Ltd

DV029 Eyejet CRT Capsular tension ring made of PMMA 14 (10mm), 14C (11mm), 14A $243.00

per-load on disposable injector (12mm)

Insight Surgical Pty Ltd

IS001 Preloaded Capsulan Tension Ring Capsular tension ring preloaded (acrylic) 13/11mm $243.00

1.4.2 - Complex

Design for Vision Pty Ltd

DV010 Morcher Coloboma Diaphram PMMA Implant 96G, 96L $334.00

1.5.1 - Long Tube

AMO Australia Pty Ltd

AO012 Baerveldt Glaucoma Implant BG 101- Non-valved artificial drainage device, Surface area 250, 350, 425mm2 $425.00

350, Baerveldt Glaucoma Implant BG composition silicone - smooth, tumble-

103-425, Baerveldt Glaucoma Implant polished finish

BG 103-250

Design for Vision Pty Ltd

DV020 Molteno Implant Double plate - dual chamber One size only $425.00

DV242 Molteno Implant Glaucoma Drainage Device - Single N/A $425.00

Plate/Single Plate-Dual Chamber/Double
Plate

v

Design for Vision Pty Ltd

DV230 Molteno 3 Drainage implant for glaucoma, made of 2 Sizes: *230 mm square $625.00

silicon *175mm square

Prostheses List by Category, Groups and Sponsor Page 18 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.5.2 - Short Tube

1.5.2.1 - Cannulated

Alcon Laboratories (Aust.) Pty Ltd

AL037 ExPress Minature Glaucoma Shunt Miniature Glaucoma Shunt 50 & 200 microns $715.00

1.6.1 - Spacers

Spectrum Surgical

SO017 FCI Ptose-up Expanded PTFE 15cm long x 2 or 3mm wide x $348.00

0.35mm thick

1.6.2 - Weights

1.6.2.1 - Gold <1.8 grams

Device Technologies Australia Pty Ltd

DE183 Lid Load Gold Eyelid Weights; Gold 0.6, 0.8, 1.0, 1.2, 1.4, 1.6 $425.00

grams

1.6.2.2 - Gold ≥1.8 grams

Device Technologies Australia Pty Ltd

DE182 Lid Load Gold Eyelid Weights; Gold 1.8, 2.0, 2.2, 2.4, 2.6, 2.8 $800.00

grams

1.6.2.3 - Platinum

CoreMed Pty Ptd

RC001 LIDCHAIN Platinum Eyelid Implant Platinum Weights - 0.8, 1.0, 1.2, 1.4, $1,300.00

1.6, 1.8 grams

Prostheses List by Category, Groups and Sponsor Page 19 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.7.1 - Intracanilicular

Design for Vision Pty Ltd

DV022 Eyetec DCR Tubes Stainless steel, silicone tubing, Bodkin 30cm $135.00

lacrimal intubation set

DV241 Eyetec DCR Tubes Crawford and Cannaliculus Intubation Sets N/A $135.00

Device Technologies Australia Pty Ltd

DE191 Canaliculus Intubation Sets Silicone, SS & Nylon 17.7 x .064 x 29cm, 15.5 x $135.00

.051 x 33cm

DE278 BD Visitec Lacrimal Intubation Sets Stainless steel probes with solid silicone 1. Probes 0.90mm x 4.5cm, $135.00

rods or silicone tubing - packaged sterile rod 40cm x 0.80mm. 2. Probes

0.40mm x 11cm, tubing 35cm
x 0.64mm. Probes 0.60mm x
11mm, tubing 35cm x 0.30mm.

Spectrum Surgical

SO021 FCI Lacrimal Intubation Set PVP Coated Silicone Tubing/PVP Coated PVP Bika: 0.64mm O.D. $135.00

Silicone Plug/Metal Probes/Polypropylene Tube/80 x 0.8mm probes, PVP
Thread Differential Bika: 0.64 &

1.18mm O.D. Tube/40 x
1.2mm probes, PVP Bika for
DCR: 0.94mm O.D. Tube/50 x
0.8mm probes, PVP Infant
Bika 0.64mm O.D. Tube/55 x
0.7mm probes, PVP Infant
Bika II: 0.64mm O.D. Tube/

SO043 FCI Bi-Canalicular Lacrimal Intubation Silicone tubing swaged, imbedded into or Probes: 40mm to 120mm x $135.00

Set around malleable and flexible stainless steel 0.7mm to 1.2mm. Tube:

probes. PEEK thread. 0.64mm to 1.18mm x 25mm to

400mm. PEEK Thread: 0.2mm
to 0.4mm x 500mm.

Prostheses List by Category, Groups and Sponsor Page 20 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

mc

Spectrum Surgical

SO044 FCI Mono-Canalicular Lacrimal Silicone tubing with plug swaged, Probes: 40mm to 120mm x $180.00

Intubation Set imbedded into or around malleable or 0.7mm to 1.2mm. Tube:

flexible stainless steel probes or guides. 0.64mm to 1.18mm x 30mm to
PEEK thread. Introducer. 350mm. PEEK Thread: 0.2mm

to 0.4mm x 500mm. Plug
Collar: 2mm to 4mm.

1.7.2 - Extracanilicular

Device Technologies Australia Pty Ltd

DE177 Lester Jones Tear Duct Tubes Glass 3 x 9 to 16mm, 3.5 x 9 to $84.00

18mm, 4.0 x 9 to 24mm, 5.0 x
9mm

1.8.1 - Intrascleral

Device Technologies Australia Pty Ltd

DE188 Acrylic Implant Acrylic 12, 14, 16, 18, 20mm. $55.00

DE202 John Weiss Glass Mule Globes Glass No: 12, 14, 16, 18, 20mm $55.00

Spectrum Surgical

SO040 FCI Orbital Implants Silicone - Sterile 12mm to 22mm $55.00

vp

Spectrum Surgical

SO006 FCI Orbital Implants Orbital Implant, Bioceramic (Aluminium Bioceramic diameter, 12, 14, $1,200.00

Oxide)/Hydroxyapatite (Synthetic) 16, 18, 20, 21, 22mm;

Synthetic Diameter, 10, 12, 14,
16, 18, 20, 22mm

Prostheses List by Category, Groups and Sponsor Page 21 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.8.2 - Extrascleral

1.8.2.1 - Complex and permeable

Stryker Australia Pty Ltd

SK521 Sphere Orbital Sphere Models 6316, 6326, 6327, Orbital Sphere Models 6316: $785.00

6317 and 6322 8702-8704. COI implant,            14mm, 6326: 16mm, 6327:
models 7222, 7223 & 80026. MCOI                  18mm, 6317: 20mm, 6322:
implant, models 7207 - 7209 Quad   22mm, 8702: 19mm, 8703:
Motility Implants 9866 - 9868 & 80022               21mm, 8704: 23mm, COI

Implants 7222: Approx 4ml,
7223: Approx 5ml, 80026:
Approx 6ml, MCOI 7207:
Approx 3ml, 7208: Approx
4.2ml, 7209: Approx 5.6ml,
QUAD Motility Small 16ml,
Medium: 18ml, Large: 20ml,
Extra Large: 22ml.

ha

Spectrum Surgical

SO007 FCI Orbital Implants Mesh wrapped orbital implant: mesh Bioceramic diameter: 16, 18, $1,600.00

wrapped bioceramic (aluminium oxide),              20, 22mm; Synthetic
mesh wrapped hydroxyapatite (synthetic),            Hydroxyapatite diameter: 16,
mesh wrap (polyglycolic acid)  18, 20, 22mm

1.8.2.2 - Multi-component

Spectrum Surgical

SO019 FCI Orbital Implants Peg & Sleeve Standard Large $863.00

1.8.3 - Fascial - solid and permeable

Device Technologies Australia Pty Ltd

DE277 Frontalis Suspension Set Stainless steel needles with solid silicone needles 0.90mm x 6.5cm, rod $315.00

rods and silicone tubing - packaged sterile 40cm - 0.80mm, sleeve 10 x

2mm

Prostheses List by Category, Groups and Sponsor Page 22 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Spectrum Surgical

SO045 FCI Ptosis Probes Stainless steel needle probes swaged with 80mm x 0.8mm needle probes, $315.00

silicone tubing. 280mm 0.64mm tubing.

1.9.1 - Buckles, bands, tyres and sponges

Austmed Pty Limited

AP003 Mira: Scleral Implants Solid Silicone- Tires-Mira 286 Wendel $45.00

Tire/Meridional/Wedge/Pad. Retinal   Symmetrical Oval Tire 6mm,
Implant used in Scleral Buckling   Mira Symmetrical Oval Tire
(Dimethylmethylvinyl Siloxane Copolymer)        7mm, Mira 287WG Murray

wide (3.5mm) grooved
symmetrical tire, 10mm wide,
Mira 288 ross symmetrical
grooved tire, low profile 10mm
wide by 2.5mm, Mira 289
Symmetrical oval tire 10m

AP004 Mira: Scleral Implants Solid Silicone-Sleeve. Retinal Implant used Sleeves-Mira 70 Sleeve 1mm $45.00

in Scleral Buckling (Dimethylmethylvinyl I.D., Mira 71 Sleeve 1mm I.D.,
Siloxane Copolymer) Mira 72 McNutt Sleeve

1.57mm I.D., Mira 270 Sleeve
0.76mm I.D.

AP006 Mira: Scleral Implants Solid Silicone-Band/Strip/Boat/Clip. Bands-Mira 40 Circling Band $45.00

Retinal Implant used in Scleral Buckling 2mm, Mira 240 Circling Band
(Dimethylmethylvinyl Siloxane Copolymer) 2.5mm. Strips-Mira 41 Strip

3.5mm, Mira 42 Strip 4mm,
Mira 20 Strip 4mm, Mira 219
Strip 4.5mm, Mira 31 Strip
4.5mm, Mira 32 Strip 5mm,
Mira 225 Oval Strip 5mm,
Mira 220 Strip 6mm. Boats-
Mira 60 Boat

Device Technologies Australia Pty Ltd

DE179 Silicon Retinal Implant Tire 7.0, 9.0, 12.5, 6.0, 8.5, 10.0mm $45.00

Prostheses List by Category, Groups and Sponsor Page 23 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

DE181 Silicon Retinal Implant Band 0.75 x 2.0 x 125mm, 0.60 x $45.00

2.5 x 125mm, 0.75 x 2.5 x
125mm

Spectrum Surgical

SO009 FCI Scleral Buckling Devices Band/strip: solid silicone Band - 2.0 x 0.75mm Type 40, $45.00

3.5 x 0.75mm Type 41, 4.0 x
1.25mm Type 42, 2.5 x 0.6mm
Type 240, Morin 3.5 x 0.6mm
Strip - 5.7mm Type 20,
7.2mm Type 31, 9.2mm Type
32, 6mm Type 219, 7.5mm
Type 220, 8mm Type 225

SO011 FCI Scleral Buckling Devices Tire: Solid Silicone Symmetrical: (2.5 mm Groove, $45.00

7 to 9mm wide), Biconvex:
(2.5mm Groove, 7 to 10mm
wide), Asymetrical: (2.5mm
Groove, 7 to 10mm wide)

SO013 FCI Scleral Buckling Devices Strip: Solid Silicone Strip: 1.4 x 4.4 x 100mm, $45.00

Morin Strip: 7mm wide x
100mm long, Caputo Zip Strip:
7 to 9mm wide x 120mm long,
Korobelnik Oval Strip: 2 x
5mm

1.9.1.1 - Sponges

Austmed Pty Limited

AP002 Mira: Scleral Implants Silicone Sponge- Retinal Implant Used in Sponge- Mira 502 Cylinder $90.00

Scleral Buckling (Silicone Elastomer 2mm, Mira 5025 Cylinder
Sponge) 2.5mm, Mira 503 Cylinder

3mm, Mira 504 Cylinder 4mm,
Mira 505 Cylinder 5mm, Mira
505G Grooved cylinder 5mm,
Mira 505T Packer tunnel
cylinder 5mm, Mira 510 Half
cylinder 5mm, Mira 515
Brucker two-thirds cyl

Prostheses List by Category, Groups and Sponsor Page 24 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Device Technologies Australia Pty Ltd

DE178 Silicon Retinal Implant Sponge 2.5 x 4.0 x 80mm, 3.0 x 5.0 x $90.00

100mm, 3.25 x 7.0 x 80mm,

5.5 x 7.5 x 80mm, 1.5 x 80mm,
2.0 x 80mm, 2.5 x 80mm, 3.0
x 80mm, 4.0 x 80mm, 5.0 x
80mm, 7.0 x 80mm

Spectrum Surgical

SO012 FCI Scleral Buckling Devices Sponge/Cord: Silicone Cord: 1.0 to 5.0mm O.D. x $90.00

150mm length; Half Cord:
3.0mm to width x1.5mm to
2.5mm height x150mm;
Circular Sponge: 3 to 5mm;
Oval Sponge: 2 to 5.5mm x 4
to 12mm; Half Sponge: 2 to
3.1mm x 4 to 7.5mm; Grooved
Sponge: 3 to 5mm x 5 to
12mm; Gain Sponge: 6 x

1.9.2 - Clips and tacks

Device Technologies Australia Pty Ltd

DE201 Labtician Tantalum Clips Tantalum 2, 2.5mm $50.00

1.9.3 - Sleeves

Device Technologies Australia Pty Ltd

DE180 Silicon Retinal Implant Sleeve 1mm, .76mm, 1.5mm $25.00

Spectrum Surgical

SO010 FCI Scleral Buckling Devices Fixation Sleeve: Solid silicone O.D: 1.65 to 2.41mm, Length $25.00

30mm

Prostheses List by Category, Groups and Sponsor Page 25 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.9.4 - Intraocular Gases

Alcon Laboratories (Aust.) Pty Ltd

AL035 ISPAN Retinal Gases for Constellation® Tamponade gases for retinal surgery C3F8 125g cylinder, dispensed in $75.00

Vision System and SF6 single dose syringe

AL036 ISPAN retinal gases Tamponade gases for retinal surgery C3F8 125 g cylinder, dispensed in $75.00

and SF6 single dose syringe

Device Technologies Australia Pty Ltd

DE284 Single Dose Ophthalmic Gases Single dose tamponading gas for retinal 30ml $75.00

surgery

1.9.5 - Intraocular Heavy Liquids

Alcon Laboratories (Aust.) Pty Ltd

AL013 Perfluoron Kits Perfluoro-n-octane for use as a retinal 5mL $240.00

surgery additive

AL014 Perfluoron Kits Perfluoro-n-octane for use as a retinal 7mL $240.00

surgery additive

Bausch & Lomb (Australia) Pty Ltd

BL017 Perfluo-octane (Oktaline) Okta-Line Perfluorocarbon Liquid for use as a retinal 5mL $240.00

surgery additive

BL018 DK Line 100% purified perfluorodecalin Perfluorodecalin 7ml $240.00

Design for Vision Pty Ltd

DV244 D.O.R.C. Eftiar Eftiar Decaline and Octane 5ml 5ml $240.00

Device Technologies Australia Pty Ltd

DE204 Arcaline (Perfluorodecaline) Liquid perfluorocarbon aid for retinal 3ml, 5ml, 7ml $240.00

surgery, operative device for retinal
surgery, in particular retinal detachment
(RD), RD with giant tear etc.

Prostheses List by Category, Groups and Sponsor Page 26 of 944

1 - OPHTHALMIC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

DE205 Arcotane (Perfloro-N-Octane) Liquid perfluoro-N-Octane aid for retinal 5ml, 7ml $240.00

surgery, pre-operative device for retinal
surgery, in particular retinal detachment
(RD), RD with giant tear, RD with
proliferative vitreal retinopathy (PVR) etc.

IQ Medical

IQ005 Densiron Heavy Tamponade Liquid Medium, 10 ml, Sterile $240.00

Postoperative

IQ008 Octane & Decalin Perfluorocarbon retinal tamponade 5ml & 7ml, Sterile $240.00

medium, intraoperative

Spectrum Surgical

SO023 FCI - DECA, FCI - OCTA FCI - DECA: Purified perfluorodecalin, 5ml $240.00

FCI - OCTA: Purified perfluoro-N-octane

SO024 FCI - DECA, FCI - OCTA FCI - DECA: Purified perfluorodecalin, 7ml $240.00

FCI - OCTA: Purified perfluoro-N-
Octane

1.9.6 - Intraocular Silicone Oils

Bausch & Lomb (Australia) Pty Ltd

BL016 Oxane LMWC Fractioned Silicone Oil Purified fractioned silicone oil 10mL $195.00

BL024 Oxane HD Silicone oil - RMN3 mixture 10ml $195.00

Design for Vision Pty Ltd

DV243 D.O.R.C. Silicon Oil D.O.R.C. Silicon Oil 1000/5000CS 10ml $195.00

Device Technologies Australia Pty Ltd

DE228 LSO Silicone Oil Silicone oil for tamponade use in 10ml, vial or syringe $195.00

vitreoretinal surgery

IQ Medical

IQ006 Siluron 1000 & Siluron 5000 Silicone Oils 10 ml, Sterile $195.00

Spectrum Surgical

SO022 FCI Purified Silicone Oil (Solvent Free) Viscosity: 1000 cst/5000 cst: solvent free 10ml $195.00

purified silicone oil

Prostheses List by Category, Groups and Sponsor Page 27 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.1.1 - Bare Metal Stents

10.1.1.1 - Balloon Expandable

Abbott Australasia Pty Ltd

AY022 Cobalt Chromium Balloon Expandable Cobalt Chromium Diameter 4-10mm, Length 12- $1,800.00

Peripheral Stent 58mm

AY024 Omnilink Stainless Steel Balloon Stainless Steel Balloon Expandable 018 & 035 system: 5-10mm $1,800.00

Deployable Peripheral Stent Peripheral Stent on 018/035 system diameter by 12, 16, 18, 28, 38,

58mm length

B Braun Australia Pty Ltd

BB244 Coroflex Blue Cobalt Chromium Alloy L605 2-4mm diameter, 8-25mm length $1,800.00

Bard Australia Pty Ltd

BA218 Lifestent Valeo Stainless Steel Balloon Expandable 6-10mm diameter 17-56mm $1,800.00

Peripheral Stent length

Biotronik Australia Pty Ltd

BT094 Dynamic PTA Balloon Expandable Stent Diameters: 5-10mm, Lengths: $1,800.00

15, 25, 38, 56mm

Boston Scientific Australia Pty Ltd

BS059 Express Vascular LD Stent; Express Stainless Steel, Balloon Expanding Stent Stent Diameters up to 10mm $1,800.00

Vascular SD Stent and lengths up to 60mm

Cook Medical Australia Pty Ltd

WC234 Formula 414 Rx Renal Stent System Balloon Expandable Vasc/Biliary Stent Rapid exchange 014/018, 80- $1,800.00

135cm delivery system.
Diameters 4-10mm, lengths 0.8
- 4cm

Johnson & Johnson Medical Pty Ltd

JJ057 Palmaz Balloon Expandable Stent Stainless steel stent Diameter 4-12mm, length 20- $1,800.00

30mm

JJ058 Palmaz Balloon Expandable Stent Stainless steel stent Extra-large $1,800.00

JJ304 Palmaz Genesis Peripheral Stent and Stainless steel balloon expandable stent Diameter 3-8mm, length 12- $1,800.00

Delivery System on Slalom mounted on a slalom balloon 39mm

JJ305 Palmaz Genesis Peripheral Stent and Stainless steel balloon expandable stent Diameter 4-8mm, length 12- $1,800.00

Delivery System on Opta Pro mounted on an Opta Pro Balloon 39mm

Prostheses List by Category, Groups and Sponsor Page 28 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

JJ306 Palmaz Genesis Peripheral Stent Stainless steel peripheral stent Diameter 4-12mm, length 11- $1,800.00

79mm

JJ479 PALMAZ GENESIS on CORDIS Peripheral balloon expandable stent and Lengths: 12, 15, 18, 24mm. $1,800.00

AMIIA RX .014 Delivery System rapid exchange delivery system Diameter: 4, 4.5, 5, 5.5, 6, 6.5,

7mm

JJ567 PALMAZ® BLUE™ .018 Peripheral L605 Cobalt Chromium Alloy Balloon 12, 15, 18, 24mm length 4, 5, $1,800.00

Stent System Expandable Stent 6, 7mm diameter

JJ688 Palmaz Blue .014 Renal Stent System CoCr balloon expandable stent 12, 15, 18, 24mm Lengths $1,800.00

(on Aviator Plus) 40, 50,

60, 70mm diameters
80, 142cm shaft
lengths

Medical Specialties Australia Pty Ltd

MS059 Thalis Inert Stent Implantation System Balloon-Expandable Peripheral Stent Diameter: 5-12mm; Length: 18- $1,800.00

Implantation System 58mm

Medical Vision Australia Pty Ltd

MF015 CP Stent CP Stent Uncovered 16, 22, 28, 24, 39 & 45mm $1,800.00

length

MF017 CP Stent CP Stent Uncovered, mounted on BIB 16, 22, 28, 24, 39 & 45mm $1,800.00

balloon length

Medtronic Australasia Pty Ltd

MC328 Racer Renal Stent System Cobalt Alloy Diameter: 4-7mm; Lengths: 12 $1,800.00

&18mm

MC773 Assurant Cobalt Stent Iliac balloon expandable stent system Diameter: 6 - 10mm , Length: $1,800.00

20 - 80mm

MC959 Hippocampus Renal Stent System Hippocampus Renal Rapid Exchange Diameter 4.0mm - 7.00mm $1,800.00

Stainless Steel Stent system, 5F sheath, Length: 10mm - 24mm
0.014" guide wire compatible

MC977 Chromis deep cobalt Chromium, Chromis deep - Cobalt Chromium, pre- Diameter: 2.0 mm 4.0mm $1,800.00

infrapopliteal OTW stent mounted balloon expandable, 0.014" Length: 10mm - 76mm

compatable stent

Prostheses List by Category, Groups and Sponsor Page 29 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.1.1.2 - Self Expandable, <150mm

Abbott Australasia Pty Ltd

AY015 Xact/ Xact Flex Carotid Stent Nitinol Self-Expanding stent on rapid Diameter 7-10mm Length 20 + $1,800.00

exchange delivery system 30mm Straight; Diameter 8-6,

9-7, 10-8mm Length 20 +
30mm Tapered

AY021 Nitinol Self Expanding Peripheral Stent Nitinol Diameter 3-10mm $1,800.00

AY031 Xpert Xpert is a laser cut nitinol self expanding 3 - 8mm in diameter, 20 - $1,800.00

stent, used to treat peripheral vessel 80mm in length
disease, Xpert is a low profile system
designed for small vessels and is 4 french.

AY032 ACCULINK Peripheral Stent System Nickel-Titanium Intra-vascular stent 4-10mm diameter, 13-56mm $1,800.00

length

AY035 Absolute Pro (Long Length) Laser cut nitinol self expanding stent Diameter 5mm to 10mm; length $1,800.00

<150mm 120mm

Bard Australia Pty Ltd

BA178 Luminex Vascular Stent Luminex nitinol self-expanding stent 4mm - 20mm diameters, 2cm - $1,800.00

12cm lengths

BA199 Lifestent Laser cut nitinol self expanding stent, used Diameter: 6-8mm, Length: $1,800.00

to treat peripheral disease 120mm

BA216 Lifestent Lifestent cut nitinol self expanding stent 6-10mm diameter 20mm- $1,800.00

120mm length

Biotronik Australia Pty Ltd

BT072 Astron Peripheral self expanding nitinol, coated Diameters: 6 - 12mm, Lengths: $1,800.00

stent 30 - 100mm

BT103 Astron Pulsar Self-expanding nitinol stent for peripheral Diameters: 4-12.0mm, Lengths: $1,800.00

vessel disease. Stent is 4Fr compatible and 20-200mm
a rapid exhange delivery system

BT126 Pulsar 18 Peripheral self expanding Pulsar 18 self expanding Nitinol stent Stent: 4-7mm Stent length: 100- $1,800.00

Nitinol stent system system 120mm Catheter length: 90-

135mm

Prostheses List by Category, Groups and Sponsor Page 30 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Boston Scientific Australia Pty Ltd

BS035 Expandable Endoprosthesis Biomedical superalloy, self expanding stent Stent Diameters up to 30mm $1,800.00

and lengths up to 100mm

BS056 Carotid Wall Stent Elgiloy self expanding stent Stent diameters up to 10mm $1,800.00

and lengths up to 40mm

BS077 Sentinol Nitinol Vascular Stent System Nitinol Stent with Uniflex Delivery System Diameter: 5 to 10mm. Length: $1,800.00

20 to 120mm

BS137 EPIC Nitinol Stent Nitinol self expanding stent Stent diameters up to 14mm $1,800.00

and lengths up to 120mm

BS167 Placehit Wallstent Biomedical cobalt-based alloy, self Stent diameters up to 19mm $1,800.00

expanding stent and lengths up to 100mm

BS168 Wallstent RP Tracheobronchial, Iliac, Biomedical 20-24mm; length 18-90mm $1,800.00

Superalloy Wire, Braided Mesh, Stainless
Steel Stent with Unistep Delivery System

BS189 Adapt Monorail Carotid Stent System Nitinol self expanding stent 21-40mm length, 4-9mm $1,800.00

diameter

BS196 Innova Self-Expanding Stent Nitinol, self expanding stent Diameters up to 8mm, lengths $1,800.00

less than 150mm

Cook Medical Australia Pty Ltd

WC168 Cook Vascular/Biliary Stent Vascular/Biliary stent 5/6 Fr delivery system, 4 - $1,800.00

14mm diameter, 2 - 8cm length

WC278 Zilver Vascular Stent with Rapid Zilver Stent Vascular Design, self- Delivery System 5Fr, 125cm. $1,800.00

Exchange Delivery System expandable nitinol stent. Preloaded in a 5.0 Stent diameter 4mm-10mm.

French Rapid Exchange delivery catheter. Stent length 2cm-8cm.

Prostheses List by Category, Groups and Sponsor Page 31 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

WC287 Zilver® Flex 35™ Vascular Stent The Zilver® Flew 35™ Stent (ZFV) is a The Zilver® Flex 35™ Stent is $1,800.00

self-expandable stent made of nitinol. The           available in the following sizes:
special laser-cut pattern of the nitinol tube            stent outer diameters of 5 -
provides a construction with a strong radial         10mm and stent lengths of 20 -
force and high flexibility. The stent has              140mm.
radiopaque markers at both ends. The
stent is supplied preloaded in a 6.0 French
inducer catheter. A radiopaque marker on
the distal tip of the sheath is used to
visualize deployment of the stent. Stent
deployment is controlled by means of a
hand held device.

WC290 Zilver® Vena ™ Venous Stent The Zilver® Vena™ Venous Stent is a 14mm and 16mm diameters, $1,800.00

self-expanding, flexible, slotted-tube nitinol and 60mm/100mm/140mm
stent. Post-deployment, the stent is lengths.
designed to impart an outward radial force
upon the inner lumen of the vessel,
establishing patency in the stented region.

Endotherapeutics Pty Ltd

ET037 SX-Ella Endovascular Stent Uncovered, self-expanding nitinol stent Dia 6-16mm, length 22-77mm $1,800.00

ev3 Australia Pty Ltd

EE006 Protégé GPS Peripheral Stent Protégé RX Peripheral Stent Diameter 6-10mm Length 20- $1,800.00

60mm

EE024 Protégé EverFlex Peripheral Stent Protégé EverFlex is a self expanding Diameter 5-8, Length 20-100mm $1,800.00

Nitinol stent premounted on an OTW
delivery system.

Johnson & Johnson Medical Pty Ltd

JJ419 SMART Control Peripheral Stent SMART Control is a laser cut nitinol self Dia 6 – 14mm; Length 20 – $1,800.00

System expanding stent, used to treat peripheral 100mm

vessel disease.

JJ463 PRECISE RX Nitinol Stent System Nitinol self expandable stent and repid Stent Lengths 20, 30, 40mm; $1,800.00

exchange delivery system Stent Diameter: 5, 6, 7, 8, 9,

10mm

JJ592 SMART Nitinol Stent System Long 120mm Stent, 6F compatible 6-8mm diameter, 120mm stent $1,800.00

length, 120cm delivery system

Prostheses List by Category, Groups and Sponsor Page 32 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

JJ646 Precise Pro Rx Nitinol Stent System Nitinol self expanding stent Diameter: 5, 6, 7, 8, 9, 10mm; $1,800.00

Length: 20, 30, 40mm

Medtronic Australasia Pty Ltd

MC743 Complete SE Stent Nitinol 20mm - 80mm $1,800.00

MC744 Complete SE Stent Nitinol 100mm - 120mm $1,800.00

MC978 Cristallo Ideale Carotid Self Expanding Cristallo Ideale Nitinol, Carotid Self Cylinder Diameter: 7.0mm - $1,800.00

Stent System Expanding Hybrid Stent system, 5F 11.0 mm. Taper Diameter

introducer sheath compatible, Rapid 6.0/9.0 - 7.0/10.0. Length
Exchange design, .014" guide wire 20mm - 40 mm.
compatible.

MI010 Maris Plus Peripheral Self-Expanding Nitinol, self expanding, peripheral stent Diameter: 6.0-12.0mm; Length: $1,800.00

Stent System system 30-120mm

Pyramed Pty Limited

PY006 Optimed Femoral Sinus Stent Sinus-wave nitinol Stent 3 - 10mm x 20-130mm $1,800.00

PY015 Optimed Iliac Sinus Stent Sinus-wave nitinol stent 6 - 14mm x 30 -120mm $1,800.00

PY028 Sinus-XL Stent Self-expanding Nitinol stent Diameter: 16mm, 18mm. $1,800.00

Length: 40-100mm nominal;
41-100 expanded.

PY029 Sinus-XL Stent ≥20mm Self-expanding Nitinol stent Diameter: 20mm, 22mm, $1,800.00

24mm, 26mm, 28mm, 30mm,
32mm, 34mm. Length: 30-
100mm nominal; 32-102
expanded.

10.1.1.3 - Self Expandable, ≥150mm

Abbott Australasia Pty Ltd

AY036 Absolute Pro (Long Length) Laser cut nitinol self expanding stent ≥150 Diameter 5mm to 10mm; length $2,970.00

150mm, 170mm, 200mm

Bard Australia Pty Ltd

BA217 Lifestent Laser cut nitinol self expanding stent Diameter 5mm to 10mm; length $2,970.00

150mm - 200mm

Prostheses List by Category, Groups and Sponsor Page 33 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

Biotronik Australia Pty Ltd

BT127 Pulsar 18 Peripheral self expanding Pulsar 18 self expanding Nitinol stent Stent: 4-7mm Stent length: 150- $2,970.00

Nitinol stent system system 200mm Catheter length: 90-

135mm

Boston Scientific Australia Pty Ltd

BS197 Innova Self-Expanding Stent Nitinol, self expanding stent Diameters up to 8mm, Lengths $2,970.00

greater than 150mm

Cook Medical Australia Pty Ltd

WC285 Zilver® Flex35™ Vascular Stent The Zilver® Flex35™ Stent (ZFV) is a Diameter: 5-8mm; $2,970.00

self-expandable stent made of nitinol. The Length:170mm and 200mm
special laser-cut pattern of the nitinol tube
provides a construction with a strong radial
force and high flexibility. The stent has
radiopaque markers at both ends.

ev3 Australia Pty Ltd

EE025 Protégé EverFlex Peripheral Stent Protégé EverFlex is a self expanding Diameter 5-8mm, Length 150- $2,970.00

Nitinol stent premounted on an OTW 200mm
delivery system.

Johnson & Johnson Medical Pty Ltd

JJ617 SMART Nitinol Stent System Long 150mm stent, 6F compatible 6-8mm diameter, 150mm $2,970.00

length, 120cm delivery system

Medtronic Australasia Pty Ltd

MC760 Complete SE Stent Nitinol 150mm $2,970.00

MI011 Maris Plus Peripheral Self-Expanding Nitinol, self expanding, peripheral stent Diameter: 6.0-12.0mm; Length: $2,970.00

Stent System system 150mm

Pyramed Pty Limited

PY016 Optimed Iliac Sinus Stent - extra long Sinus-wave nitinol stent - extra long 6-8 mm x 150-200mm $2,970.00

Prostheses List by Category, Groups and Sponsor Page 34 of 944

10 - VASCULAR

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.1.2 - Drug Eluting Stents

Cook Medical Australia Pty Ltd

WC289 Zilver PTX The Zilver PTX Drug Eluting Peripheral 6French: 5, 6, 7, 8, 9, 10mm $2,400.00

Stent is a self-expanding stent made of diameters in 20, 30, 40, 60, 80,
nitinol and coated with the drug Paclitaxel. 100, 120mm lengths

peripherally inserted central catheter PICC (peripherally inserted central

(PICC) set catheter) set

CM024 Arrow Pressure Injectable Triple-Lumen Pressure injectable triple lumen PICC 6Fg x 50cm, triple lumen $230.00

PICC. (Peripherally Inserted Central Catheter) Set

Grand Total: 9731 Records

Prostheses List by Category, Groups and Sponsor Page 944 of 944

PART B - Human Tissue List February 2012

1 - OPHTHALMIC

Billing Code Facility Minimum Benefit Maximum Benefit

Amniotic Membrane

LEM03 Lions Eye Donation Service $770.00

Cornea

LEM01 Lions Eye Donation Service $2,000.00

LEN01 Lions NSW Eye Bank $1,633.00

LEW01 Lions Eye Bank of Western Australia $2,500.00

QEB01 Queensland Eye Bank $2,100.00

SAE01 The Eye Bank of South Australia $1,838.00

Cornea for Endothelial Lamellar Keratoplasty

LEM04 Lions Eye Donation Service $2,660.00

Cornea For Lamellar

LEN03 Lions NSW Eye Bank $980.00

Sclera

LEM02 Lions Eye Donation Service $150.00

LEN02 Lions NSW Eye Bank $245.00

LEW02 Lions Eye Bank of Western Australia $250.00

QEB02 Queensland Eye Bank $298.00

SAE02 The Eye Bank of South Australia $196.00

Conduit - Aortic

TBV56 Donor Tissue Bank of Victoria $1,013.00

Conduit - Aortic + Valve

QHV09 The Prince Charles Hospital - Queensland Heart Valve Bank $6,000.00

Conduit - Arterial

SHV03 Sydney Heart Valve Bank, St. Vincent's Hospital $987.00

Conduit - Pulmonary

TBV03 Donor Tissue Bank of Victoria $1,012.00

Conduit - Pulmonary + Valve

QHV08 The Prince Charles Hospital - Queensland Heart Valve Bank $6,000.00

Page 1 of 15

CARDIO-THORACIC

Billing Code Facility Minimum Benefit Maximum Benefit

Conduit - Pulmonary large

QHV07 The Prince Charles Hospital - Queensland Heart Valve Bank $1,660.00

Patch - Mitral

QHV03 The Prince Charles Hospital - Queensland Heart Valve Bank $1,660.00

Patch - Pericardium

QHV05 The Prince Charles Hospital - Queensland Heart Valve Bank $1,660.00

Patch - Tricuspid

QHV04 The Prince Charles Hospital - Queensland Heart Valve Bank $1,660.00

Pericardium

TBV50 Donor Tissue Bank of Victoria $490.00

Thoracic Aorta

QHV11 The Prince Charles Hospital - Queensland Heart Valve Bank $1,662.00

Valve - Aortic

QHV01 The Prince Charles Hospital - Queensland Heart Valve Bank $6,000.00

RPH01 Royal Perth Hospital T/A Heart Valve Bank $6,406.00

SHV01 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00

TBV01 Donor Tissue Bank of Victoria $6,598.00

Valve - Mitral

QHV10 The Prince Charles Hospital - Queensland Heart Valve Bank $6,000.00

Valve - Pulmonary

QHV02 The Prince Charles Hospital - Queensland Heart Valve Bank $6,000.00

RPH02 Royal Perth Hospital T/A Heart Valve Bank $6,406.00

SHV02 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00

TBV02 Donor Tissue Bank of Victoria $6,598.00

Autologous Skull Flap

MVS23 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $1,396.00

QBB60 The Queensland Bone Bank $1,568.00

RNB02 Hunter New England Bone Bank $1,470.00

Autologous Skull Flap - processed

QBB56 The Queensland Bone Bank $1,986.00

Bone - Cancellous Bone Matrix, Lyophilised 40cc

Page 2 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

TBV52 Victorian Institute of Forensic Medicine $619.00

Bone - Cancellous Bone Matrix, Lyophilised 80cc

TBV53 Victorian Institute of Forensic Medicine $1,237.00

Bone - Cancellous Crunch 15cc

NBB62 New South Wales Bone Bank $903.00

Bone - Cancellous Crunch 30cc

NBB61 New South Wales Bone Bank $1,647.00

Bone - Cancellous Crunch 60cc

NBB60 New South Wales Bone Bank $2,498.00

Bone - Cancellous Cubes (6) Freeze Dried

QBB09 The Queensland Bone Bank $1,609.00

Bone - Cancellous Strips (2) Freeze Dried

QBB10 The Queensland Bone Bank $680.00

Bone - Chips/cubes 40cc

TBV09 Donor Tissue Bank of Victoria $973.00

Bone - Chips/cubes 80cc

TBV10 Donor Tissue Bank of Victoria $1,853.00

Bone - Cortico-Cancellous Crunch (40/60) 15cc

NBB65 New South Wales Bone Bank $903.00

Bone - Cortico-Cancellous Crunch (40/60) 30cc

NBB64 New South Wales Bone Bank $1,647.00

Bone - Cortico-Cancellous Crunch (40/60) 60cc

NBB63 New South Wales Bone Bank $2,498.00

Bone – Cortico-Cancellous Crunch <20g Sterile

AUB08 Australian Biotechnologies $2,215.00

Bone – Cortico-Cancellous Crunch <30g

AUB04 Australian Biotechnologies $2,070.00

Bone - Demineralised Bone Matrix, Lyophilised 10g

TBV55 Donor Tissue Bank of Victoria $1,049.00

Bone - Demineralised Bone Matrix, Lyophilised 5g

Page 3 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

TBV54 Donor Tissue Bank of Victoria $524.00

Bone - Milled <30g Freeze Dried

PBT37 Perth Bone and Tissue Bank $750.00

Bone - Milled <30gr (60cc equivalent)

PBT08 Perth Bone and Tissue Bank $2,209.00

Bone - Milled >50gr (100cc equivalent)

PBT10 Perth Bone and Tissue Bank $3,245.00

Bone - Milled 20g

QBB45 The Queensland Bone Bank $1,993.00

Bone - Milled 20g Freeze Dried

QBB03 The Queensland Bone Bank $2,524.00

Bone - Milled 30 - 50gr (60 - 100cc equivalent)

PBT09 Perth Bone and Tissue Bank $2,830.00

Bone - Milled 30-50g Freeze Dried

PBT38 Perth Bone and Tissue Bank $900.00

Bone - Milled 40cc

TBV11 Donor Tissue Bank of Victoria $1,165.00

Bone - Milled 80cc

TBV12 Donor Tissue Bank of Victoria $2,084.00

Bone - Milled Femoral Head

AUB02 Australian Biotechnologies $2,457.00

Bone - Ronguered Chips

QBB68 The Queensland Bone Bank $2,022.00

Bone - Ronguered Chips Freeze Dried

QBB67 The Queensland Bone Bank $2,524.00

Bone Plug/Dowel - Cancellous

NBB05 New South Wales Bone Bank $1,224.00

PBT03 Perth Bone and Tissue Bank $500.00

TBV07 Donor Tissue Bank of Victoria $691.00

Bone Plug/Dowel - Tricortical

Page 4 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

TBV08 Donor Tissue Bank of Victoria $750.00

Cartilage - costal segments

PBT11 Perth Bone and Tissue Bank $300.00

QBB12 The Queensland Bone Bank $210.00

TBV17 Donor Tissue Bank of Victoria $390.00

Cortical Strut

AUB05 Australian Biotechnologies $2,451.00

QBB52 The Queensland Bone Bank $441.00

TBV14 Donor Tissue Bank of Victoria $763.00

Cortical Strut >15 - 20cm

PBT07 Perth Bone and Tissue Bank $2,364.00

Cortical Strut >20cm

PBT48 Perth Bone and Tissue Bank $2,532.00

Cortical Struts 10-15cm

PBT06 Perth Bone and Tissue Bank $1,981.00

Disc - Freeze Dried

QBB04 The Queensland Bone Bank $713.00

Elbow - joint

QBB14 The Queensland Bone Bank $2,205.00

TBV18 Donor Tissue Bank of Victoria $5,247.00

Fascia Lata

NBB09 New South Wales Bone Bank $922.00

TBV21 Donor Tissue Bank of Victoria $806.00

Fascia Lata - Large (15cm x 10cm)

PBT15 Perth Bone and Tissue Bank $1,590.00

Fascia Lata - per sq cm

QBB11 The Queensland Bone Bank $5.00

Fascia Lata - Small (10cm x 5cm)

PBT16 Perth Bone and Tissue Bank $854.00

Femoral Head

ACT01 ACT Bone Bank $2,432.00

Page 5 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

APH01 The Avenue Private Hospital Bone Bank $1,131.00

AUB03 Australian Biotechnologies $2,354.00

CSA01 Rachel Forster Bone Bank $802.00

DHR01 Barwon Health Bone Bank $3,028.00

HBB01 The Hobart Private Hospital Bone Bank $2,113.00

LPH01 Lingard Private Hospital Bone Bank $1,103.00

MMH01 Mater Misericordiae Hospital Bone Bank Theatres $400.00

MVS05 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,370.00

NBB16 New South Wales Bone Bank $2,354.00

PBT22 Perth Bone and Tissue Bank $2,432.00

QBB27 The Queensland Bone Bank $2,163.00

RNB01 Hunter New England Bone Bank $2,050.00

SVN01 Mater Hospital $731.00

TBV26 Donor Tissue Bank of Victoria $2,354.00

Femoral Head - Autologous

QBB61 The Queensland Bone Bank $2,163.00

Femoral Head - Freeze Dried

QBB28 The Queensland Bone Bank $2,163.00

Femoral Hemi-condyle

NBB59 New South Wales Bone Bank $2,271.00

PBT21 Perth Bone and Tissue Bank $2,295.00

TBV46 Donor Tissue Bank of Victoria $1,206.00

Femoral Rings

NBB17 New South Wales Bone Bank $1,606.00

PBT24 Perth Bone and Tissue Bank $1,662.00

QBB30 The Queensland Bone Bank $1,591.00

Femoral Rings - Freeze Dried

QBB31 The Queensland Bone Bank $670.00

Femoral Shaft

QBB23 The Queensland Bone Bank $2,247.00

Femoral Shaft - Freeze Dried

QBB66 The Queensland Bone Bank $2,811.00

Page 6 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Femoral Shaft - Half

NBB57 New South Wales Bone Bank $2,778.00

Femoral Shaft - Middle Third

NBB13 New South Wales Bone Bank $2,507.00

TBV24 Donor Tissue Bank of Victoria $2,137.00

Femoral Shaft - Segment

NBB56 New South Wales Bone Bank $1,687.00

Femoral Shaft - Third

NBB55 New South Wales Bone Bank $1,687.00

Femoral Shaft/Tibial Shaft - Middle third

PBT19 Perth Bone and Tissue Bank $2,791.00

Femur - Distal (Shaft & Condyles)

MVS02 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

PBT17 Perth Bone and Tissue Bank $3,471.00

TBV22 Donor Tissue Bank of Victoria $3,854.00

Femur - Distal Half

NBB10 New South Wales Bone Bank $2,778.00

QBB20 The Queensland Bone Bank $2,800.00

Femur - Distal third

NBB11 New South Wales Bone Bank $2,606.00

Femur - Entire

MVS03 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB12 New South Wales Bone Bank $6,200.00

QBB22 The Queensland Bone Bank $4,268.00

TBV23 Donor Tissue Bank of Victoria $6,455.00

Femur - Entire head removed

PBT18 Perth Bone and Tissue Bank $5,882.00

Femur - Proximal (shaft, trochanter, neck)

MVS04 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

PBT20 Perth Bone and Tissue Bank $3,471.00

TBV25 Donor Tissue Bank of Victoria $3,826.00

Page 7 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Femur - Proximal half

NBB15 New South Wales Bone Bank $2,921.00

QBB25 The Queensland Bone Bank $3,020.00

Femur - Proximal third

NBB14 New South Wales Bone Bank $1,306.00

Femur - Proximal with femoral head

TBV51 Donor Tissue Bank of Victoria $3,713.00

Fibula - Entire

MVS07 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB18 New South Wales Bone Bank $6,041.00

PBT25 Perth Bone and Tissue Bank $2,667.00

QBB32 The Queensland Bone Bank $2,651.00

TBV27 Donor Tissue Bank of Victoria $6,222.00

Fibula - Segment

NBB54 New South Wales Bone Bank $2,359.00

PBT28 Perth Bone and Tissue Bank $1,472.00

Fibula - Segment (12cm)

MVS14 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

TBV29 Donor Tissue Bank of Victoria $1,055.00

Fibula - Segment (6cm)

MVS13 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

TBV28 Donor Tissue Bank of Victoria $691.00

Fibular Shaft

TBV30 Donor Tissue Bank of Victoria $2,193.00

Hemipelvis - Acetabulum

NBB21 New South Wales Bone Bank $2,905.00

PBT29 Perth Bone and Tissue Bank $2,940.00

QBB33 The Queensland Bone Bank $2,762.00

TBV31 Donor Tissue Bank of Victoria $2,992.00

Hemipelvis - Complete

MVS08 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

Page 8 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

NBB24 New South Wales Bone Bank $6,500.00

PBT30 Perth Bone and Tissue Bank $5,411.00

QBB37 The Queensland Bone Bank $4,268.00

TBV32 Donor Tissue Bank of Victoria $6,788.00

Hemipelvis - iliac crest

NBB22 New South Wales Bone Bank $2,705.00

PBT31 Perth Bone and Tissue Bank $1,174.00

QBB34 The Queensland Bone Bank $2,478.00

TBV33 Donor Tissue Bank of Victoria $2,705.00

Hemipelvis - Tricortical iliac wedge

NBB23 New South Wales Bone Bank $1,195.00

PBT32 Perth Bone and Tissue Bank $1,067.00

QBB35 The Queensland Bone Bank $1,195.00

TBV34 Donor Tissue Bank of Victoria $1,042.00

Hemipelvis - Tricortical iliac wedge Freeze Dried

QBB36 The Queensland Bone Bank $735.00

Humeral Head

TBV37 Donor Tissue Bank of Victoria $1,653.00

Humeral Head Addition

NBB26 New South Wales Bone Bank $1,545.00

Humeral Shaft

NBB50 New South Wales Bone Bank $3,090.00

QBB39 The Queensland Bone Bank $1,612.00

Humeral Shaft - Half

NBB51 New South Wales Bone Bank $1,671.00

Humerus - Distal

MVS19 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB25 New South Wales Bone Bank $2,359.00

TBV49 Donor Tissue Bank of Victoria $2,241.00

Humerus - Entire

MVS20 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

Page 9 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

NBB29 New South Wales Bone Bank $3,142.00

QBB43 The Queensland Bone Bank $3,035.00

Humerus - Entire with rotator cuff

NBB30 New South Wales Bone Bank $3,182.00

PBT33 Perth Bone and Tissue Bank $3,343.00

Humerus - Proximal

NBB27 New South Wales Bone Bank $2,769.00

PBT35 Perth Bone and Tissue Bank $1,174.00

TBV36 Donor Tissue Bank of Victoria $2,769.00

Humerus - Proximal half with rotator cuff

NBB28 New South Wales Bone Bank $2,778.00

Humerus - Proximal with rotator cuff

MVS09 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

PBT34 Perth Bone and Tissue Bank $2,886.00

TBV35 Donor Tissue Bank of Victoria $2,646.00

Humerus - Ring

NBB53 New South Wales Bone Bank $1,448.00

Ligament - Medial

NBB31 New South Wales Bone Bank $1,781.00

TBV38 Donor Tissue Bank of Victoria $1,781.00

Meniscal Graft

PBT47 Perth Bone and Tissue Bank $1,921.00

Meniscus

QBB05 The Queensland Bone Bank $1,400.00

TBV40 Donor Tissue Bank of Victoria $1,184.00

Meniscus with Ligaments

TBV39 Donor Tissue Bank of Victoria $2,147.00

Osteotomy Wedge

PBT60 Perth Bone and Tissue Bank $1,067.00

Patella

QBB47 The Queensland Bone Bank $788.00

Page 10 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

TBV41 Donor Tissue Bank of Victoria $1,020.00

Patellar unit whole with tibial block

PBT40 Perth Bone and Tissue Bank $2,654.00

Radius

MVS18 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB06 New South Wales Bone Bank $3,024.00

PBT13 Perth Bone and Tissue Bank $1,800.00

QBB15 The Queensland Bone Bank $2,258.00

TBV19 Donor Tissue Bank of Victoria $3,115.00

Radius - Ring

NBB49 New South Wales Bone Bank $1,854.00

Radius - Shaft

NBB47 New South Wales Bone Bank $2,975.00

Rib (5cm)

MVS21 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $382.00

PBT41 Perth Bone and Tissue Bank $300.00

TBV43 Donor Tissue Bank of Victoria $487.00

Spinal Ring

AUB07 Australian Biotechnologies $1,854.00

Tendon

AUB10 Australian Biotechnologies $2,184.00

Tendon - Achilles

NBB01 New South Wales Bone Bank $1,922.00

PBT61 Perth Bone and Tissue Bank $1,985.00

QBB62 The Queensland Bone Bank $1,922.00

TBV05 Donor Tissue Bank of Victoria $1,024.00

Tendon - Achilles Hemi

QBB65 The Queensland Bone Bank $1,433.00

Tendon - Achilles with bone block

NBB02 New South Wales Bone Bank $2,228.00

PBT01 Perth Bone and Tissue Bank $2,301.00

Page 11 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

QBB01 The Queensland Bone Bank $1,922.00

TBV06 Donor Tissue Bank of Victoria $2,085.00

Tendon - Achilles with bone plug

AUB09 Australian Biotechnologies $2,228.00

Tendon - Achilles with machined conical bone block

NBB69 New South Wales Bone Bank $2,728.00

Tendon - EHL

QBB69 The Queensland Bone Bank $1,922.00

Tendon - Gracilis

QBB59 The Queensland Bone Bank $1,922.00

Tendon - Patellar

QBB48 The Queensland Bone Bank $2,055.00

Tendon - Patellar Hemi

QBB63 The Queensland Bone Bank $1,570.00

Tendon - Patellar split with bone plugs

PBT02 Perth Bone and Tissue Bank $1,918.00

Tendon - Patellar with bone plugs

NBB33 New South Wales Bone Bank $2,147.00

TBV42 Donor Tissue Bank of Victoria $2,147.00

Tendon - Patellar with machined conical bone plug

NBB68 New South Wales Bone Bank $2,647.00

Tendon - Patellar with Quads

NBB72 New South Wales Bone Bank $2,184.00

Tendon - Peroneus Longus

NBB73 New South Wales Bone Bank $2,184.00

Tendon - Semi tendinosis

NBB70 New South Wales Bone Bank $2,185.00

QBB70 The Queensland Bone Bank $1,922.00

Tendon - Single (ant and post tibilias, FDL, EDL, hamstring, gracilis)

PBT46 Perth Bone and Tissue Bank $2,198.00

Page 12 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Tendon - Tibialis Anterior

NBB67 New South Wales Bone Bank $2,184.00

QBB58 The Queensland Bone Bank $1,922.00

TBV57 Donor Tissue Bank of Victoria $2,085.00

Tendon - Tibialis Posterior

NBB71 New South Wales Bone Bank $2,184.00

QBB57 The Queensland Bone Bank $1,922.00

Tibia - Condyles only

TBV47 Donor Tissue Bank of Victoria $1,661.00

Tibia - Distal

MVS17 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

QBB51 The Queensland Bone Bank $1,892.00

TBV48 Donor Tissue Bank of Victoria $2,177.00

Tibia - Plateau (prox 1/3)

NBB35 New South Wales Bone Bank $2,518.00

Tibia - Proximal

NBB36 New South Wales Bone Bank $2,551.00

PBT45 Perth Bone and Tissue Bank $2,635.00

QBB54 The Queensland Bone Bank $2,365.00

Tibia - Proximal 16-25cm

TBV45 Donor Tissue Bank of Victoria $2,468.00

Tibia - Proximal 7-15cm

TBV44 Donor Tissue Bank of Victoria $2,562.00

Tibia - Proximal half

MVS11 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

Tibia – Proximal third

AUB06 Australian Biotechnologies $2,562.00

Tibia - Proximal with Patella

QBB08 The Queensland Bone Bank $2,800.00

Tibia - Proximal with Patella & Tendon

PBT44 Perth Bone and Tissue Bank $4,118.00

Page 13 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Tibia - Proximal with Patellar Tendon

NBB46 New South Wales Bone Bank $3,986.00

Tibia - Ring

NBB45 New South Wales Bone Bank $1,448.00

Tibia - Whole

MVS16 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB37 New South Wales Bone Bank $4,065.00

QBB55 The Queensland Bone Bank $4,248.00

Tibia - Whole with Patella

QBB64 The Queensland Bone Bank $4,268.00

Tibia - Whole with Patellar Tendon

NBB44 New South Wales Bone Bank $5,455.00

Tibia Shaft

QBB53 The Queensland Bone Bank $992.00

Tibial Shaft

NBB41 New South Wales Bone Bank $3,747.00

Tibial Shaft - half

NBB43 New South Wales Bone Bank $2,450.00

Tibial Shaft - third

NBB42 New South Wales Bone Bank $2,645.00

Tibial Shaft Freeze Dried

QBB02 The Queensland Bone Bank $872.00

Tri Cortical Osteotomy

NBB66 New South Wales Bone Bank $1,208.00

Ulna

MVS15 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00

NBB07 New South Wales Bone Bank $2,787.00

PBT14 Perth Bone and Tissue Bank $1,500.00

QBB16 The Queensland Bone Bank $2,258.00

TBV20 Donor Tissue Bank of Victoria $2,871.00

Page 14 of 15

ORTHOPAEDIC

Billing Code Facility Minimum Benefit Maximum Benefit

Ulna - Ring

NBB40 New South Wales Bone Bank $1,854.00

Ulna - Shaft

NBB38 New South Wales Bone Bank $2,450.00

Grand Total: 272 Records

Page 15 of 15

Part C - Other Prostheses February 2012

8 - CARDIAC

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

8.14.1 - Implantable Cardiac Event Recorders

Medtronic Australasia Pty Ltd

MC763 Reveal XT Reveal XT Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume $3,900.00

of 9cc

MC768 Reveal DX Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume $3,900.00

of 9cc

St Jude Medical Australia Pty Ltd

SJ152 SJM Confirm Model DM2102 Implantable cardiac monitor with atrial 6.5cc, 12g $3,900.00

fibrillation monitoring.

SJ159 SJM Confirm Model DM2100 Implantable cardiac monitor 6.5cc, 12g $3,900.00

Page 1 of 3

GENERAL MISCELLANEOUS

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

3.2.3 External Infusion Pumps, Battery Powered

3.2.3.1 Insulin infusion pump, variable basal insulin rates, intermittent boluses

Roche Diagnostics Australia Pty Ltd

RO020 Accu-chek Spirit Insulin Pump Insulin infusion pump One size only $4,000.00 $5,000.00

3.2.3.2 Insulin infusion pump (as 3.2.3.1) with integral calculator to determine boluses and active

Managing Diabetes Pty Ltd

DF001 DANAIIS Insulin Pump Continuous insulin infusion pump 75mm x 45mm x 19mm $4,000.00

Roche Diagnostics Australia Pty Ltd

RO044 Accu-Chek Combo System Insulin delivery device capable of remotely The Accu-Chek Combo $8,000.00

receiving and acting on information about System is only available in one
blood glucose levels, performing bolus size.
calculation and bolus advice on additional
parameters than what is normally provided.

DE, SS

Australasian Medical & Scientific Ltd

AN011 Animas Vibe Insulin Pump & CGM Ambulatory insulin infusion pump with real- Pump/Monitor: 8.26 x 5.08 x $8,000.00

System time continuous glucose monitoring (CGM) 2.18cm

capability Sensor/Transmitter: 3.8 x 2.3 x

1.3cm

Managing Diabetes Pty Ltd

DF002 DANAR Insulin Pump The DANAR Insulin Pump is a small 75 x 45 x 19mm, 60grams $5,100.00

device about the size of a pager. It holds
up to 300 units of insulin, which is
delivered continuously through a small tube
to the patient. The DANAR Insulin Pump
also has an integrated blood glucose meter
and remote control via bluetooth
communication.

Medtronic Australasia Pty Ltd

MC353 Medtronic MiniMed Insulin Infusion Pump Paradigm Model MMT-722. 'Smart' Pump dimensions: 5.1 x 9.4 x $8,000.00 $8,950.00

Insulin Pump with REAL-Time continuous 2.0cm
glucose monitoring capability and with
remote control

Page 2 of 3

GENERAL MISCELLANEOUS

Minimum Maximum

Billing Code Product Name Description Size Benefit Benefit Notations

MC354 Medtronic MiniMed Insulin Infusion Pump Paradigm Model MMT-522. 'Smart' Pump Dimensions: 5.1 x 7.6 x $8,000.00 $8,950.00

Insulin Pump with REAL-Time continuous 2.0cm
glucose monitoring capability and with
remote control

SS

Australasian Medical & Scientific Ltd

AN005 Animas 2020 Insulin Pump. Ambulatory Insulin Infusion Pump 7.4cm x 5cm x 1.9cm $7,750.00

Medical Specialties Australia Pty Ltd

MS031 Medical Specialties "Deltec Cozmo Ambulatory Insulin Infusion Pump Deltec Cozmo Insulin Pump - $8,000.00 $9,360.00

Insulin Pump" each

Medtronic Australasia Pty Ltd

MC351 Medtronic MiniMed Insulin Infusion Pump Paradigm Model MMT - 715 Pump Dimensions: 5.1 x 9.4 x $8,000.00

2.0cm

MC352 Medtronic MiniMed Insulin Infusion Pump Paradigm Model MMT - 515 Pump Dimensions: 5.1 x 7.6 x $8,000.00

2.0cm

3.2.3.3 Device capable of automatically adjusting insulin delivery based on continuous glucose

DE, SS

Medtronic Australasia Pty Ltd

MC839 Medtronic MiniMed Insulin Infusion Pump Paradigm Veo Model MMT-554. 'Smart' 5.1 x 7.6 x 2.0cm $8,000.00 $9,500.00

Insulin Pump with REAL-Time continuous
glucose monitoring capability,
incorporating a low glucose suspend and
with remote control.

MC840 Medtronic MiniMed Insulin Infusion Pump Paradigm Veo Model MMT-754. 'Smart' 5.1 x 9.4 x 2.0cm $8,000.00 $9,500.00

Insulin Pump with REAL-Time continuous
glucose monitoring capability,
incorporating a low glucose suspend and
with remote control.

Grand Total: 17 Records

Page 3 of 3
Notes

The Private Health Insurance (Prostheses) Rules 2012 (No. 1) as shown in this compilation are

amended as indicated in the tables below.

Table of Instruments

Instrument	Date of FRLI registration	Date of commencement	Application, saving or transitional provision
Private Health Insurance (Prostheses) Rules 2012 (No.1)	17 February 2012 (see F2012L00335)	3 March 2012
Private Health Insurance (Prostheses) Amendment Rules 2012 (No.1)	4 April 2012 (see F2012L00788)	9 April 2012

Table of Amendments

ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted
Schedule Part A	am. 2012 No. F2012L00788

ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted

Provision affected

How affected

Schedule

Part A

am. 2012 No. F2012L00788

Actions

Download as PDF Download as Word Document

Citations

Private Health Insurance (Prostheses) Rules 2012 (No. 1) (Cth)

Cases Citing This Decision

0

Cases Cited

0

Statutory Material Cited

0