Private Health Insurance (Prostheses) Rules 2015 (No. 2) (Cth)
Private Health Insurance (Prostheses) Rules 2015 (No. 2)
I, Shane Porter, delegate of the Minister for Health, make these Rules under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
Dated 14 August 2015
Shane Porter
Shane Porter
Assistant Secretary
Medical Benefits Division
Department of Health
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 prostheses 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 2015 (No. 2).
Commencement and authority
(1)These Rules commence on 8 September 2015.
(2)These Rules are made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
Revocation
These Rules revoke the Private Health Insurance (Prostheses) Rules 2015 (No. 1).
Definitions
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.
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.
Schedule means the Schedule in these Rules.
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
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 in 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 in 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 in 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' in the Schedule.
(4)For a gap permitted prosthesis provided as part of an episode of hospital treatment in 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 subsection 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.
Note 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.
Note 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 August 2015
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
01.01.01 - Aphakic
01.01.01.01 - 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 13.75mm length. 6.0mm $156.00
121UV; L122UV PMMA Anterior lens 1 piece optic size, diopter range 3-
Chamber Lens 30d. L122UV: 6.0mm optic,
13.75mm length, power
range; 5.0 to 30.0 Diopters
ifc
AMO Australia Pty Ltd
AO019 Verisyse AC IOL Aphakic Model 5mm Optic Diameter x 8.5 $250.00
overall length
Emagin Pty Ltd
EG009 Artisan Anterior Chamber Aphakia ModelComposition: PMMA 5.00mm Optic Diameter x $250.00
Intraocular Lens 8.5 in overall length
m
AMO Australia Pty Ltd
AO001 Intraocular Lens: Model AC 51L Duralens PMMA, Anterior Chamber 6.00 mm Optic Diameter x $198.00
IOL 13.0mm in overall length
01.01.02 - Phakic
01.01.02.01 - Rigid
AMO Australia Pty Ltd
AO016 Verisyse AC IOL Phakic Intraocular Lens: Model 5mm Optic Diameter x 8.5 $680.00
Myopia. Composition: PMMA overall length; 6mm Optic
Diameter x 8.5 overall
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 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Emagin Pty Ltd
EG012 Artisan Anterior Chamber IOL Phakic Intraocular Lens Myopic / 5.00mm Optic Diameter x $680.00
Hyperopic 8.5 in overall length;
t1
AMO Australia Pty Ltd
AO030 Verisyse Toric (Custom) Phakic intraocular lens: Model toric 5mm Optic Diameter x $1,056.00
7.5mm overall length
t1, ifc
Emagin Pty Ltd
EG019 Artisan Toric (Custom) T1 AC Iris clip IOL Toric 5.00mm Optic Diameter x $1,150.00
7.5 Overall
t2
AMO Australia Pty Ltd
AO029 Verisyse Toric (Custom) Phakic intraocular lens: Model toric 5mm Optic Diameter x $1,358.00
7.5mm overall length
t2, ifc
Emagin Pty Ltd
EG020 Artisan Toric (Custom) T2 AC Iris clip IOL Toric 5.00mm Optic Diameter x $1,452.00
7.5 Overall
01.01.02.02 - Foldable
AMO Australia Pty Ltd
AO025 VeriFlex Foldable Phakic IOL Anterior chamber foldable phakic -2 to -14.5d in 0.5d $723.00
silicone intraocular lens increments. Overall
diameter 8.5mm. Optic
6.0mm
Emagin Pty Ltd
EG010 Artiflex Anterior Chamber Optic: Hydrophobic Polysiloxane. 6mm optic diameter x 8.5 in $723.00
Intraocular Lens Haptic: PMMA overall length
Prostheses List by Category, Groups and Sponsor Page 2 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
01.02.01 - Rigid
Alcon Laboratories (Aust.) Pty Ltd
AL002 Models MZ60BD, MC50BD, CZ70BD Other:PMMA Range of Powers:-10 to +34 $156.00
D
01.02.02 - Foldable
01.02.02.01 - Microincision
Carl Zeiss Pty Ltd
CZ040 CT SPHERIS 209M Micro incision, aspheric (aberration Diopter range :0.00 to + $322.00
correcting), foldable square-edged 32.0. Optic Size : 6mm
single-piece intraocular lens for Overall Length : 11mm
capsular bag fixation.
at
Carl Zeiss Pty Ltd
CZ016 CT ASPHINA 409M ZEISS Micro Incision Aspheric 6mm optic, 11mm overall $364.00
(aberration neutral) IOL: Foldable, diameter. Diopter range 0.0
square-edged, single piece IOL for to +32.0D (0.5D steps from
capsular bag fixation 10.0 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
square-edged, single piece IOL for to +32.0D (0.5D steps from
capsular bag fixation 10.0 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, (15.50-22D), 10.5mm
preloaded, with aberration control, (22.50-30D)
Prostheses List by Category, Groups and Sponsor Page 3 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Carl Zeiss Pty Ltd
CZ028 CT ASPHINA 409MP Preloaded, micro incision, aspheric Diopter range: 0.0 to $374.00
(aberration neutral), foldable square- 32.0D; Optic size: 6.0mm;
edged single piece intraocular lens for Overall length: 11.0mm
capsular bag fixation.
CZ037 CT ASPHINA 509MP Preloaded, micro incision, aspheric Diopter range: 0.0 to + $374.00
(aberration correcting), foldable 32.0D; Optic Size: 6.0mm;
square-edged single-piece intraocular Overall length: 11.0mm
lens for capsular bag fixation
Designs for Vision Pty Ltd
DV263 Rayner C-flex Advance Aspheric Mini incision pre-loaded aspheric IOL Power range +8.0 - +34.0 $374.00
dioptres in 0.5 increments
Emagin Pty Ltd
EG016 ARTIS PL E Preloaded Intraocular lens 0 to 35D $374.00
EG017 LUXIOL 60 Preloaded Intraocular lens +10 to +35D $374.00
Kevin Grundy (IBD) Pty Ltd
KG015 Rayner C-flex Advance Aspheric Mini incision pre-loaded aspheric IOL Power range +8.0 - +34.0 $374.00
dioptres in 0.5 increments
at, pl, t1
Carl Zeiss Pty Ltd
CZ031 AT TORBI 709MP (Standard Bitoric, preloaded, micro incision, Diopter range: Sph -10.0 to $760.00
aspheric (aberration neutral), foldable, 32.0, Cyl +1.0 to 6.5
square-edged, single-piece IOL for Optic size: 6.0mm, Overall
capsular bag fixation length: 11.0mm
Emagin Pty Ltd
EG015 ARTIS T PL Preloaded Toric Intraocular lens +18 to +25D / C +1.50D $760.00
at, pl, t2
Carl Zeiss Pty Ltd
CZ032 AT TORBI 709MP (high cyl) Bitoric, preloaded, micro incision, Diopter range: Sph -10.0 to $1,061.00
aspheric (aberration neutral), foldable, 32.0, Cyl +7.0 to 12.0,
square-edged, single-piece IOL for Optic size: 6.0mm. Overall
capsular bag fixation Length 11.0mm
Prostheses List by Category, Groups and Sponsor Page 4 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
at, pl, vblf
Insight Surgical Pty Ltd
IS017 Preloaded Monofocal Hydrophilic Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $405.00
677PY with Blue light Filter for Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
Medjet PL-MA 2.2 single use optimized 13.0 mm ±0.20 mm
injection system Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0 - +45.0 D ±0.5
increment: 1.0 D
at, 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:
(abberation neutral) IOL: Foldable, Sph -10.0 to +32.0D, Cyl
square-edged, single piece IOL for +1.0 to 6.5D (all 0.5D
capsular bag fixation
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:
neutral) IOL: Foldable square edged, Sph -10.0 to +32.0D, +7.0
single piece IOL for capsular bag to 12.0D (all 0.5D steps)
fixation
01.02.02.02 - No edge modification
Ellex Australia Pty Ltd
XE002 Staar foldable silicone intraocular Polyimide haptics 6.3mm optic - low 14.0mm length $281.00
lens: Model AQ 5010V diopters
Prostheses List by Category, Groups and Sponsor Page 5 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
t1
Ellex Australia Pty Ltd
XE001 Staar Toric foldable silicone Plate haptics 6.0mm optic 10.8mm - 11.2mm length $579.00
intraocular lens: Model AA4203TF;
Model AA4203TL
01.02.02.03 - Edge modification
Alcon Laboratories (Aust.) Pty Ltd
AL004 Acrysof Multipiece Models Foldable Acrylic Multi-piece Lens -5 D to +30 D $322.00
MA50BM, 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 Soft Acrylic, Foldable, UV Range available from -10D $322.00
IOL, Sensar OptiEdge AR40e Absorbing, Posterior to +30D. 6 mm Optic
Foldable Acrylic IOL Diameter x 13mm in overall
length.
Carl Zeiss Pty Ltd
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.
Device Technologies Australia Pty Ltd
DE398 Oculentis LENTIS L-302-1 Foldable one-piece monofocal C loop Optic Size 6.0mm, Overall $322.00
acrylic IOL. Length 12.00mm. +-0.0D to
+35.0D (1.0D steps) and
+15.5D to +26.5D (0.5D
steps).
Ellex Australia Pty Ltd
XE003 Staar foldable silicone IOLs: Plate haptics 6.0mm; Polymide 10.8mm 0 13.5mm length $322.00
Models AQ2010V, AQ2017V and haptics 5.5 or 6.3mm optic;
Kevin Grundy (IBD) Pty Ltd
KG001 Rayner C-Flex Hydrophilic HEMA-MMA 5.75mm dia optic, 12.00mm $322.00
copolymer, foldable with injector dia overall
Prostheses List by Category, Groups and Sponsor Page 6 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
KG002 Superflex Hydrophilic HEMA-MMA 6.25mm dia optic, 12.5mm $322.00
copolymer, foldable with injector dia overall
at
Alcon Laboratories (Aust.) Pty Ltd
AL038 Acrysof Aspheric UV-absorbing Foldable Acrylic Single-piece Lens + 6.0 D to +30.0 D $364.00
with UV Absorbing and Aspheric
Correction
AMO Australia Pty Ltd
AO014 TECNIS® Intraocular Lens (Z9002 Foldable Intraocular Lenses - 5-10 dioptre in 1.0 dioptre $364.00
& ZA9003) Ultraviolet light absorbing posterior increments; 10.5 - 30
chamber intraocular lenses, dioptre in 0.5 increments
Silicone/Acrylic
AO024 Tecnis® One Piece (ZCB00) One piece intraocular lens with edge +5 to +34 diopter powers in $364.00
modification and 360 degree square 0.5d increments. Overall
edge diameter 13mm, Optic size
6mm
Bausch & Lomb (Australia) Pty Ltd
BL022 SofPort Advanced Optic (AO) Posterior chamber, foldable silicone 0 D to 30.0 D $364.00
IOL with anterior optic-haptic square
edge, posterior optic-haptic square
edge, 360-degree optic square edge
and asperic optic for aberration control
BL023 Akreos Advanced Optic Posterior chamber, foldable acrylic 0 D to 30.0 D $364.00
IOL, with anterior optic-haptic square
edge, posterior optic-haptic square
edge, 360 degree optic square edge
and aspheric optic for aberration
BL030 enVista The enVista, Model MX60, is an ultra- Overall diameter 12.5mm, $364.00
violet-absorbing, posterior chamber, optic body diameter 6.0mm
hydrophobic acrylic one-piece in dioptric powers ranging
foldable intraocular lens (IOL) Has from +0.0 to +34D
an aspheric lens optic, square 0.0D to 10.0D in 1 Diopter
posterior edge, modified C haptics and increments
available in dioptric powers ranging 11.0D to 30.0D in 0.5
from +0.0 to +34.0D. Diopter increments
31.0D to 34.0D in 1
Diopter increments
Prostheses List by Category, Groups and Sponsor Page 7 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Carl Zeiss Pty Ltd
CZ030 CT ASPHINA 404 Small incision, foldable, single piece, Diopter range: -10.0 to $364.00
monofocal, aspheric (aberration 42.0, Optic size: 6.0mm,
neutral), square-edged, hydrophilic Overall length: 11.0mm
acrylic (with hydrophobic surface
properties) intraocular lens for
capsular bag fixation. (Monofocal lens
for powers outside standard 409MP
MICS range).
Device Technologies Australia Pty Ltd
DE399 Oculentis LENTIS L-312 Foldable one-piece monofocal acrylic Optic size 6.0mm, Overall $364.00
C Loop IOL Length 12.00mm. Central
Thickness 1.02mm
(+22.0D). Available
Diopters: -10.0D to35.0D
(1.0D steps). +10.5D to
DE400 Oculentis LENTIS L-313 Foldable one-piece monofocal acrylic Optic size 6.0mm, Overall $364.00
plate haptic IOL Length 11.00mm. Available
Diopters: +-0.0D to 35.0D
(1.0D steps). +10.5D to
29.5D (0.5D steps)
DE401 Oculentis LENTIS L-402 Foldable three piece monofocal acrylic Optic Size 6.0mm, Overall $364.00
IOL. Length 13.00mm. +-0.0D to
+35.0D (1.0D) + 15.5D to
+26.5D (0.5D). Minus range
on demand.
Insight Surgical Pty Ltd
IS010 BiFlex 677AB Hydrophilic Acrylic Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $364.00
Foldable Aspheric Monofocal Lens Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
(without Blue light Filter) optimized 13.0 mm ±0.20 mm
Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0 - +45.0 D ±0. D
increment: 1.0 D
Prostheses List by Category, Groups and Sponsor Page 8 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
IS035 BiFlex 877FAB Hydrophobic Posterior Chamber IOL, special 360° Optic diameter: 6.0 mm $364.00
Acrylic Foldable Aspheric sharp edge, Aspheric - Aberration ±0.10 mm, Overall diameter:
Monofocal Lens without Blue light Balanced 13.0 mm ±0.20 mm
Powers available:
-0.0 - +9.0 D ±0.25
D increment: 1.0 D
+10.0 - +25.0 D ±0.25
D increment: 0.5 D
+25.5 - +30.0 D ±0.5
D increment: 0.5 D
+31.0 - +35.0 D ±0.5
D increment: 1.0 D
IQ Medical
IQ004 Softec Acrylic, single piece, foldable Available in dioptric $364.00
intraocular lens with anterior and powers from -5.0 to +36.0,
posterior optic-haptic square edge, 1D steps: -5.0 to +10.0 and
360 degree optic square edge design, +31.0 to +36.0; 0.5D steps:
precision power calculation and +10.5 to +18.0 and +25.0 to
aberration technology +29.5; 0.25D steps: +18.0
to +25.0
IQ013 PreciSAL 302AC Acrylic, single piece, foldable Available in dioptric $364.00
intraocular lens with anterior and powers from 0.0 to +30.0.
posterior optic-haptic square edge, 1D steps: 0.0 to +10.0;
360 degree optic square edge design, 0.5D steps: +10.5 to + 17.5
precision power calculation, and +28.5 to +30.0; 0.25D
aberration technology and UV light steps: +18.0 to +28.0
Kevin Grundy (IBD) Pty Ltd
KG012 Rayner "C-Flex" and Superflex" Aspheric Intra Ocular Lenses with C-Flex -970C + 22.5D to $364.00
Aspheric IOL Amon-Apple enhanced 360 Degree +34D Superflex-920H - 10D
square edge, Anti-vaulting Haptics to +22D
Spectrum Surgical
SO074 HumanOptics Aspira Posterior chamber IOL, foldable, UV -6.0 to +40.0 D $364.00
absorber, Aspheric, aberration
technology, 360° LEC barrier, HD
Prostheses List by Category, Groups and Sponsor Page 9 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
at, pl
AMO Australia Pty Ltd
AO034 TECNIS® iTec 1-Piece Pre-Loaded 1-piece IOL Posterior Chamber +5.0 to +34.0 diopter $374.00
IOL Intraocular lens, incorporates a powers in 0.5 diopter
proprietary wavefront-designed increments. Overall
aspheric optic with a squared diameter 13mm, Optic size
posterior optic edge designed to
provide a 360 degree barrier. The edge
of the optic has a frosted design to
reduce potential edge glare effects.
Supplied pre-loaded in a screw style
disposable injector.
Ellex Australia Pty Ltd
XE004 Preloaded Aspheric Intraocular Silicone intraocular lens 6.0mm $374.00
Insight Surgical Pty Ltd
IS031 Medicontur Preloaded Monofocal Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $374.00
Hydrophilic 677P without Blue Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
light Filter for Medjet PL-MA 2.2 optimized 13.0 mm ±0.20 mm
single use injection system Powers available:
-10.0 - +9.0 D ±0.25
D increment: 1.0 D
+10.0 - +25.0 D ±0.25
D increment: 0.5 D
+25.5 - +30.0 D ±0.5
D increment: 0.5 D
+31.0 - +45.0 D ±0.5
D increment: 1.0 D
IS032 Medicontur Preloaded Monofocal Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $374.00
Hydrophilic 640P without Blue Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
light Filter for Medjet PL-MA 2.2 optimized 13.0 mm ±0.20 mm
single use injection system Powers available:
-10.0 - +9.0 D ±0.25
D increment: 1.0 D
+10.0 - +25.0 D ±0.25
D increment: 0.5 D
+25.5 - +30.0 D ±0.5
D increment: 0.5 D
+31.0 - +45.0 D ±0.5
D increment: 1.0 D
Prostheses List by Category, Groups and Sponsor Page 10 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
IS036 BiFlex 877PA Preloaded Posterior Chamber IOL, special 360° Optic diameter: 6.0 mm $374.00
Hydrophobic Acrylic Foldable sharp edge, Aspheric Aberration ±0.10 mm, Overall diameter:
Aspheric Monofocal Lens without Balanced 13.0 mm ±0.20 mm
Blue Light Filter Powers available:
-0.0 - +9.0 D ±0.25
D increment: 1.0 D
+10.0 - +25.0 D ±0.25
D increment: 0.5 D
+25.5 - +30.0 D ±0.5
D increment: 0.5 D
+31.0 - +35.0 D ±0.5
D increment: 1.0 D
IQ Medical
IQ014 PreciSAL P302AC Preloaded Acrylic, single piece, Available in dioptric $374.00
foldable intraocular lens with anterior powers from 0.0 to +30.0.
and posterior optic-haptic square 1D steps: 0.0 to +10.0;
edge, 360 degree optic square edge 0.5D steps: +10.5 to + 17.5
design, precision power calculation, and +28.5 to +30.0; 0.25D
aberration technology and UV light steps: +18.0 to +28.0
Spectrum Surgical
SO075 HumanOptics Aspira Preloaded Preloaded posterior chamber IOL, +10.0 to +40.0 D $374.00
foldable, UV absorber, Aspheric,
aberration technology, 360° LEC
barrier, HD optic
at, pl, t1
Bausch & Lomb (Australia) Pty Ltd
BL032 enVista Toric The enVista toric (Model MX60T) is a Overall diameter is 12.5mm $760.00
one-piece glistening-free for the entire lens power
hydrophobic foldable IOL. The range, with spherical
enVista Toric, model MX60T IOL has equivalent powers from +6.0
a Toric aspheric lens optic, a square to +30.0 Diopters in 0.5
posterior edge and modified C haptics, Diopter steps and cylinder
an overall diameter of 12.5mm and an powers from +1D to 6D
optic body of 6.0mm. It is available in Diopters (at the IOL plane).
multiple spherical and cylindrical
powers.
Prostheses List by Category, Groups and Sponsor Page 11 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Insight Surgical Pty Ltd
IS026 Medicontur BiFlex 677PT Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $760.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens without Blue light Filter, Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Preloaded Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+1.5 D - +7.0 D increment:
0.75 D
IQ Medical
IQ017 PreciSAL Toric T302AC Acrylic single piece, foldable Available in spherical $760.00
intraocular lens with anterior and dioptric powers from 0.0 to
posterior optic-haptic square edge, +30.0. 1D steps: 0.0 to
360 degree optic square edge design, +10.0; 0.5D steps: +10.5 to
precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, toric 0.25D steps: +18.0 to
correction on anterior surface with +28.0; Cylinder powers
cylinder marks to indicate flat from 1.0D to 6.0D
meridian plus the cylinder axis to
allow alignment for astigmatic
correction, and UV filter.
IQ018 PreciSAL Toric PT302AC Pre-loaded acrylic single piece, Available in spherical $760.00
foldable intraocular lens with anterior dioptric powers from 0.0 to
and posterior optic-haptic square +30.0. 1D steps: 0.0 to
edge, 360 degree optic square edge +10.0; 0.5D steps: +10.5 to
design, precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, toric 0.25D steps: +18.0 to
correction on anterior surface with +28.0; Cylinder powers
cylinder marks to indicate flat from 1.0D to 6.0D
meridian plus the cylinder axis to
allow alignment for astigmatic
correction, and UV filter.
Prostheses List by Category, Groups and Sponsor Page 12 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
at, pl, t1, vblf
Designs for Vision Pty Ltd
DV253 HOYA AF-1 351 Toric Preloaded injector system, correct IOL Power: + 10.0 to 30.0 $800.00
T3/T4/T5/T6/T7/T8/T9 corneal astigmatism micro-incision, (0.5 steps), IOL Cylinder
ashperic, blue-blocker, single piece power: 1.50D (351T3),
hydophobic. 2.25D (351T4), 3.00D
(351T5), 3.75D (351T6),
4.50D (351T7), 5.25D
(351T8), 6.00D (351T9)
at, pl, vblf
Alcon Laboratories (Aust.) Pty Ltd
AL024 AcrySert model SN60WS Foldable Acrylic Single-piece Lens +6 to +30 D $405.00
with 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
AL039 AcrySof IQ Aspheric IOL with Pre-loaded foladable Acrylic Single- +6.0D to +30.0D $405.00
UltraSert pre-loaded delivery piece Lens with Blue light protection
and Aspheric correction (SN60WF)
Bausch & Lomb (Australia) Pty Ltd
BL035 MICRO+ AY 123 Preloaded, posterior chamber, UV An overall diameter of $405.00
absorbing, foldable, aspheric, acrylic, 10.75mm and optic diamter
single piece lens with blue light of 6.15mm. From 0 to +35
protection. diopters with 0.5 diopter
increments.
BL037 MicroPure 123 Preloaded, posterior chamber, UV Overall diameter of 10D to $405.00
absorbing, foldable, aspheric, acrylic, 24.5D: 11.00mm
single piece hydrophobic glistening- 25D to 30D: 10.75mm
free Intra Ocular Lens.
Optic diameter of 10D to
24.5D: 6.00mm
25D to 30 D: 5.75mm
Power from 10D to 30D
with 0.5 diopter increments.
Prostheses List by Category, Groups and Sponsor Page 13 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Designs for Vision Pty Ltd
DV250 Hoya-PS AF-1 (UY) PY-60AD Preloaded in cartridge, Aspheric, Blue +6.0D to +30.0D (0.5D $405.00
blocker, Foldable, Single-Piece,
Hydrophobic Acrylic
DV252 HOYA iSert® 251 Preloaded injector system, Micro- +6.0D to 30.0D (5 steps) $405.00
incision, Aspheric, Blue-Blocker,
Single Piece, Hydrophobic
DV262 Hoya 751 Intra Ocular Lens Intra Ocular Lens Power +10 dioptres - +26 $405.00
dioptres
DV264 Hoya Vivinex iSert Preloaded IOL Intra Ocular Lens Power +6 dioptres - +30 $405.00
(Model XY1) dioptres
Insight Surgical Pty Ltd
IS034 BiFlex Preloaded 877PAY Posterior Chamber IOL, special 360° Optic diameter: 6.0 mm $405.00
Hydrophobic Acrylic Foldable sharp edge, Aspheric - Aberration ±0.10 mm, Overall diameter:
Aspheric Monofocal Lens with Blue Balanced 13.0 mm ±0.20 mm Powers
light Filter available: -0.0 - +9.0 D
±0.25 D increment: 1.0 D
+10.0 -+25.0 D ±0.25 D
increment: 0.5 D
+25.5- +30.0 D ±0.5 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1
IQ Medical
IQ016 PreciSAL P302A Preloaded Acrylic, single piece, Available in dioptric $405.00
foldable intraocular lens with anterior powers from 0.0 to +30.0.
and posterior optic-haptic square 1D steps: 0.0 to +10.0;
edge, 360 degree optic square edge 0.5D steps: +10.5 to +17.5
design, precision power calculation, and +28.5 to +30.0; 0.25D
aberration technology and blue light steps: +18.0 to +28.0
Nvision Surgical Pty Ltd
VI001 Nidek SZ-1 Pre-Loaded IOL Pre-Loaded Intra Ocular Lens Power +11 dioptres to 30+ $405.00
Injector System Implantation system dioptres
Spectrum Surgical
SO067 HumanOptics Aspira Y Preloaded Preloaded posterior chamber IOL, +10.0 to +30.0 D $405.00
foldable, UV absorber, Aspheric,
aberration technology, 360° LEC
barrier, HD optic, Blue light filter
Prostheses List by Category, Groups and Sponsor Page 14 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
SO071 Mediphacos Easyflex Preloaded posterior chamber IOL, +5.0 to +30.0 D $405.00
foldable, UV absorber, Aspheric,
aberration technology, double square
edge, Blue light filter
at, t1
AMO Australia Pty Ltd
AO039 TECNIS® Toric 1-Piece IOL 1-piece IOL Posterior chamber +5.0 to +34.0 diopter $740.00
Intraocular lens, incorporates a powers in 0.5 diopter
proprietary wavefront designed toric increments. Cylinder
aspheric optic with a squared power: 1.00 diopter, 1.50
posterior optic edge designed to diopter, 2.25 diopter, 3.00
provide a 360 degree barrier. The edge diopter, 3.75 diopter, 4.00
of the optic has a frosted design to diopter, 4.50 diopter, 5.25
reduce potential edge glare effects. diopter and 6.00 diopter (as
measured at the IOL plane).
Overall diameter 13mm,
Optic size 6mm.
Device Technologies Australia Pty Ltd
DE390 Oculentis LENTIS Tplus LU-313T Patient Specific: Foldable one-piece Optic Size 6.0mm, overall $740.00
monofocal toric acrylic IOL length 11.0mm. Sph +/-0.0D
to +35.0D (in 0.01D
increments) Cyl +0.25 to
+6.99D cyl (in 0.01D
increments)
DE397 Oculentis LENTIS Tplus LS-313 Foldable one-piece monofocal toric Optic Size 6.0mm, Overall $740.00
T1-T6 acrylic IOL. Length 11.00mm. Available
diopters: +10.0D to +30.0D
(0.5D). Cyl: (T1 +1.5D) (T2
+2.25D) (T3 +3.0D) (T4
+3.75D) (T5 +4.5D) (T6
+5.25D)
Prostheses List by Category, Groups and Sponsor Page 15 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Insight Surgical Pty Ltd
IS024 Medicontur BiFlex 677TA Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $740.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens without Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+1.5 D - +7.0 D increment:
0.75 D
Spectrum Surgical
SO060 HumanOptics Torica Toric posterior chamber IOL, foldable, Sphere +10D to +30D, $740.00
UV absorber, Aspheric, aberration Cylinder 1D to 6D
technology, 360° LEC barrier, HD
at, t1, pl, vblf
Insight Surgical Pty Ltd
IS028 Medicontur BiFlex 677PTY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $800.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens with Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+1.5 D - +7.0 D increment:
0.75 D
Prostheses List by Category, Groups and Sponsor Page 16 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
IQ Medical
IQ020 PreciSAL Toric PT302A Pre-loaded acrylic single piece, Available in spherical $800.00
foldable intraocular lens with anterior dioptric powers from 0.0 to
and posterior optic-haptic square +30.0. 1D steps: 0.0 to
edge, 360 degree optic square edge +10.0; 0.5D steps: +10.5 to
design, precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, toric 0.25D steps: +18.0 to
correction on anterior surface with +28.0; Cylinder powers
cylinder marks to indicate flat from 1.0D to 6.0D
meridian plus the cylinder axis to
allow alignment for astigmatic
correction, and UV and blue light
filters.
at, t1, vblf
Device Technologies Australia Pty Ltd
DE392 Oculentis LENTIS LU-313-TY Patient Specific: Foldable one-piece Optic Size: 6.0mm, overall $780.00
monofocal toric acrylic IOL. Violet length 11.00mm. Sph +/-
Light Filter 0.0D to +35.0D (in 0.01D
increments) Cyl +0.25D to
+6.99D cyl (in 0.01D
increments)
Insight Surgical Pty Ltd
IS022 Medicontur BiFlex 677TAY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $780.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens with Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+1.5 D - +7.0 D increment:
0.75 D
Prostheses List by Category, Groups and Sponsor Page 17 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
IQ Medical
IQ019 PreciSAL Toric T302A Acrylic single piece, foldable Available in spherical $780.00
intraocular lens with anterior and dioptric powers from 0.0 to
posterior optic-haptic square edge, +30.0. 1D steps: 0.0 to
360 degree optic square edge design, +10.0; 0.5D steps: +10.5 to
precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, toric 0.25D steps: +18.0 to
correction on anterior surface with +28.0; Cylinder powers
cylinder marks to indicate flat from 1.0D to 6.0D
meridian plus the cylinder axis to
allow alignment for astigmatic
correction, and UV and blue light
filters.
Spectrum Surgical
SO057 HumanOptics Torica Y Toric posterior chamber IOL, foldable, Sphere +10D to +30D, $780.00
UV absorber, Aspheric, aberration Cylinder 1D to 6D
technology, 360° LEC barrier, HD
optic, Blue light filter
SO072 Mediphacos Miniflex Toric Toric posterior chamber IOL, foldable, Sphere +5.0 to +30.0 D, $780.00
UV absorber, Aspheric, aberration Cylinder < 7D
technology, double square edge, Blue
light filter
at, t2
AMO Australia Pty Ltd
AO040 TECNIS® Toric 1-Piece IOL 1-piece IOL Posterior chamber +5.0 to +34.0 diopter $1,042.00
Intraocular lens, incorporates a powers in 0.5 diopter
proprietary wavefront designed toric increments. Cylinder
aspheric optic with a squared power: 7.00 diopter, 8.00
posterior optic edge designed to diopter (as measured at the
provide a 360 degree barrier. The edge IOL plane). Overall
of the optic has a frosted design to diameter 13mm, Optic size
reduce potential edge glare effects.
Device Technologies Australia Pty Ltd
DE391 Oculentis LENTIS Tplus LU-313T Patient Specific: Foldable one-piece Optic Size: 6.0mm, overall $1,042.00
monofocal toric acrylic IOL length 11.00mm. Sph +/-
0.0D to +35.0D (in 0.01D
increments) Cyl +6.99D to
+12.0D cyl (in 0.01D
increments)
Prostheses List by Category, Groups and Sponsor Page 18 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Insight Surgical Pty Ltd
IS025 Medicontur BiFlex 677TA Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $1,042.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens without Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+7.0 D - +9.0 D increment:
0.75 D
+9.0 D - +10.0 D increment:
1.0 D
Spectrum Surgical
SO059 HumanOptics Torica Toric posterior chamber IOL, foldable, Sphere +10D to +30D, $1,042.00
UV absorber, Aspheric, aberration Cylinder 7D to 12D
technology, 360° LEC barrier, HD
at, t2, pl
Insight Surgical Pty Ltd
IS027 Medicontur BiFlex 677PT Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $1,052.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens without Blue light Filter, Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Preloaded Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+7.0 D - +9.0 D increment:
0.75 D
+9.0 D - +10.0 D increment:
1.0 D
at, t2, vblf
Device Technologies Australia Pty Ltd
DE393 Oculentis LENTIS T plus LU-313-TY Patient Specific: Foldable one-piece Optic Size: 6.0mm, overall $1,084.00
monofocal toric acrylic IOL. Violet length 11.00mm. Available
Light Filter. diopters: Cyl +7.00D to
+12.0D inclusive in 0.01D
increments.
Prostheses List by Category, Groups and Sponsor Page 19 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Insight Surgical Pty Ltd
IS023 Medicontur BiFlex 677TAY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $1,084.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens with Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+7.0 D - +9.0 D increment:
0.75 D
+9.0 D - +10.0 D increment:
1.0 D
IS030 Medicontur BiFlex 677TBY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $1,084.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.10 mm,
Lens with Blue light Filter Aspheric – Coma optimized – Toric Overall diameter: 13.0 mm
±0.20 mm
Powers available:
+5.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
Cylinders available:
+10.0 D - +24.0 D ±0.5 D
increment: 1.0 D
Spectrum Surgical
SO058 HumanOptics Torica Y Toric posterior chamber IOL, foldable, Sphere +10D to +30D, $1,084.00
UV absorber, Aspheric, aberration Cylinder 7D to 12D
technology, 360° LEC barrier, HD
optic, Blue light filter
Prostheses List by Category, Groups and Sponsor Page 20 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
at, t2, vblf, pl
Insight Surgical Pty Ltd
IS029 Medicontur BiFlex 677PTY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $1,094.00
Hydrophilic Acrylic Foldable Toric Square Edge, ±0.05 mm, Overall diameter:
Lens with Blue light Filter Aspheric – Coma optimized – Toric 13.0 mm ±0.10 mm
Powers available:
-10.0 - +30.0 D ±0.25 D
increment: 0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1.0 D
Cylinders available:
+7.0 D - +9.0 D increment:
0.75 D
+9.0 D - +10.0 D increment:
1.0 D
at, vblf
Alcon Laboratories (Aust.) Pty Ltd
AL021 Alcon AcrySof SN60WF Foldable Acrylic Single-piece Lens + 6.0 D to +30.0 D $385.00
with Blue Light Protection and
Aspheric Correction
Bausch & Lomb (Australia) Pty Ltd
BL025 SofPort Advanced Optic (AO) Posterior chamber, aphakic, foldable 6mm optic 13mm overall $385.00
Violet Shield silicone, anterior & posterior edge lengthModified C 5
modification intraocular lens with degree angulation 0-30D,
aberration technology, a violet light 0.5D steps
Designs for Vision Pty Ltd
DV247 HOYA AF-1 iMics1 NY-60 Mini Incision, Aspheric, Blue- +6.0D to 30.0D (0.5 steps) $385.00
blocker, Single-piece, Hydrophobic
Device Technologies Australia Pty Ltd
DE402 Oculentis LENTIS LS-312Y Foldable one-piece monofocal C Loop Optic Size 6.0mm, Overall $385.00
Acrylic IOL. Violet Light filter. Length 12.0mm. Available
Diopters: +-0.0D to 35.0D
(1.0D steps) +15.5D to
26.5D (0.5D steps).
DE403 Oculentis LENTIS LS-313Y Foldable one-piece monofocal acrylic Optic Size 6.0mm, Overall $385.00
plate haptic IOL. Violet Light Filter Length 11.00mm. Available
Diopters: +-0.0D to 35.0D
(1.0D steps). +15.5D to
26.5D (0.5D steps).
Prostheses List by Category, Groups and Sponsor Page 21 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Insight Surgical Pty Ltd
IS016 BiFlex 677ABY Hydrophilic Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $385.00
Acrylic Foldable Aspheric Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
Monofocal Lens with Blue light optimized 13.0 mm ±0.20 mm
Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0 - +45.0 D ±0. D
increment: 1.0 D
IS033 BiFlex 877FABY Hydrophobic Posterior Chamber IOL, special 360° Optic diameter: $385.00
Acrylic Foldable Aspheric sharp edge, Aspheric - Aberration 6.0 mm ±0.10 mm, Overall
Monofocal Lens with Blue light Balanced diameter: 13.0 mm ±0.20 mm
Powers available: -0.0 -
+9.0 D ±0.25 D increment:
1.0 D +10.0 -+25.0 D ±0.25
D increment: 0.5 D +25.5-
+30.0 D ±0.5 D increment:
0.5 D
+31.0 - +35.0 D ±0.5 D
increment: 1
IQ Medical
IQ009 Softec HDY Acrylic, single piece, foldable Available in dioptric $385.00
intraocular lens with anterior and powers from -5.0 to + 36.0,
posterior optic-haptic square edge, 1D steps: -5.0 to +10.0 and
360 degree optic square edge design, +31.0 to +36.0; 0.5D steps:
precision power calculation, +10.5 to +18.0 and +25.0 to
aberration technology and blue light 29.5; 0.25D steps: + 18.0 to
+25.0
IQ015 PreciSAL 302A Acrylic, single piece, foldable Available in dioptric $385.00
intraocular lens with anterior and powers from 0.0 to +30.0.
posterior optic-haptic square edge, 1D steps: 0.0 to +10.0;
360 degree optic square edge design, 0.5D steps: +10.5 to +17.5
precision power calculation, and +28.5 to +30.0; 0.25D
aberration technology and blue light steps: +18.0 to +28.0
Prostheses List by Category, Groups and Sponsor Page 22 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Spectrum Surgical
SO055 HumanOptics Aspira Y Posterior chamber IOL, foldable, UV -6.0 to +40.0 D $385.00
absorber, Aspheric, aberration
technology, 360° LEC barrier, HD
optic, Blue light filter
SO073 Mediphacos Miniflex/Mediflex Posterior chamber IOL, foldable, UV +5.0 to +30.0 D $385.00
absorber, Aspheric, aberration
technology, double square edge, Blue
light filter
pl
Ellex Australia Pty Ltd
XE005 Staar KS-Xs Preloaded Acrylic Preloaded acrylic lens with anterior Optic diameter 6.0mm, $332.00
Intraocular Lens and posterior edge modification overall length 12.5mm,
diopter range +10 to +28.0
t1
Kevin Grundy (IBD) Pty Ltd
KG003 Rayner Standard Toric C-Flex Hydrophilic HEMA-MMA 5.00mm dia optic, 12.00mm $698.00
copolymer, 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 $780.00
foldable, acrylic, toric, single piece to 6.00 D cylinder.
lens with blue light protection and
aspheric correction
Designs 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, (0.5 steps)lOL Cylinder
Single 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 $740.00
foldable, acrylic, toric, single piece to 6.00 D cylinder
lens with blue light protection
Prostheses List by Category, Groups and Sponsor Page 23 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
t2
Kevin Grundy (IBD) Pty Ltd
KG004 Rayner Premium Toric C-Flex HEMA-MMA copolymer, foldable 5.75mm dia optic, 12.00mm $1,000.00
with 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 -10.0D to 0.00D Sphere: 1D $1,000.00
to 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 Foldable Acrylic Single-piece Lens, +6 to +40D $364.00
SN60AT asymmetric optic/consistent edge,
with blue light protection
AL025 AcrySof Multipiece Models Foldable Acrylic multi-piece Lens - 5 D to + 30 D $364.00
MN60MA, MN60AC with Blue light Protection
01.02.02.04 - Multifocal or bifocal
at
AMO Australia Pty Ltd
AO026 TECNIS® Multifocal Intraocular Posterior chamber lens with UV light- +5 to +34 diopter powers in $822.00
Lens (ZMA00) absorbing, foldable acrylic, 3-piece 0.5d increments. Overall
with a diffractive posterior optic and a diameter 13mm, Optic size
modified anterior surface technology 6mm
with edge modification and 360
degree square edge.
AO027 TECNIS® Multifocal 1-Piece Lens, A multifocal posterior chamber lens 6.0mm Optic Diameter x $822.00
Models ZMB00, ZKB00, ZLB00 with UV-blocking, foldable acrylic, 1- 13.0mm in overall length.
piece with a diffractive posterior optic +5.0 Diopter to +34.0
and a modified anterior surface Diopter in 0.5 Diopter
technology with edge modification increments. ZMB00 +4.00
and a 360 degree square edge. Diopter add, ZKB00 +2.75
add,
AO037 TECNIS® Symfony Extended Range Extended Range of Vision Posterior +5.0 to 34.0 diopter powers $822.00
of Vision (ZXR00) Chamber IOL in 0.5 diopter increments
Overall diamter 13mm,
Optic size 6mm
Prostheses List by Category, Groups and Sponsor Page 24 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Carl Zeiss Pty Ltd
CZ015 AT LISA 809M ZEISS micro incision, aspheric 6mm optic, 11mm diameter. $822.00
multifocal IOL. Diffractive bifocal Diopter range 0.0D to
anterior surface with asymmetric light +32.0D (0.5D steps)
distribution (65% distance / 35%
near), 3.75D addition for near focus.
Device Technologies Australia Pty Ltd
DE396 Oculentis LENTIS Mplus LS-313 Foldable one-piece multifocal plate Overall Length 11.0mm and $822.00
haptic acrylic IOL. Optic Size 6.0mm Available
diopters +-0.0D to +36.0D
(0.05D steps)
IQ Medical
IQ023 PreciSAL Multifocal M302AC Acrylic single piece, foldable Available in spherical $822.00
intraocular lens with anterior and dioptric powers from 0.0D
posterior optic-haptic edge, 360 to +30.0D. 1D steps: 0.0D
degree optic square edge design, to+10.0D; 0.5D steps:
precision power calculation, +10.5 to +17.5 and +28.5 to
abreration technology, pupil +30.0; 0.25D steps: +18.0
independent diffractive anterior to +28.0; near sight
surface with a near sigh correction correction addition up to
addition of up to +3.5D, and UV +3.5D on all spherical
Filter. dioptric powers.
Kevin Grundy (IBD) Pty Ltd
KG009 Rayner "M-Flex" Mulitfocal Acrylic, Foldable, Single piece multi- 6.5mm Optic-Overall $822.00
Foldable IOL zoned refractive aspheric multifocal diameter 12.5mm: +3D or +
with Amon-Apple 360 Degree Square 4D Addition: +14D to
edge, Anti Vaulting Haptics +25D in 1.0D increments:
+8.5D to +23.5D in 0.5D
Spectrum Surgical
SO063 HumanOptics Diffractiva Multifocal posterior chamber IOL, Sphere: +10D to +30D, $822.00
foldable, UV absorber, Aspheric, Near addition +3.5D
aberration technology, 360° LEC
barrier, HD optic
at, pl
AMO Australia Pty Ltd
AO036 TECNIS® Multifocal 1-Piece IOL Preloaded 1-Piece Multifocal +5.0 to 34.0 diopter powers $842.00
with iTec Preloaded delivery system posterior chamger IOL in 0.5 diopter increments
Overall diamter 13mm,
Optic size 6mm
Prostheses List by Category, Groups and Sponsor Page 25 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
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 Optic size: 6.0mm. Overall
IOL for capsular bag fixation. The length: 11.0mm
anterior aspheric bifocal surface has an
asymmetric light distribution 65/35
for distance/near vision, and 3.75D
add for the near focus.
CZ034 AT LISA tri 839MP Trifocal (aspheric) micro incision, Diopter range: 0.0 to $842.00
single-piece IOL for capsular bag +32.0D (0.5D increments).
fixation, implantable with preloaded Optic size: 6.0mm. Overall
injector system. The trifocal (anterior) Length: 11.0mm
optic provides two diffractive focal
points (+3.33D near focus and +1.66D
intermediate focus) with asymmetric
light distribution 50% distance / 20%
intermediate / 30% near vision.
IQ Medical
IQ024 PreciSAL Mulitfocal PM302AC Pre-loaded acrylic single piece, Available in spherical $842.00
foldable intraocular lens with anterior dioptric powers from 0.0 to
and posterior optichaptic square +30.0. 1D steps: 0.0 to
edge, 360 degree optic square edge +10.0; 0.5D steps: +10.5 to
design, precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, pupil 0.25D steps: +18.0 to
independent diffractive anterior +28.0; near sight correction
surface with a near sight correction addition up to +3.5D on all
addition of up to +3.5D, and UV filter. spherical dioptric powers.
Spectrum Surgical
SO065 HumanOptics Diffractiva Preloaded Preloaded Multifocal posterior Sphere: +10D to +30D, $842.00
chamber IOL, foldable, UV absorber, Near addition +3.5D
Aspheric, aberration technology,
360° LEC barrier, HD optic
at, pl, t1
Carl Zeiss Pty Ltd
CZ035 AT LISA toric 909MP ZEISS pre-loaded, micro incision, 6mm optic, 11mm diameter. $1,218.00
multifocal toric IOL. Aspheric toric Diopter range: Sph +6.0D
anterior surface, diffractive bifocal to 24.0D, Cyl +1.0 to 4.0D
posterior surface with asymmetric (all 0.5D steps)
light distribution (65% distance/ 35%
near), and 3.75D addition for near
Prostheses List by Category, Groups and Sponsor Page 26 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
CZ036 AT LISA tri Toric 939MP Trifocal (aspheric), bitoric, micro Diopter range -10.00 to $1,218.00
incision, single-piece IOL for +28.0 and +1 to +4.0 DC
capsular bag fixation, implantable Optic size: 6..00mml;
with preloaded injector system. The Overall length: 11.mm
trifocal (anterior) optic provides two
diffractive focal points (+3.33D near
focus and + 1.66D intermediate focus)
with asymmetric light distribution
50% distance / 20% intermediate /
30% near vision,
at, pl, vblf
Insight Surgical Pty Ltd
IS020 Medicontur BiFlex Preloaded Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $884.00
677PMY Hydrophilic Acrylic Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
Foldable Multifocal Lens with Blue optimized 13.0 mm ±0.20 mm
light Filter Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0- +45.0 D ±0. D
increment: 1.0 D
IS021 Medicontur QFlex 640PMY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $884.00
Hydrophilic Acrylic Foldable Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
Multifocal Lens with Blue light optimized 13.0 mm ±0.20 mm
Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0- +45.0 D ±0. D
increment: 1.0 D
Prostheses List by Category, Groups and Sponsor Page 27 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
IQ Medical
IQ025 PreciSAL Multifocal PM302A Pre-loaded acrylic single piece, Available in spherical $884.00
foldable intraocular lens with anterior dioptric powers from 0.0 to
and posterior optichaptic square +30.0. 1D steps: 0.0 to
edge, 360 degree optic square edge +10.0; 0.5D steps: +10.5 to
design, precision power calculation, +17.5 and +28.5 to +30.0;
aberration technology, pupil 0.25D steps: +18.0 to
independent diffractive anterior +28.0; near sight correction
surface with a near sight correction addition up to +3.5D on all
addition of up to +3.5D, and UV and spherical dioptric powers.
blue filter powers.
Spectrum Surgical
SO066 HumanOptics Diffractiva Y Preloaded Multifocal posterior Sphere: +10D to +30D, $884.00
chamber IOL, foldable, UV absorber, Near addition +3.5D
Aspheric, aberration technology,
360° LEC barrier, HD optic, Blue
at, t1
AMO Australia Pty Ltd
AO033 TECNIS® Multifocal Toric Toric Multifocal Intraocular Lens Available +5.0 Diopters to $1,198.00
+34.0 Diopters in 0.5
Diopter increments.
Cylinder powers 1.50D,
2.25D, 3.00D and 4.00D (as
measured on the IOL
AO038 TECNIS Symfony Toric Extended Extended Range of Vision Toric +6 to +30 in 0.5d steps $1,198.00
Range of Vision (ZXT00) Multifocal Posterior Chamber IOL Available Cyl powers
+1.0d, 1.5d, 2.25d, 3.00d,
Carl Zeiss Pty Ltd
CZ038 AT LISA tri toric 939M low cylinder Trifocal (aspheric), bitoric, micro Diopter range: -10.00 to + $1,198.00
incision, single-piece IOL for 32.0 DS and +1 to +6.5DC
capsular bag fixation. The trifocal Optic Size: 6.0mm. Overall
(anterior) optic provides two Length: 11.0mm
diffractive focal points (+3.33D near
focus and +1.66D intermediate focus)
with asymmetric light distribution
50% distance / 20% intermediate /
30% near vision.
Prostheses List by Category, Groups and Sponsor Page 28 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Device Technologies Australia Pty Ltd
DE388 Oculentis LENTIS Mplus Toric LU- Patient specific one-piece multifocal- Overall Length 11.0mm and $1,198.00
313MFT toric plate haptic acrylic IOL Optic Size 6.0mm + 0.0D to
+36.0D inclusive in 0.01D
increments. Cyl +0.25 to
+6.99D inclusive in 0.01D
increments
at, t1, vblf
Bausch & Lomb (Australia) Pty Ltd
BL036 FineVision Toric POD FT Posterior chamber, toric, trifocal An overall diameter of $1,240.00
diffractive (aspheric), UV and blue 11.40mm and optic diameter
light blocker, single piece acrylic of 6.00mm. From 0 to +35
Diopters with 0.5 diopter
increments.
Device Technologies Australia Pty Ltd
DE394 Oculentis LENTIS Mplus Toric LU- Patient specific one-piece multifocal- Overall Length 11.0mm and $1,240.00
313 MF30TY toric plate haptic acrylic IOL. Optic Size 6.0mm, +-0.0D to
+36.0D inclusive in 0.01D
increments. Cyl +0.25D to
+6.99D inclusive in 0.01D
increments.
at, t2
Carl Zeiss Pty Ltd
CZ039 AT LISA tri toric 939M high Trifocal (aspheric), bitoric, micro Diopter range: -10.00 to + $1,500.00
powered cylinder incision, single-piece IOL for 32.0 DS and +7 to +12 DC
capsular bag fixation. The trifocal Optic Size: 6.0mm. Overall
(anterior) optic provides two Length: 11.0mm
diffractive focal points (+3.33D near
focus and +1.66D intermediate focus)
with asymmetric light distribution
50% distance / 20% intermediate /
30% near vision.
Device Technologies Australia Pty Ltd
DE389 Oculentis LENTIS Mplus LU- Patient specific one-piece multifocal- Overall Length 11.0mm and $1,500.00
313MFT toric acrylic plate haptic IOL Optic size 6.0mm +-0.0D to
+36.0D inclusive in 0.01D
increments. Cyl +6.99D to
+12.0D inclusive in 0.01D
increments
Prostheses List by Category, Groups and Sponsor Page 29 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
at, t2, vblf
Device Technologies Australia Pty Ltd
DE395 Oculentis LENTIS Mplus LU-313 Patient specific one-piece multifocal Overall Length 11.00mm $1,542.00
MFTY toric plate haptic acrylic IOL. Violet and Optic Size 6.0mm +-
Light Filter 0.0D to +36.0D inclusive in
0.01D increments. Cyl
+7.00D to +12.0D inclusive
in 0.01D increments.
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, Posterior Chamber, UV absorbing, +6 D to + 34 D $864.00
SV25T0 and MN6AD1 foldable, acrylic, single piece lens
with apodised diffractive optic and
blue light protection
AL040 AcrySof IQ PanOptix Presbyopia Trifocal posterior chamber, UV +13.0 to +30.0D in 0.5 $864.00
Correcting IOL absorbing, foldable, acrylic, aspheric, Diopter increments and
single piece lens with apodised +31.0 to +34.0D in 1.0
diffractive trifocal optic and blue light Diopter increments
protection.
The apodised diffractive trifocal optic
(anterior) provides two diffractive
focal points (+3.25D near focus and
2.17D intermediate focus).
Bausch & Lomb (Australia) Pty Ltd
BL033 FineVision POD F Posterior chamber, UV absorbing, An overall diameter of $864.00
foldable, aspheric, acrylic, single 11.40mm and optic diameter
piece lens with apodised diffractive, of 6.00mm. From 0 to +35
trifocal optic and blue light diopters with 0.5 diopters
with 0.5 diopter increments.
BL034 FineVision Micro F Posterior chamber, UV absorbing, An overall diameter of $864.00
foldable, aspheric, acrylic, single 10.75mm and optic diameter
piece lens with apodised diffractive , of 6.15mm. From 0 to +35
trifocal optic and blue light dopters with 0.5 diopter
increments.
Prostheses List by Category, Groups and Sponsor Page 30 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Designs 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
Insight Surgical Pty Ltd
IS019 Medicontur BiFlex 677MY Posterior chamber IOL, 360° Special Optic diameter: 6.0 mm $864.00
Hydrophilic Acrylic Foldable Square Edge, Aspheric – Coma ±0.10 mm, Overall diameter:
Multifocal Lens with Blue light optimized 13.0 mm ±0.20 mm
Powers available:
-10.0 - +9.0 D ±0.25 D
increment: 1.0 D
+10.0 - +25.0 D ±0.25 D
increment: 0.5 D
+25.5 - +30.0 D ±0.5 D
increment: 0.5 D
+31.0- +45.0 D ±0. D
increment: 1.0 D
IQ Medical
IQ022 PresiSAL Multifocal M302A Acrylic single piece, foldable Available in sperical $864.00
intraocular lens with anterior and dioptric powers from 0.0D
posterior optic-haptic square edge, to +30.0D. 1D steps: 0.0D
360 degree optic square edge design, to +10.0D; 0.5D steps:
precision power calculation. +10.5 to +17.5 and +28.5 to
Aberration technology, pupil +30.0; 0.25D steps: +18.0.0
independent diffractive anterior to +28.0; near sight
surface with a near sight correction correction addition up to
addition of up to +3.5D, and UV and +3.5D on all spherical
blue light fliters. dioptric powers.
Spectrum Surgical
SO064 HumanOptics Diffractiva Y Multifocal posterior chamber IOL, Sphere: +10D to +30D, $864.00
foldable, UV absorber, Aspheric, Near addition +3.5D
aberration technology, 360° LEC
barrier, HD optic, Blue light filter
Prostheses List by Category, Groups and Sponsor Page 31 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
t1, at
Carl Zeiss Pty Ltd
CZ025 AT LISA toric 909M ZEISS micro incision, multifocal toric 6mm optic, 11mm diameter. $1,198.00
IOL (standard cyl range). Aspheric Diopter range: Sph -10.0D
toric anterior surface, diffractive to +32.0D, Cyl +1.0 to 6.5D
bifocal posterior surface with (all 0.5D steps)
asymmetric light distribution (65%
distance / 35% near), 3.75D addition
for near focus.
Kevin Grundy (IBD) Pty Ltd
KG010 Rayner M-Flex Toric (Standard) Acrylic, Foldable, Single Piece, 5.75mm / 12.0mm: 6.25mm / $1,198.00
Multi-zoned Refractive Aspheric 12.5mm +3.00D or +4.00D
Toric Mulitfocal with Amon-Apple Addition FAR: +14.0D to
enhanced 360 degree Square edge, +32.00D in 0.5 STEPS:
Anti Vaulting Haptics +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 Acrylic, Foldable, Single Piece, Muli- 5.75/12.0mm: 6.25/12.5mm $1,198.00
Standard) Zoned Refractive, Toric Multifocal +3.00D to +4.00D Addition
with Amon-Apple enhanced 360 FAR: +14.0D to +32.0D in
Degree square edge, Anti-vaulting 0.5D Increments: NEAR:
Haptics, Patient 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 Posterior chamber UV absorbing +6 to +34 D spherical; 1.00 $1,240.00
IOL (SND1T2-5; SV25T2-6) foldable, acrylic, aspheric, toric single to 3.00 D cylinder
piece lens with apodised diffractive
optic and blue light protection.
Prostheses List by Category, Groups and Sponsor Page 32 of 1109
01 - OPHTHALMIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
t2, at
Carl Zeiss Pty Ltd
CZ024 AT LISA toric 909M ZEISS micro incision, multifocal toric 6mm optic, 11mm diameter. $1,500.00
IOL (high cyl range). Aspheric toric Diopter range: Sph -10.0D
anterior surface, diffractive bifocal to +32.0D, Cyl +7.0 to
posterior surface with asymmetric 12.0D (all 0.5D steps)
light distribution (65% distance /
35% near), 3.75D addition for near
01.02.02.05 - Accommodative
pa
iNova Pharmaceuticals Australia Pty Ltd
IL001 Crystalens HD Accommodating lens with > 3 10.0 to 33.0 Dioptres in .05 $780.00
Dioptres of accommodation with dual Dioptre steps
mechanism of 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 $780.00
accommodating intraocular lens with powers from +5.0 to +36.0,
sqare edge design, custom control 1D steps: +31.0 to +36.0;
precision and closed loop haptic 0.5D steps: +5.0 to +18.0
and +25.0 to +30.0; 0.2D
steps; +18.0 to +25.0
pa, at
iNova Pharmaceuticals Australia Pty Ltd
Endplate endplate 12deg
LB098 FORTIFY R Corpectomy Spacer Expandable corpectomy spacer 14mm 14-18mm 0-7deg $1,200.00
Endplate
Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes
SY342 Expandable Cage Titanium Synex II, Titanium endplate Angle 0 - 40 degree. $1,200.00
Endplate Size 19x20,
22x25, 26x30
SY795 XRL Endplate -10˚/+15˚ Degrees $1,200.00
Nuvasive Australia and NZ Pty Ltd
NV079 X-CORE (End Cap) End plate Round 12-30mm x -8° to $1,200.00
16°; Rectangular 12-22mm x
15-60mm x -8° to 16°
Orthotech Pty Ltd
OH302 Obelisc vertebral body replacement End PieceMade from titanium. diameter - 20mm, angle 0° $1,200.00
diameter - 20mm, angle 5°
diameter - 20mm, angle 10°
diameter - 24mm, angle 0°
diameter - 24mm, angle 5°
diameter - 24mm, angle 10°
diameter - 26mm, angle 0°
diameter - 26mm, angle 5°
diameter - 26mm, angle 10°
Stryker Australia Pty Ltd
SK339 VLIFT End cap Diameters 12 to 22mm $1,200.00
Zimmer Pty Ltd
ZI678 InFix Interbody Fusion System Endplate Small - Large $1,200.00
ZI680 InFix Interbody Fusion System Endcap 8-10mm $1,200.00
Prostheses List by Category, Groups and Sponsor Page 1102 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
13.12.02 - Stackable Cage
Emergo Asia Pacific Pty Ltd
ER164 Signus Athlet VBR System - Main Peek Vertebral Body Replacement 12, 18, 24, 30, 36 and 42mm $4,400.00
Body System (Main body) lengths
ER165 Signus Athlet VBR System - End Peek Vertebral Body Replacement 4, 6, 8mm heights $4,400.00
Body System (End body)
Johnson & Johnson Medical Pty Ltd
DP513 Stackable Corpectomy CFRP Cage Stackable Cage Xsmall-Xlarge $4,400.00
System
DY322 Carbon Fibre Interbody Fusion Stackable C/F Cage System Wedges 11 Degree Small-Large $4,400.00
Medtronic Australasia Pty Ltd
MC603 Union Verte-Stack 8 - 20mm $4,400.00
MC606 Union Verte-Stack Centre Piece 5-40mm $4,400.00
MC632 Verte-Stack XS Centre Piece. Stackable Height 5-50mm $4,400.00
Corpectomy Device.
Prism Surgical Designs Pty Ltd
PZ021 VerteLoc Spine System Locking Screw 20mm - 150mm $4,400.00
PZ022 VerteLoc Spine System Stackable Cage Extra Small- Extra large $4,400.00
PZ023 VerteLoc Spine System Locking Nut one size only $4,400.00
Emergo Asia Pacific Pty Ltd
ER175 Santorini Stackable Corpectomy Corpectomy Cage, Peek (12x17)mm footprint x (2- $4,400.00
Cage-Small 62)mm height
ER176 Santorini Stackable Corpectomy Corpectomy Cage, Peek (16x20) or (21x25)mm $4,400.00
Cage-Medium/Large footprint x (2-98)mm height
Prostheses List by Category, Groups and Sponsor Page 1103 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
13.12.03 - Mesh
Johnson & Johnson Medical Pty Ltd
DP427 Surgical Titanium Mesh System Various shapes 10- 26 x 15 -150mm $3,605.00
DP438 Surgical Titanium Mesh System Mesh - Oblong 12 - 13 x 15 -17mm x 10 - $3,605.00
20mm
Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes
SY293 Synmesh Mesh, Oblong 6mm - 88mm $3,605.00
SY294 Synmesh Mesh, Round 6mm - 88mm $3,605.00
Medtronic Australasia Pty Ltd
MC378 Pyramesh Titanium Surgical Mesh 51 - 500mm $3,605.00
MC379 Pyramesh Titanium Surgical Mesh 5 - 50mm $3,605.00
MC449 Pyramesh Angled 25 - 150mm $3,605.00
MC450 Pyramesh Curved / Round 20 - 150mm $3,605.00
MC451 Pyramesh Ovoid 8 - 130mm $3,605.00
Nuvasive Australia and NZ Pty Ltd
NV015 Titanium Mesh Oval/Flat/Long/Round 10mm - 16mm Diameter, 6mm $3,605.00
- 14mm Length
NV016 Titanium Mesh Oval/Flat/Long/Round 10mm - 16mm Diameter, $3,605.00
15mm - 90mm Length
NV017 Titanium Mesh Oval/Flat/Long/Round 20mm + Diameter, 30mm - $3,605.00
90mm Length
Orthofix Australia Pty Limited
OF051 Blackstone - Surgical Mesh 4 lobe, 6 lobe 4 lobe: 12 x 15mm, 8mm - 17 $3,605.00
x 22, 15mm, 6 lobe:
(diameter x height) 10 - 16 x
10 - 16mm (2mm
increments), 7 - 70mm
Prostheses List by Category, Groups and Sponsor Page 1104 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Scient'x Australia
SX057 Novel CP Corpectomy Spinal PEEK vertebral body replacement, Small: 14mm width x 12mm $3,605.00
Spacer System thoracolumbar depth; height: 10mm - 50mm
(2mm increments)
Medium: 17mm width x
15mm depth; height: 10mm -
50mm (2mm increments)
Stryker Australia Pty Ltd
SK338 VBOSS/VLIFT Titanium Available from 10 to 25mm $3,605.00
in Diameter and from 8 to
120mm in Length
Matrix Medical Innovations
BF002 A-Mesh Spinal Titanium Mesh A-Mesh® Spinal Titanium Mesh is Diameter: 10mm, Length: $3,605.00
designed to restore biomechanical 20mm, 50mm 70mm
integrity throughout the thoracic and Diameter: 12mm, Length:
lumbar spine following vertebrectomy 20mm, 50mm, 70mm
or corpectomy for patients with spine Diameter: 14mm, Length:
tumors or fractures. 20mm, 50mm, 70mm
Diameter: 16mm, Length:
20mm, 50mm, 70mm, 90mm
Diameter: 20mm, Length:
20mm, 50mm, 70mm, 90mm
Diameter: 25mm, Length:
20mm, 50mm, 70mm, 90mm
Diameter: 30mm, Length:
20mm, 50mm, 70mm, 90mm
Diameter: 35mm, Length:
20mm, 50mm, 70mm, 90mm
13.12.04 - Mesh, End Plate
Johnson & Johnson Medical Pty Ltd
DY087 Surgical Titanium Mesh System End Plate or Screws or End Cap 10-33mm $1,325.00
(Round / Oblong / Trapezoidal)
DY088 Surgical Titanium Mesh System Rings (Standard and Angled) 17-26mm x 22-33mm $1,325.00
Prostheses List by Category, Groups and Sponsor Page 1105 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes
SY295 Synmesh End rings round/oblong $1,325.00
Medtronic Australasia Pty Ltd
MC539 Pyramesh End ring/cap 10 - 25mm $1,325.00
MC821 T2 End Cap 13-31 mm, 0, 4, 8, 15 degree $1,325.00
lordosis
Orthofix Australia Pty Limited
OF052 Blackstone - End Ring Surgical Mesh [Surgical mesh X Angle] 10- $1,325.00
16mm (2mm increments) X 0-
2.5 degrees
Stryker Australia Pty Ltd
SK424 VBOSS End cap Sizes 10 to 25mm $1,325.00
Matrix Medical Innovations
BF020 A-Mesh Spinal Titanium Mesh Plate A-Mesh Spinal Titanium Mesh is Diameter 10m 12, 14, 16, 20, $1,325.00
and Set Screw designed to restore biomechanical 15, 30 or 35mm
integrity throughout the thoracic and
lumbar spine following vertebrectomy
or corpectomy for patients with spine
tumors or fractures
13.12.05 - Non Stackable Cage, other
Emergo Asia Pacific Pty Ltd
ER138 Santorini Solid Corpectomy Cage Cage, fixed height, Peek (12x14) or (16x20) mm $3,605.00
System footprint x (18-62) mm
ER262 Amendia Samson Corpectomy Amendia Samson Corpectomy dia 13.5x height (14-48 mm) $3,605.00
Vertebral Body Replacement System Vertebral Body Replacement System
Prostheses List by Category, Groups and Sponsor Page 1106 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
13.13.01 - Interspinous Fixation Device
Lifehealthcare Pty Ltd
LH483 Coflex-F Interspinous fusion device 8, 10, 12, 14, 16mm $1,425.00
Medtronic Australasia Pty Ltd
MC637 CD Horizon Spire Plate 35-41mm $1,425.00
Nuvasive Australia and NZ Pty Ltd
NV064 Affix Plate Spinous process plate with an 25mm - 55mm $1,425.00
integrated canted-coil locking
mechanism.
Globus Medical Australia
LB113 SP-Fix™ Spinous Process Fixation Posterior non-pedicle supplemental 35-55mm $1,425.00
fixation device
National Surgical Pty Ltd
NK027 Axle Interspinous fusion System Interspinous fusion plate system Plates: 28mm to 55mm $1,425.00
Inserts: 8-18mm
Scient'x Australia
SX091 Bridgepoint Spinous Process Spinous process fixation system with Small 35-40mm, Medium 40- $1,425.00
Fixation System intergrated set screws 45mm, Large 45-50mm
Signature Spine and Joint Pty Ltd
SV044 Romeo 2 PAD System Interspinous fusion device 8mm to 18mm $1,425.00
13.14.01 - Sacroiliac Joint Fusion Device
Globus Medical Australia
LB062 SI-LOK™ Stabilization System Fusion Screw 8.0-12.0mm diameter x 25- $260.00
60mm length
Prostheses List by Category, Groups and Sponsor Page 1107 of 1109
13 - SPINAL
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
National Surgical Pty Ltd
NK032 Silex Sacroiliac Joint Fusion System The Silex Sacroiliac Joint Fusion 7mm – 12.5mm (diameter) $260.00
System consists of different diameter and 30mm -70mm (length)
bone screws in various
lengths and thread configurations to
accommodate variations in patient
anatomy.
13.15.01 - Annular closure/reconstruction device
Global Orthopaedic Technology
GO274 Barricaid Annular replacement prosthesis Height: 14mm; Width 8mm, $5,900.00
10mm, 12mm
Prostheses List by Category, Groups and Sponsor Page 1108 of 1109
ORTHOPAEDIC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Condition
Grafts, Bone
Zimmer Pty Ltd
ZI265 Continuum hip system Hedrocel AVN Rod 3mm - 12mm block $3,208.00
Grand Total: 10249 Records
Prostheses List by Category, Groups and Sponsor Page 1109 of 1109
PART B - Human Tissue List August 2015
Billing Code Facility Minimum Benefit Maximum Benefit
CARDIO-THORACIC
Conduit - Aortic
TBV56 Donor Tissue Bank of Victoria $1,505.00
Conduit - Aortic + Valve
QHV09 The Prince Charles Hospital - Queensland Heart Valve Bank $6,962.00
Conduit - Arterial
SHV03 Sydney Heart Valve Bank, St. Vincent's Hospital $1,263.00
Conduit - Pulmonary
TBV03 Donor Tissue Bank of Victoria $1,504.00
Conduit - Pulmonary + Valve
QHV08 The Prince Charles Hospital - Queensland Heart Valve Bank $7,294.00
Conduit - Pulmonary large
QHV07 The Prince Charles Hospital - Queensland Heart Valve Bank $2,116.00
Patch - Mitral
QHV03 The Prince Charles Hospital - Queensland Heart Valve Bank $1,926.00
Patch - Pericardium
QHV05 The Prince Charles Hospital - Queensland Heart Valve Bank $2,116.00
Patch - Tricuspid
QHV04 The Prince Charles Hospital - Queensland Heart Valve Bank $1,926.00
Pericardium
TBV50 Donor Tissue Bank of Victoria $915.00
Thoracic Aorta
QHV11 The Prince Charles Hospital - Queensland Heart Valve Bank $2,116.00
Valve - Aortic
QHV01 The Prince Charles Hospital - Queensland Heart Valve Bank $7,294.00
RPH01 Royal Perth Hospital T/A Heart Valve Bank $6,406.00
SHV01 Sydney Heart Valve Bank, St. Vincent's Hospital $6,842.00
TBV01 Donor Tissue Bank of Victoria $7,808.00
Valve - Mitral
Page 1 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
QHV10 The Prince Charles Hospital - Queensland Heart Valve Bank $6,962.00
Valve - Pulmonary
QHV02 The Prince Charles Hospital - Queensland Heart Valve Bank $7,294.00
RPH02 Royal Perth Hospital T/A Heart Valve Bank $6,406.00
SHV02 Sydney Heart Valve Bank, St. Vincent's Hospital $6,842.00
TBV02 Donor Tissue Bank of Victoria $7,808.00
DERMATOLOGIC
Skin < 25cm² - acellular dermal matrix allograft from human origin
SYN03 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $2,200.00
Skin > 300cm² - acellular dermal matrix allograft from human origin
SYN07 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $27,000.00
Skin 100cm² - frozen skin graft from human origin
QBB72 The Queensland Bone Bank $527.00
Skin 121 to 300cm² - acellular dermal matrix allograft from human origin
SYN06 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $14,000.00
Skin 200cm² - frozen skin graft from human origin
QBB73 The Queensland Bone Bank $779.00
Skin 26 to 60cm² - acellular dermal matrix allograft from human origin
SYN04 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $3,500.00
Skin 50cm² - frozen skin graft from human origin
QBB71 The Queensland Bone Bank $274.00
Skin 61 to 120cm² - acellular dermal matrix allograft from human origin
SYN05 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $5,700.00
OPHTHALMIC
Amniotic Membrane
LEM03 Lions Eye Donation Service $770.00
Cornea
LEM01 Lions Eye Donation Service $2,000.00
LEN01 Lions NSW Eye Bank $2,287.00
LEW01 Lions Eye Bank of Western Australia $2,500.00
QEB01 Queensland Eye Bank $2,321.00
SAE01 The Eye Bank of South Australia $1,890.00
Page 2 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
Cornea for Endothelial Keratoplasty
LEN04 Lions NSW Eye Bank $2,695.00
LEW03 Lions Eye Bank of Western Australia $3,000.00
SAE03 The Eye Bank of South Australia $2,849.00
Cornea for Endothelial Lamellar Keratoplasty
LEM04 Lions Eye Donation Service $2,660.00
Cornea For Lamellar
LEN03 Lions NSW Eye Bank $1,372.00
Sclera
LEM02 Lions Eye Donation Service $150.00
LEN02 Lions NSW Eye Bank $343.00
LEW02 Lions Eye Bank of Western Australia $250.00
QEB02 Queensland Eye Bank $329.00
SAE02 The Eye Bank of South Australia $230.00
ORTHOPAEDIC
Autologous Skull Flap
MVS23 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $1,396.00
QBB60 The Queensland Bone Bank $1,733.00
RNB02 Hunter New England Bone Bank $1,470.00
Autologous Skull Flap - processed
QBB56 The Queensland Bone Bank $2,195.00
Bone - Cancellous Bone Matrix, Lyophilised 40cc
TBV52 Donor Tissue Bank of Victoria $683.00
Bone - Cancellous Bone Matrix, Lyophilised 80cc
TBV53 Donor Tissue Bank of Victoria $1,364.00
Bone - Cancellous Crunch 15cc
NBB62 New South Wales Bone Bank $1,169.00
Bone - Cancellous Crunch 30cc
NBB61 New South Wales Bone Bank $2,131.00
Bone - Cancellous Crunch 60cc
NBB60 New South Wales Bone Bank $3,232.00
Bone - Cancellous Cubes (6) Freeze Dried
Page 3 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
QBB09 The Queensland Bone Bank $1,778.00
Bone - Cancellous Strips (2) Freeze Dried
QBB10 The Queensland Bone Bank $751.00
Bone - Chips/cubes 40cc
TBV09 Donor Tissue Bank of Victoria $1,254.00
Bone - Chips/cubes 80cc
TBV10 Donor Tissue Bank of Victoria $2,247.00
Bone - Cortico-Cancellous Crunch (40/60) 15cc
NBB65 New South Wales Bone Bank $1,169.00
Bone - Cortico-Cancellous Crunch (40/60) 30cc
NBB64 New South Wales Bone Bank $2,131.00
Bone - Cortico-Cancellous Crunch (40/60) 60cc
NBB63 New South Wales Bone Bank $3,232.00
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, DBX Putty, 10cc
SYN02 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $3,400.00
Bone - Demineralised Bone Matrix, DBX Putty, 5cc
SYN01 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $2,650.00
Bone - Demineralised Bone Matrix, Lyophilised 10g
TBV55 Donor Tissue Bank of Victoria $1,157.00
Bone - Demineralised Bone Matrix, Lyophilised 5g
TBV54 Donor Tissue Bank of Victoria $578.00
Bone - Milled <30g Freeze Dried
PBT37 Perth Bone and Tissue Bank $750.00
Bone - Milled <5 gr (<10cc equivalent)
PBT62 Perth Bone and Tissue Bank $550.00
Bone - Milled >50gr (100cc equivalent)
PBT10 Perth Bone and Tissue Bank $4,050.00
Bone - Milled 10-19 gr (20-38cc equivalent)
Page 4 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
PBT64 Perth Bone and Tissue Bank $2,050.00
Bone - Milled 20-29gr (40-58cc equivalent)
PBT08 Perth Bone and Tissue Bank $2,950.00
Bone - Milled 20g
QBB45 The Queensland Bone Bank $2,202.00
Bone - Milled 20g Freeze Dried
QBB03 The Queensland Bone Bank $2,789.00
Bone - Milled 30 - 50gr (60 - 100cc equivalent)
PBT09 Perth Bone and Tissue Bank $3,550.00
Bone - Milled 30-50g Freeze Dried
PBT38 Perth Bone and Tissue Bank $900.00
Bone - Milled 40cc
TBV11 Donor Tissue Bank of Victoria $1,471.00
Bone - Milled 5-9 gr (10-18cc equivalent)
PBT63 Perth Bone and Tissue Bank $1,150.00
Bone - Milled 80cc
TBV12 Donor Tissue Bank of Victoria $2,508.00
Bone - Milled Femoral Head
AUB02 Australian Biotechnologies $2,457.00
Bone - Ronguered Chips
QBB68 The Queensland Bone Bank $2,235.00
Bone - Ronguered Chips Freeze Dried
QBB67 The Queensland Bone Bank $2,789.00
Bone Plug/Dowel - Cancellous
NBB05 New South Wales Bone Bank $1,584.00
PBT03 Perth Bone and Tissue Bank $1,200.00
TBV07 Donor Tissue Bank of Victoria $935.00
Bone Plug/Dowel - Tricortical
TBV08 Donor Tissue Bank of Victoria $1,002.00
Cartilage - costal segments
PBT11 Perth Bone and Tissue Bank $300.00
QBB12 The Queensland Bone Bank $232.00
Page 5 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
TBV17 Donor Tissue Bank of Victoria $596.00
Cortical Strut
AUB05 Australian Biotechnologies $2,451.00
QBB52 The Queensland Bone Bank $487.00
TBV14 Donor Tissue Bank of Victoria $1,017.00
Cortical Strut >15 - 20cm
PBT07 Perth Bone and Tissue Bank $2,664.00
Cortical Strut >20cm
PBT48 Perth Bone and Tissue Bank $3,032.00
Cortical Struts 10-15cm
PBT06 Perth Bone and Tissue Bank $1,981.00
DBX Putty - 1.00cc
SYN08 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $1,450.00
DBX Putty - 2.5cc
SYN09 Johnson & Johnson Medical Pty Ltd t/a DePuy Synthes $1,800.00
Disc - Freeze Dried
QBB04 The Queensland Bone Bank $788.00
Elbow - joint
QBB14 The Queensland Bone Bank $2,437.00
TBV18 Donor Tissue Bank of Victoria $6,076.00
Fascia Lata
NBB09 New South Wales Bone Bank $1,193.00
TBV21 Donor Tissue Bank of Victoria $1,065.00
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 $6.00
Fascia Lata - Small (10cm x 5cm)
PBT16 Perth Bone and Tissue Bank $854.00
Femoral Head
ACT01 ACT Bone Bank $2,432.00
AUB03 Australian Biotechnologies $2,354.00
Page 6 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
CSA01 Rachel Forster Bone Bank $802.00
DHR01 Barwon Health Bone Bank $3,028.00
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 $2,932.00
QBB27 The Queensland Bone Bank $2,390.00
RNB01 Hunter New England Bone Bank $2,500.00
TBV26 Donor Tissue Bank of Victoria $2,812.00
Femoral Head - Autologous
QBB61 The Queensland Bone Bank $2,390.00
Femoral Head - Freeze Dried
QBB28 The Queensland Bone Bank $2,390.00
Femoral Hemi-condyle
NBB59 New South Wales Bone Bank $2,939.00
PBT21 Perth Bone and Tissue Bank $2,900.00
TBV46 Donor Tissue Bank of Victoria $1,517.00
Femoral Rings
NBB17 New South Wales Bone Bank $2,078.00
PBT24 Perth Bone and Tissue Bank $1,800.00
QBB30 The Queensland Bone Bank $1,758.00
Femoral Rings - Freeze Dried
QBB31 The Queensland Bone Bank $740.00
Femoral Shaft
QBB23 The Queensland Bone Bank $2,483.00
Femoral Shaft - Freeze Dried
QBB66 The Queensland Bone Bank $3,106.00
Femoral Shaft - Half
NBB57 New South Wales Bone Bank $3,595.00
Femoral Shaft - Middle Third
NBB13 New South Wales Bone Bank $3,244.00
TBV24 Donor Tissue Bank of Victoria $2,567.00
Femoral Shaft - Segment
NBB56 New South Wales Bone Bank $2,183.00
Page 7 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
Femoral Shaft - Third
NBB55 New South Wales Bone Bank $2,183.00
Femoral Shaft/Tibial Shaft - Middle third
PBT19 Perth Bone and Tissue Bank $3,200.00
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 $4,220.00
TBV22 Donor Tissue Bank of Victoria $4,505.00
Femur - Distal Half
NBB10 New South Wales Bone Bank $3,595.00
QBB20 The Queensland Bone Bank $3,094.00
Femur - Distal third
NBB11 New South Wales Bone Bank $3,372.00
Femur - Entire
MVS03 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB12 New South Wales Bone Bank $8,023.00
QBB22 The Queensland Bone Bank $4,717.00
TBV23 Donor Tissue Bank of Victoria $7,440.00
Femur - Entire head removed
PBT18 Perth Bone and Tissue Bank $8,000.00
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 $4,220.00
TBV25 Donor Tissue Bank of Victoria $4,473.00
Femur - Proximal half
NBB15 New South Wales Bone Bank $3,780.00
QBB25 The Queensland Bone Bank $3,337.00
Femur - Proximal third
NBB14 New South Wales Bone Bank $1,690.00
Femur - Proximal with femoral head
TBV51 Donor Tissue Bank of Victoria $4,345.00
Fibula - Entire
Page 8 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
MVS07 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB18 New South Wales Bone Bank $7,817.00
PBT25 Perth Bone and Tissue Bank $3,500.00
QBB32 The Queensland Bone Bank $2,930.00
TBV27 Donor Tissue Bank of Victoria $7,177.00
Fibula - Segment
NBB54 New South Wales Bone Bank $3,053.00
PBT28 Perth Bone and Tissue Bank $2,000.00
Fibula - Segment (12cm)
MVS14 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV29 Donor Tissue Bank of Victoria $1,347.00
Fibula - Segment (6cm)
MVS13 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV28 Donor Tissue Bank of Victoria $935.00
Fibular Shaft
TBV30 Donor Tissue Bank of Victoria $2,631.00
Hemipelvis - Acetabulum
NBB21 New South Wales Bone Bank $3,759.00
PBT29 Perth Bone and Tissue Bank $2,940.00
QBB33 The Queensland Bone Bank $3,052.00
TBV31 Donor Tissue Bank of Victoria $3,532.00
Hemipelvis - Complete
MVS08 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB24 New South Wales Bone Bank $8,411.00
PBT30 Perth Bone and Tissue Bank $7,000.00
QBB37 The Queensland Bone Bank $4,717.00
TBV32 Donor Tissue Bank of Victoria $7,815.00
Hemipelvis - iliac crest
NBB22 New South Wales Bone Bank $3,500.00
PBT31 Perth Bone and Tissue Bank $2,000.00
QBB34 The Queensland Bone Bank $2,738.00
TBV33 Donor Tissue Bank of Victoria $3,209.00
Hemipelvis - Tricortical iliac wedge
Page 9 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
NBB23 New South Wales Bone Bank $1,546.00
PBT32 Perth Bone and Tissue Bank $1,500.00
QBB35 The Queensland Bone Bank $1,321.00
TBV34 Donor Tissue Bank of Victoria $1,331.00
Hemipelvis - Tricortical iliac wedge Freeze Dried
QBB36 The Queensland Bone Bank $812.00
Humeral Head
TBV37 Donor Tissue Bank of Victoria $2,021.00
Humeral Head Addition
NBB26 New South Wales Bone Bank $1,999.00
Humeral Shaft
NBB50 New South Wales Bone Bank $3,998.00
QBB39 The Queensland Bone Bank $1,781.00
Humeral Shaft - Half
NBB51 New South Wales Bone Bank $2,162.00
Humerus - Distal
MVS19 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB25 New South Wales Bone Bank $3,053.00
TBV49 Donor Tissue Bank of Victoria $2,685.00
Humerus - Entire
MVS20 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB29 New South Wales Bone Bank $4,066.00
QBB43 The Queensland Bone Bank $3,354.00
Humerus - Entire with rotator cuff
NBB30 New South Wales Bone Bank $4,118.00
PBT33 Perth Bone and Tissue Bank $3,343.00
Humerus - Proximal
NBB27 New South Wales Bone Bank $3,583.00
PBT35 Perth Bone and Tissue Bank $2,800.00
TBV36 Donor Tissue Bank of Victoria $3,280.00
Humerus - Proximal half with rotator cuff
NBB28 New South Wales Bone Bank $3,595.00
Humerus - Proximal with rotator cuff
Page 10 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
MVS09 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
PBT34 Perth Bone and Tissue Bank $4,200.00
TBV35 Donor Tissue Bank of Victoria $3,142.00
Humerus - Ring
NBB53 New South Wales Bone Bank $1,874.00
Ligament - Medial
NBB31 New South Wales Bone Bank $2,305.00
TBV38 Donor Tissue Bank of Victoria $2,165.00
Meniscal Graft
PBT47 Perth Bone and Tissue Bank $1,921.00
Meniscus
QBB05 The Queensland Bone Bank $1,547.00
TBV40 Donor Tissue Bank of Victoria $1,492.00
Meniscus with Ligaments
TBV39 Donor Tissue Bank of Victoria $2,578.00
Osteotomy Wedge
PBT60 Perth Bone and Tissue Bank $2,000.00
Patella
QBB47 The Queensland Bone Bank $871.00
TBV41 Donor Tissue Bank of Victoria $1,307.00
Patellar unit whole with or without tibial block
PBT40 Perth Bone and Tissue Bank $2,954.00
Proximal Femur with Femoral Head
PBT65 Perth Bone and Tissue Bank $6,300.00
Radius
MVS18 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB06 New South Wales Bone Bank $3,913.00
PBT13 Perth Bone and Tissue Bank $1,800.00
QBB15 The Queensland Bone Bank $2,495.00
TBV19 Donor Tissue Bank of Victoria $3,671.00
Radius - Ring
NBB49 New South Wales Bone Bank $2,399.00
Page 11 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
Radius - Shaft
NBB47 New South Wales Bone Bank $3,850.00
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 $705.00
Spinal Ring
AUB07 Australian Biotechnologies $1,854.00
Tendon
AUB10 Australian Biotechnologies $2,184.00
Tendon - Achilles
NBB01 New South Wales Bone Bank $2,487.00
PBT61 Perth Bone and Tissue Bank $1,985.00
QBB62 The Queensland Bone Bank $2,124.00
TBV05 Donor Tissue Bank of Victoria $1,311.00
Tendon - Achilles Hemi
QBB65 The Queensland Bone Bank $1,584.00
Tendon - Achilles with bone block
NBB02 New South Wales Bone Bank $2,883.00
PBT01 Perth Bone and Tissue Bank $2,800.00
QBB01 The Queensland Bone Bank $2,124.00
TBV06 Donor Tissue Bank of Victoria $2,509.00
Tendon - Achilles with bone plug
AUB09 Australian Biotechnologies $2,228.00
Tendon - Achilles with machined conical bone block
NBB69 New South Wales Bone Bank $3,530.00
Tendon - EHL
QBB69 The Queensland Bone Bank $2,124.00
Tendon - Gracilis
QBB59 The Queensland Bone Bank $2,124.00
Tendon - Patellar
QBB48 The Queensland Bone Bank $2,271.00
Page 12 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
Tendon - Patellar Hemi
QBB63 The Queensland Bone Bank $1,735.00
Tendon - Patellar split with bone plugs
PBT02 Perth Bone and Tissue Bank $2,500.00
Tendon - Patellar with bone plugs
NBB33 New South Wales Bone Bank $2,778.00
TBV42 Donor Tissue Bank of Victoria $2,578.00
Tendon - Patellar with machined conical bone plug
NBB68 New South Wales Bone Bank $3,425.00
Tendon - Patellar with Quads
NBB72 New South Wales Bone Bank $2,826.00
Tendon - Peroneus Longus
NBB73 New South Wales Bone Bank $2,826.00
Tendon - Semi tendinosis
NBB70 New South Wales Bone Bank $2,827.00
QBB70 The Queensland Bone Bank $2,124.00
Tendon - Single (ant and post tibilias, FDL, EDL, hamstring, gracilis)
PBT46 Perth Bone and Tissue Bank $2,800.00
Tendon - Tibialis Anterior
NBB67 New South Wales Bone Bank $2,826.00
QBB58 The Queensland Bone Bank $2,124.00
TBV57 Donor Tissue Bank of Victoria $2,509.00
Tendon - Tibialis Posterior
NBB71 New South Wales Bone Bank $2,826.00
QBB57 The Queensland Bone Bank $2,124.00
Tibia - Condyles only
TBV47 Donor Tissue Bank of Victoria $2,030.00
Tibia - Distal
MVS17 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
QBB51 The Queensland Bone Bank $2,091.00
TBV48 Donor Tissue Bank of Victoria $2,612.00
Tibia - Plateau (prox 1/3)
Page 13 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
NBB35 New South Wales Bone Bank $3,258.00
Tibia - Proximal
NBB36 New South Wales Bone Bank $3,301.00
PBT45 Perth Bone and Tissue Bank $2,635.00
QBB54 The Queensland Bone Bank $2,614.00
Tibia - Proximal 16-25cm
TBV45 Donor Tissue Bank of Victoria $2,941.00
Tibia - Proximal 7-15cm
TBV44 Donor Tissue Bank of Victoria $3,047.00
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 $3,094.00
Tibia - Proximal with Patella & Tendon
PBT44 Perth Bone and Tissue Bank $5,000.00
Tibia - Proximal with Patellar Tendon
NBB46 New South Wales Bone Bank $5,158.00
Tibia - Ring
NBB45 New South Wales Bone Bank $1,874.00
Tibia - Whole
MVS16 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB37 New South Wales Bone Bank $5,260.00
QBB55 The Queensland Bone Bank $4,694.00
Tibia - Whole with Patella
QBB64 The Queensland Bone Bank $4,717.00
Tibia - Whole with Patellar Tendon
NBB44 New South Wales Bone Bank $7,059.00
Tibia Shaft
QBB53 The Queensland Bone Bank $1,096.00
Tibial Shaft
Page 14 of 15
Billing Code Facility Minimum Benefit Maximum Benefit
NBB41 New South Wales Bone Bank $4,849.00
Tibial Shaft - half
NBB43 New South Wales Bone Bank $3,170.00
Tibial Shaft - third
NBB42 New South Wales Bone Bank $3,423.00
Tibial Shaft Freeze Dried
QBB02 The Queensland Bone Bank $964.00
Tri Cortical Osteotomy
NBB66 New South Wales Bone Bank $1,563.00
Ulna
MVS15 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB07 New South Wales Bone Bank $3,606.00
PBT14 Perth Bone and Tissue Bank $1,500.00
QBB16 The Queensland Bone Bank $2,495.00
TBV20 Donor Tissue Bank of Victoria $3,396.00
Ulna - Ring
NBB40 New South Wales Bone Bank $2,399.00
Ulna - Shaft
NBB38 New South Wales Bone Bank $3,170.00
Grand Total: 286 Records
Page 15 of 15
Part C - Other Prostheses August 2015
03 - GENERAL MISCELLANEOUS
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Notations
03.02.03 - Infusion Pumps, Battery Powered
03.02.03.02 - Insulin infusion pump (as 3.2.3.1) with integral calculator to determine boluses and
Managing Diabetes Pty Ltd
DF001 DANAIIS Insulin Pump Continuous insulin infusion pump 75mm x 45mm x 19mm $4,000.00
DE, SS
Australasian Medical & Scientific Ltd
AN011 Animas Vibe Insulin Pump & CGM Ambulatory insulin infusion pump Pump/Monitor: 8.26 x 5.08 $8,950.00
System with real-time continuous glucose x 2.18cm
monitoring (CGM) 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 $8,950.00
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.
Roche Diagnostics Australia Pty Ltd
RO044 Accu-Chek Combo System Insulin delivery device capable of The Accu-Chek Combo $8,950.00
remotely receiving and acting on System is only available in
information about blood glucose one size.
levels, performing bolus calculation
and bolus advice on additional
parameters than what is normally
RO051 ACCU-CHEK Insight System Insulin delivery device capable of No variable sizes offered. $8,950.00
remotely receiving and acting on Only one system provided.
information about blood glucose
levels, performing bolus calculation
and bolus advice on additional
parameters than what is normally
Page 1 of 3
03 - GENERAL MISCELLANEOUS
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Notations
SS
Australasian Medical & Scientific Ltd
AN005 Animas 2020 Insulin Pump. Ambulatory Insulin Infusion Pump 7.4cm x 5cm x 1.9cm $7,750.00
03.02.03.03 - Device has capability to automatically adjust the insulin delivery based on
DE, SS
Medtronic Australasia Pty Ltd
MC839 Medtronic MiniMed Insulin Paradigm Veo Model MMT-554. 5.1 x 7.6 x 2.0cm $9,500.00
Infusion Pump 'Smart' Insulin Pump with REAL-
Time continuous glucose monitoring
capability, incorporating a low
glucose suspend and with remote
MC840 Medtronic MiniMed Insulin Paradigm Veo Model MMT-754. 5.1 x 9.4 x 2.0cm $9,500.00
Infusion Pump 'Smart' Insulin Pump with REAL-
Time continuous glucose monitoring
capability, incorporating a low
glucose suspend and with remote
MI150 MiniMed 640G Insulin Pump MiniMed 640G Insulin Pump with 1.8ml and 3.0ml $9,500.00
SmartGuard Technology and
continuous glucose monitoring
capability, designed to automatically
suspend insulin delivery before
dangerous lows occur, and
automatically resume after levels
recover.
Page 2 of 3
08 - CARDIAC
Minimum Maximum
Billing Code Product Description Size Benefit Benefit Notations
08.14.01 - Implantable Cardiac Event Recorders
Medtronic Australasia Pty Ltd
MC763 Reveal XT Reveal XT Insertable Cardiac Monitor 61 x 19 x 8 mm with a $3,900.00
volume of 9cc
MC768 Reveal DX Insertable Cardiac Monitor 61 x 19 x 8 mm with a $3,900.00
volume of 9cc
St Jude Medical Australia Pty Ltd
SJ152 SJM Confirm Model DM2102 Implantable cardiac monitor with 6.5cc, 12g $3,900.00
atrial fibrillation monitoring.
SJ159 SJM Confirm Model DM2100 Implantable cardiac monitor 6.5cc, 12g $3,900.00
i
Biotronik Australia Pty Ltd
BT153 BioMonitor Implantable cardiac monitor for 53.3mm x 42.7mm x 7.1mm, $3,900.00
continuous remote monitoring of 26 grams
patients with Atrial Fibrillation (AF)
or unexplained syncope
Medtronic Australasia Pty Ltd
MI141 Reveal LINQ Insertable Cardiac Monitor 45 x 7 x 3.5mm, 1.18cc $3,900.00
Grand Total: 15 Records
Page 3 of 3
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