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

As amended

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

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

Prepared by the Department of Health and Ageing, Canberra

Contents

Part 1 Preliminary 

1. Name of Rules 

2. Commencement 

3. Revocation 

4. Definitions 

Part 2 Benefit requirements 

5. Listing of, and benefits for, prostheses 

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

5B. Conditions in relation to provision of listed prostheses 

6. Benefits for prostheses provided as part of hospital treatment 

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

Part 3 Other 

8. Timing of applications to have a prosthesis listed 

9. Minister may have regard to recommendations and advice 

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

Part 1 Preliminary

1.                     Name of Rules

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

2.                     Commencement

These Rules commence on 3 March 2012.

3.                     Revocation

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

4.                     Definitions

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

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

In these Rules:

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

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

Act means the Private Health Insurance Act 2007.

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

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

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

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

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

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

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

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

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

National Law means:

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

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

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

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

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

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

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

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

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

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

Schedule means the Schedule in these Rules.
 

Part 2  Benefit requirements

5.                    Listing of, and benefits for, prostheses

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

(a)                   the Schedule lists the kinds of prostheses:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6.                    Benefits for prostheses provided as part of hospital treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Part 3  Other

8.                    Timing of applications to have a prosthesis listed

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

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

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

9.                      Minister may have regard to recommendations and advice

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

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

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

(i) insulin infusion pump; or

(ii) implantable cardiac event recorder.

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

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

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

Part A - Prostheses List February 2012

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.1.1 - Aphakic

 1.1.1.1 - Rigid

 Alcon Laboratories (Aust.) Pty Ltd

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

 Bausch & Lomb (Australia) Pty Ltd

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

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

 Chamber Lens L122UV: 6.0mm optic,

 13.75mm length, power range;

 5.0 to 30.0 Diopters

 Emagin Pty Ltd

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

 Lens in overall length

 ifc

 AMO Australia Pty Ltd

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

 overall length

 m

 AMO Australia Pty Ltd

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

 13.0mm in overall length

1.1.2 - Phakic

 1.1.2.1 - Rigid

 AMO Australia Pty Ltd

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

 Composition: PMMA overall length; 6mm Optic

 Diameter x 8.5 overall length

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

 Hyperopia.  Composition: PMMA overall length

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Emagin Pty Ltd

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

 Hyperopic in overall length;

 t1

 AMO Australia Pty Ltd

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

 overall length

 Emagin Pty Ltd

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

 Lens Composition: PMMA in overall length

 t2

 AMO Australia Pty Ltd

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

 overall length

 1.1.2.2 - Foldable

 Alcon Laboratories (Aust.) Pty Ltd

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

 piece phakic lens diopter increments

 AMO Australia Pty Ltd

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

 intraocular lens increments.  Overall diameter

 8.5mm. Optic 6.0mm

 Emagin Pty Ltd

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

 Lens PMMA overall length

1.2.1 - Rigid

 Alcon Laboratories (Aust.) Pty Ltd

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

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Bausch & Lomb (Australia) Pty Ltd

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

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

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

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

 optic, 13.35mm length, Power

 range: 10.0 to 30.0 Diopter

1.2.2 - Foldable

 1.2.2.1 - Microincision

 Carl Zeiss Pty Ltd

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

 (aberration neutral) IOL: Foldable, square- diameter. Diopter range 0.0 to

 edged, single piece IOL for capsular bag  +32.0D (0.5D steps from 10.0

 fixation to 30.0D, 1.0D outside this

 range)

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

 (aberration correcting) IOL: Foldable,  diameter. Diopter range 0.0 to

 square-edged, single piece IOL for  +32.0D (0.5D steps from 10.0

 capsular bag fixation to 30.0D, 1.0D outside this

 range)

 at, pl

 Bausch & Lomb (Australia) Pty Ltd

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

 foldable acrylic, aphakic, anterior &  11.0mm(10D-15D), 10.7mm

 posterior edge modification, preloaded,  (15.50-22D), 10.5mm (22.50-

 with aberration contro, intraocular lens 30D)

 Carl Zeiss Pty Ltd

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

 (aberration neutral), foldable square-edged Optic size: 6.0mm; Overall

  single piece inraocular lens for capsular  length: 11.0mm

 bag fixation.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 at, pl, t1

 Carl Zeiss Pty Ltd

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

  (aberration neutral), foldable, square- 32.0, Cyl +1.0 to 6.5

 edged, single-piece IOL for capsular bag  Optic size: 6.0mm, Overall

 fixation length: 11.0mm

 at, pl, t2

 Carl Zeiss Pty Ltd

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

  (aberration neutral), foldable, square- 32.0, Cyl +7.0 to 12.0, Optic

 edged, single-piece IOL for capsular bag  size: 6.0mm. Overall Length

 fixation 11.0mm

 t1

 Carl Zeiss Pty Ltd

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

 ZEISS Micro Incision Aspheric  diameter. Diopter range: Sph

 (abberation neutral) IOL: Foldable,  +6.0 to +32.0D, Cyl +1.0 to

 square-edged, single piece IOL for  6.5D (all 0.5D steps)

 capsular bag fixation

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

  Incision Aspheric (aberration neutral)  diameter. Diopter range: Sph -

 IOL: Foldable, square-edged, single piece  10.0 to +5.5D, Cyl +1.0 to

 IOL for capsular bag fixation 6.5D (all 0.5D steps)

 t2, at

 Carl Zeiss Pty Ltd

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

 Micro Incision Aspheric (aberration  diameter.  Diopter range: Sph -

 neutral) IOL: Foldable square edged,  10.0 to +32.0D, +7.0 to 12.0D

 single piece IOL for capsular bag fixation  (all 0.5D steps)

 1.2.2.2 - No edge modification

 Ellex Australia Pty Ltd

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

 Model AQ 5010V diopters

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 t1

 Ellex Australia Pty Ltd

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

 lens: Model AA4203TF; Model

 AA4203TL

 1.2.2.3 - Edge modification

 Alcon Laboratories (Aust.) Pty Ltd

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

 MA60AC

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

 asymmetric optic/consistent edge

 AMO Australia Pty Ltd

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

 Sensar OptiEdge AR40e Foldable  Posterior in overall length.     

 Acrylic IOL

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

 Chamber Intraocular Lens design

 Bausch & Lomb (Australia) Pty Ltd

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

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

  vial.  Four haptic design 25.0 Diopter in 0.5 Diopter

 increments25.0 to 30.0

 Diopter in 1.0 Diopter

 increments

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

 Chamber posterior chamber intraocular lenses Diopter - Optic diameter

 6.0mm; 13.0mm length

 Carl Zeiss Pty Ltd

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

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

 blocker

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

 edged, hydrophilic acrylic (with  Optic size: 6.0mm, Overall

 hydrophobic surface properties)  length: 13.0mm

 intraocular lens for capsular bag or sulcus

 fixation.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Ellex Australia Pty Ltd

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

 AQ2010V, AQ2017V and AO2003V  or 6.3mm optic;

 Kevin Grundy (IBD) Pty Ltd

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

 foldable with injector dia overall

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

 foldable with injector overall

 at

 AMO Australia Pty Ltd

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

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

 intraocular lenses, Silicone/Acrylic  0.5 increments

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

 modification and 360 degree square edge 0.5d increments

 Bausch & Lomb (Australia) Pty Ltd

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

 with anterior optic-haptic square edge,

 posteriof optic-haptic square edge, 360-

 degree optic square edge and asperic optic

  for aberration control

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

 with anterior optic-haptic square edge,

 posterior optic-haptic square edge, 360

 degree optic square edge and aspheric

 optic for aberration control

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

 violet-absorbing, posterior chamber,   body diameter 6.0mm in

 hydrophobic acrylic one-piece intraocular  dioptric powers ranging from

 lens (IOL)  Has an aspheric lens optic,  +0.0 to +34D

 square posterior edge, modified C haptics  0.0D to 10.0D in 1 Diopter

 and available in dioptric powers ranging  increments

 from +0.0 to +34.0D. 11.0D to 30.0D in 0.5 Diopter

 increments

 31.0D to 34.0D in 1 Diopter

 increments

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Carl Zeiss Pty Ltd

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

 monofocal, aspheric (aberration neutral),  Optic size: 6.0mm, Overall

 square-edged, hydrophilic acrylic (with  length: 11.0mm

 hydrophobic surface properties)

 intraocular lens for capsular bag fixation.

 (Monofocal lens for powers outside

 standard 409MP MICS range).

 IQ Medical

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

 lens with anterior and posterior optic- from -5.0 to +36.0, 1D steps: -

 haptic square edge, 360 degree optic  5.0 to +10.0 and +31.0 to

 square edge design, precision power  +36.0; 0.5D steps: +10.5 to

 calculation and aberration technology +18.0 and +25.0 to +29.5;

 0.25D steps: +18.0 to +25.0

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

 lens with anterior and posterior optic- from 0.0 to +30.0. 1D steps:

 haptic square edge, 360 degree optic  0.0 to +10.0; 0.5D steps:

 square edge design, precision power  +10.5 to + 17.5 and +28.5 to

 calculation, aberration technology and UV  +30.0; 0.25D steps: +18.0 to

 light filter. +28.0

 Kevin Grundy (IBD) Pty Ltd

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

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

 Anti-vaulting Haptics to +22D

 at, pl

 Carl Zeiss Pty Ltd

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

 single piece, trihaptic IOL with square   Diameter

 edge design, for use with SkyJet injector

 Ellex Australia Pty Ltd

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

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 at, pl, t1, vblf

 Design for Vision Pty Ltd

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

 astigmatism micro-incision, ashperic, blue- (0.5 steps), IOL Cylinder

 blocker, single piece hydophobic. power: 1.50D (T3), 2.25D

 (T4), 3.00D (T5).

 at, pl, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 Blue light protection and aspheric

 correction, in cartridge.

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

 foldable, acrylic, single piece lens with blue

  light protection and aspheric correction, in

  cartridge

 Design for Vision Pty Ltd

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

 blocker, Foldable, Single-Piece,

 Hydrophobic Acrylic

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

 Aspheric, Blue-Blocker, Single Piece,

 Hydrophobic

 at, t1

 AMO Australia Pty Ltd

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

 Intraocular lens, incorporates a proprietary in 0.5 diopter increments. 

  wavefront designed toric aspheric optic  Cylinder power: 1.00 diopter,

 with a squared posterior optic edge  1.50 diopter, 2.25 diopter,

 designed to provide a 360 degree barrier.  3.00 diopter and 4.00 diopter

 The edge of the optic has a frosted design  (as measured at the IOL plane).

 to reduce potential edge glare effects.  Overall diameter 13mm, Optic

 size 6mm.

 at, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 Blue Light Protection and Aspheric

 Correction

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Bausch & Lomb (Australia) Pty Ltd

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

 Shield silicone, anterior & posterior edge  Modified  C 5 degree

 modification intraocular lens with  angulation 0-30D, 0.5D steps

 aberration technology, a violet light

 Design for Vision Pty Ltd

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

 Single-piece, Hydrophobic

 IQ Medical

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

 lens with anterior and posterior optic- from -5.0 to + 36.0, 1D steps:

 haptic square edge, 360 degree optic  -5.0 to +10.0 and +31.0 to

 square edge design, precision power  +36.0; 0.5D steps: +10.5 to

 calculation, aberration technology and blue +18.0 and +25.0 to 29.5;

  light filter 0.25D steps: + 18.0 to +25.0

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

 lens with anterior and posterior optic- from 0.0 to +30.0. 1D steps:

 haptic square edge, 360 degree optic  0.0 to +10.0; 0.5D steps:

 square edge design, precision power  +10.5 to +17.5 and +28.5 to

 calculation, aberration technology and blue +30.0; 0.25D steps: +18.0 to

  light filter. +28.0

 pl

 Ellex Australia Pty Ltd

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

 Intraocular Lens posterior edge modification length 12.5mm, diopter range

 +10 to +28.0

 t1

 Bausch & Lomb (Australia) Pty Ltd

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

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

 surface and axis marks on the posterior  power range (spherical

 optic's flat meridian. equivalent powers from +10.0

 to +30.0 diopters in 0.5 diopter

  steps and cylinder powers of

 +1.25, +2.00 & +2.75

 diopters).

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Kevin Grundy (IBD) Pty Ltd

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

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

  2D increments

 t1, at, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 foldable, acrylic, toric, single piece lens  6.00 D cylinder.

 with blue light protection and aspheric

 correction

 Design for Vision Pty Ltd

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

 incision,Aspheric, Blue-Blocker, Single  (0.5 steps)lOL Cylinder

 Piece, Hydrophobic Power: 1.50D (311T3), 2.25D

 (311T4), 3.00D (311T5)

 t1, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 foldable, acrylic, toric, single piece lens  6.00 D cylinder

 with blue light protection

 t2

 Kevin Grundy (IBD) Pty Ltd

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

 injector dia overall, cyls 1.5D to 11.0D

 in 0.5D increments

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

  11.00D Cylinder in 0.25 steps

           +31.00D to +35.00 Spit:

  1D to 11.00D Cylinder in

 0.25steps

 vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 asymmetric optic/consistent edge, with

 blue light protection

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 MN60AC Blue light Protection

 1.2.2.4 - Multifocal or bifocal

 AMO Australia Pty Ltd

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

 Lens intraocular lens 13.0mm overall length

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

 (ZM900) Chamber Diffractive Intraocular Lens   0.5 diopter increments

 Model ZM900.  Posterior Chamber lens

 with UV light-absorbing, foldable, silicone,

  3 piece with a diffractive posterior optic

 and a Modified Prolate Anterior Surface

 Technology

 at

 AMO Australia Pty Ltd

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

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

 diffractive posterior optic and a modified

 anterior surface technology with edge

 modification and 360 degree square edge.

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

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

 with a diffractive posterior optic and a  Diopter to +34.0 Diopter in 0.5

 modified anterior surface technology with   Diopter increments.

 edge modification and a 360 degree

 square edge.

 Carl Zeiss Pty Ltd

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

 IOL.  Diffractive bifocal anterior surface  Diopter range 0.0D to +32.0D

 with asymmetric light distribution (65%  (0.5D steps)

 distance / 35% near), 3.75D addition for

 near focus.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Kevin Grundy (IBD) Pty Ltd

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

  refractive aspheric multifocal with Amon- 12.5mm: +3D or + 4D

 Apple 360 Degree Square edge, Anti  Addition: +14D to +25D in

 Vaulting Haptics 1.0D increments: +8.5D to

 +23.5D in 0.5D increments

 at, pl

 Carl Zeiss Pty Ltd

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

 bifocal, square edged, single-piece IOL for Optic size: 6.0mm.  Overall

  capsular bag fixation. The anterior  length: 11.0mm

 aspheric bifocal surface has an asymmetric

 light distribution 65/35 for distance/near

 vision, and 3.75D add for the near focus.

 at, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

 foldable, acrylic, single piece lens with

 apodised diffractive optic and blue light

 protection

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

 MN6AD1 foldable, acrylic, single and multiple lenses

 with apodised diffractive optic and blue

 light protection

 Design for Vision Pty Ltd

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

 Aspheric, Blue-blocker, Single Piece,

 Hydrophobic

 t1, at

 Carl Zeiss Pty Ltd

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

 (standard cyl range). Aspheric toric  Diopter range: Sph -10.0D to

 anterior surface, diffractive bifocal  +32.0D, Cyl +1.0 to 6.5D (all

 posterior surface with asymmetric light  0.5D steps)

 distribution (65% distance / 35% near),

 3.75D addition for near focus.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Kevin Grundy (IBD) Pty Ltd

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

 zoned Refractive Aspheric Toric Mulitfocal 12.5mm +3.00D or +4.00D

  with Amon-Apple enhanced 360 degree  Addition FAR: +14.0D to

 Square edge, Anti Vaulting Haptics +32.00D in 0.5 STEPS:

 +2.00D +3.00D  +4.00D

 Cylinder. NEAR: +14.0D to

 27.0D in 0.5 STEPS: +2.00D

 +3.00D  +4.00D Cylinder

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

 Zoned Refractive, Toric Multifocal with  +3.00D to +4.00D Addition

 Amon-Apple enhanced 360 Degree  FAR: +14.0D to +32.0D in

 square edge, Anti-vaulting Haptics, Patient 0.5D Increments: NEAR:

  Specific. +14.0D to +27.0D in 0.50D

 Increments Cylinder: 1.0D to

 1.5D and 2.5D to 6.00D in 0.5

 increments

 t1, at, vblf

 Alcon Laboratories (Aust.) Pty Ltd

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

  acrylic, aspheric, toric single piece lense   3.00 D cylinder

 with apodised diffractive optic and blue

 light protection.

 t2, at

 Carl Zeiss Pty Ltd

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

 (standard cyl range). Aspheric toric  Diopter range: Sph -10.0D to

 anterior surface, diffractive bifocal  +32.0D, Cyl +7.0 to 12.0D (all

 posterior surface with asymmetric light   0.5D steps)

 distribution (65% distance / 35% near),

 3.75D addition for near focus.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 1.2.2.5 - Accommodative

 pa

 Bausch & Lomb (Australia) Pty Ltd

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

 accommodation with dual mechanism of  Dioptre steps

 action: (1) forward axial movement of lens

 and (2) accommodative arching of optic. 

 Posterior chamber, polyspheric optics, 3-

 piece, plate haptic, foldable UV light

 filtering, bic

 IQ Medical

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

 accommodating intraocular lens with sqare  from +5.0 to +36.0, 1D steps:

 edge design, custom control precision and  +31.0 to +36.0; 0.5D steps:

 closed loop haptic design +5.0 to +18.0 and +25.0 to

 +30.0; 0.2D steps; +18.0 to

 +25.0

 pa, at

 Bausch & Lomb (Australia) Pty Ltd

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

 > 3 Diopters of accommodation with dual  steps.  10.0 - 16.5 Diopters

 mechanism of action: (1) forward axial  (12mm length) and 17.0 - 33.0

 movement of lens and (2) accommodative  Diopters (11.5mm length).

 arching of optic.  Posterior chamber,

 aspheric, aberration free optics, 3-piece,

 plate haptic, fol

 pa, pl

 AMO Australia Pty Ltd

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

 Posterior Chamber IOL 6.00mm Interior Optic,

 9.80mm Overall Length,

 Diopter Range: +16.00 to

 +28.00 in 0.5D Increments

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.2.3 - Pseudo-phakic, piggy-back

 1.2.3.1 - Monofocal

 Design for Vision Pty Ltd

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

 I.O.L. increments.                +5.50D

 to 10.00D in 0.5D increments

 at

 Kevin Grundy (IBD) Pty Ltd

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

 t1, at

 Kevin Grundy (IBD) Pty Ltd

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

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

 Standard undulating Haptics and Posterior Haptic

 Angulation (Standard)

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

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

 undulating Haptics and Posterior Haptic  0.5D steps

 Angulation (Premium)

 1.2.3.2 - Multi-focal

 at

 Kevin Grundy (IBD) Pty Ltd

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

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

 Fixated with Undulating Haptics and  3.00 Addition

 Posterior Haptic Angulation

1.3.1 - Viscoelastic

 Alcon Laboratories (Aust.) Pty Ltd

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

 SOLUTION

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

AL015 Cellugel viscoelastic fluid Hypromellose 2% . $80.00

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

 Device chondroitin sulfate 40mg/mL

 AMO Australia Pty Ltd

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

 Bausch & Lomb (Australia) Pty Ltd

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

 for intraocular use

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

 intraocular use

 Carl Zeiss Pty Ltd

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

 sodium hyaluronate (NaHA, 1.5%) and  ampoules

 lidocaine hydrochloride (1%). Also

 contains two topical ampoules with NaHA

 (0.3%) and lidocaine (2%)

 IQ Medical

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

 Hydroxypropylmethylcellulose for intraocular use. Pre-loaded in a sterile

 syringe with one cannula for injection, in a

 sterile Tyvek pouch

 hmw

 AMO Australia Pty Ltd

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

  .

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

 Carl Zeiss Pty Ltd

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

 hyaluronate 10mg/ml.  (previously called

 Ophthalin)

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 hyaluronate 15mg/ml.  (previously called

 Opthalin Plus)

 1.3.1.1 - Dual Fluids

 Alcon Laboratories (Aust.) Pty Ltd

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

 SYSTEM VISCOAT contains chondroitin sulfate

 and sodium hyaluronate

 Carl Zeiss Pty Ltd

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

 dispersive viscoelastic in one syringe,

 separated by a valve.  Dispersive: sodium

 hyaluronate (2.2%).  Cohesive: sodium

 hyaluronate (1%)

1.3.2 - Non Viscous

 Design for Vision Pty Ltd

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

1.4.1 - Simple

 Alcon Laboratories (Aust.) Pty Ltd

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

 - 14.5 uncompressed

 AMO Australia Pty Ltd

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

 Carl Zeiss Pty Ltd

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

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Design for Vision Pty Ltd

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

 Emagin Pty Ltd

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

 pl

 Design for Vision Pty Ltd

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

 per-load on disposable injector  (12mm)

 Insight Surgical Pty Ltd

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

1.4.2 - Complex

 Design for Vision Pty Ltd

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

1.5.1 - Long Tube

 AMO Australia Pty Ltd

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

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

 103-425, Baerveldt Glaucoma Implant  polished finish

 BG 103-250

 Design for Vision Pty Ltd

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

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

 Plate/Single Plate-Dual Chamber/Double

 Plate

 v

 Design for Vision Pty Ltd

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

 silicon *175mm square

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.5.2 - Short Tube

 1.5.2.1 - Cannulated

 Alcon Laboratories (Aust.) Pty Ltd

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

1.6.1 - Spacers

 Spectrum Surgical

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

 0.35mm thick

1.6.2 - Weights

 1.6.2.1 - Gold <1.8 grams

 Device Technologies Australia Pty Ltd

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

 grams

 1.6.2.2 - Gold ≥1.8 grams

 Device Technologies Australia Pty Ltd

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

 grams

 1.6.2.3 - Platinum

 CoreMed Pty Ptd

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

 1.6, 1.8 grams

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.7.1 - Intracanilicular

 Design for Vision Pty Ltd

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

 lacrimal intubation set

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

 Device Technologies Australia Pty Ltd

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

 .051 x 33cm

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

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

  0.40mm x 11cm, tubing 35cm

 x 0.64mm. Probes 0.60mm x

 11mm, tubing 35cm x 0.30mm.

 Spectrum Surgical

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

  Silicone Plug/Metal Probes/Polypropylene Tube/80 x 0.8mm probes, PVP

  Thread  Differential Bika: 0.64 &

 1.18mm O.D. Tube/40 x

 1.2mm probes, PVP Bika for

 DCR: 0.94mm O.D. Tube/50 x

  0.8mm probes, PVP Infant

 Bika 0.64mm O.D. Tube/55 x

 0.7mm probes, PVP Infant

 Bika II: 0.64mm O.D. Tube/

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

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

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

 400mm.  PEEK Thread: 0.2mm

  to 0.4mm x 500mm.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 mc

 Spectrum Surgical

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

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

 flexible stainless steel probes or guides.  0.64mm to 1.18mm x 30mm to

 PEEK thread. Introducer. 350mm.  PEEK Thread: 0.2mm

  to 0.4mm x 500mm.  Plug

 Collar: 2mm to 4mm.

1.7.2 - Extracanilicular

 Device Technologies Australia Pty Ltd

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

 18mm, 4.0 x 9 to 24mm, 5.0 x

 9mm

1.8.1 - Intrascleral

 Device Technologies Australia Pty Ltd

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

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

 Spectrum Surgical

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

 vp

 Spectrum Surgical

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

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

 Synthetic Diameter, 10, 12, 14,

  16, 18, 20, 22mm

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.8.2 - Extrascleral

 1.8.2.1 - Complex and permeable

 Stryker Australia Pty Ltd

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

  6317 and 6322 8702-8704. COI implant, 14mm, 6326: 16mm, 6327:

  models 7222, 7223 & 80026. MCOI  18mm, 6317: 20mm, 6322:

 implant, models 7207 - 7209 Quad  22mm, 8702: 19mm, 8703:

 Motility Implants 9866 - 9868 & 80022 21mm, 8704: 23mm, COI

 Implants 7222: Approx 4ml,

 7223: Approx 5ml, 80026:

 Approx 6ml, MCOI 7207:

 Approx 3ml, 7208: Approx

 4.2ml,  7209: Approx 5.6ml,

 QUAD Motility Small 16ml,

 Medium: 18ml, Large: 20ml,

 Extra Large: 22ml.

 ha

 Spectrum Surgical

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

 wrapped bioceramic (aluminium oxide),  20, 22mm; Synthetic

 mesh wrapped hydroxyapatite (synthetic),  Hydroxyapatite diameter: 16,

 mesh wrap (polyglycolic acid) 18, 20, 22mm

 1.8.2.2 - Multi-component

 Spectrum Surgical

SO019 FCI Orbital Implants Peg & Sleeve Standard Large $863.00

1.8.3 - Fascial - solid and permeable

 Device Technologies Australia Pty Ltd

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

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

 2mm

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Spectrum Surgical

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

 silicone tubing. 280mm 0.64mm tubing.

1.9.1 - Buckles, bands, tyres and sponges

 Austmed Pty Limited

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

 Tire/Meridional/Wedge/Pad. Retinal  Symmetrical Oval Tire 6mm,

 Implant used in Scleral Buckling  Mira Symmetrical Oval Tire

 (Dimethylmethylvinyl Siloxane Copolymer) 7mm, Mira 287WG Murray

 wide (3.5mm) grooved

 symmetrical tire, 10mm wide,

 Mira 288 ross symmetrical

 grooved tire, low profile 10mm

 wide by 2.5mm, Mira 289

 Symmetrical oval tire 10m

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

  in Scleral Buckling (Dimethylmethylvinyl  I.D., Mira 71 Sleeve 1mm I.D.,

 Siloxane Copolymer)  Mira 72 McNutt Sleeve

 1.57mm I.D., Mira 270 Sleeve

 0.76mm I.D.

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

 Retinal Implant used in Scleral Buckling  2mm, Mira 240 Circling Band

 (Dimethylmethylvinyl Siloxane Copolymer) 2.5mm. Strips-Mira 41 Strip

 3.5mm, Mira 42 Strip 4mm,

 Mira 20 Strip 4mm, Mira 219

 Strip 4.5mm, Mira 31 Strip

 4.5mm, Mira 32 Strip 5mm,

 Mira 225 Oval Strip 5mm,

 Mira 220 Strip 6mm. Boats-

 Mira 60 Boat

 Device Technologies Australia Pty Ltd

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

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 2.5 x 125mm, 0.75 x 2.5 x

 125mm

 Spectrum Surgical

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

  3.5 x 0.75mm Type 41, 4.0 x

 1.25mm Type 42, 2.5 x 0.6mm

  Type 240, Morin 3.5 x 0.6mm

 Strip - 5.7mm Type 20,

 7.2mm Type 31, 9.2mm Type

 32, 6mm Type 219, 7.5mm

 Type 220, 8mm Type 225

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

 7 to 9mm wide), Biconvex:

 (2.5mm Groove, 7 to 10mm

 wide), Asymetrical: (2.5mm

 Groove, 7 to 10mm wide)

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

 Morin Strip: 7mm wide x

 100mm long, Caputo Zip Strip:

 7 to 9mm wide x 120mm long,

 Korobelnik Oval Strip: 2 x

 5mm

 1.9.1.1 - Sponges

 Austmed Pty Limited

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

 Scleral Buckling (Silicone Elastomer  2mm, Mira 5025 Cylinder

 Sponge) 2.5mm, Mira 503 Cylinder

 3mm, Mira 504 Cylinder 4mm,

 Mira 505 Cylinder 5mm, Mira

 505G Grooved cylinder 5mm,

 Mira 505T Packer tunnel

 cylinder 5mm, Mira 510 Half

 cylinder 5mm, Mira 515

 Brucker two-thirds cyl

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Device Technologies Australia Pty Ltd

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

 100mm, 3.25 x 7.0 x 80mm,

 5.5 x 7.5 x 80mm, 1.5 x 80mm,

  2.0 x 80mm, 2.5 x 80mm, 3.0

 x 80mm, 4.0 x 80mm, 5.0 x

 80mm, 7.0 x 80mm

 Spectrum Surgical

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

 150mm length; Half Cord:

 3.0mm to width x1.5mm to

 2.5mm height x150mm;

 Circular Sponge: 3 to 5mm;

 Oval Sponge: 2 to 5.5mm x 4

 to 12mm; Half Sponge: 2 to

 3.1mm x 4 to 7.5mm; Grooved

 Sponge: 3 to 5mm x 5 to 

 12mm; Gain Sponge: 6 x

1.9.2 - Clips and tacks

 Device Technologies Australia Pty Ltd

DE201 Labtician Tantalum Clips Tantalum 2, 2.5mm $50.00

1.9.3 - Sleeves

 Device Technologies Australia Pty Ltd

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

 Spectrum Surgical

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

 30mm

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

1.9.4 - Intraocular Gases

 Alcon Laboratories (Aust.) Pty Ltd

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

  Vision System  and SF6 single dose syringe

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

  and SF6 single dose syringe

 Device Technologies Australia Pty Ltd

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

 surgery

1.9.5 - Intraocular Heavy Liquids

 Alcon Laboratories (Aust.) Pty Ltd

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

 surgery additive

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

 surgery additive

 Bausch & Lomb (Australia) Pty Ltd

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

  surgery additive

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

 Design for Vision Pty Ltd

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

 Device Technologies Australia Pty Ltd

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

 surgery, operative device for retinal

 surgery, in particular retinal detachment

 (RD), RD with giant tear etc.

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

1 - OPHTHALMIC

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 surgery, pre-operative device for retinal

 surgery, in particular retinal detachment

 (RD), RD with giant tear, RD with

 proliferative vitreal retinopathy (PVR) etc.

 IQ Medical

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

 Postoperative

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

 medium, intraoperative

 Spectrum Surgical

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

 FCI - OCTA: Purified perfluoro-N-octane

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

 FCI - OCTA: Purified perfluoro-N-

 Octane

1.9.6 - Intraocular Silicone Oils

 Bausch & Lomb (Australia) Pty Ltd

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

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

 Design for Vision Pty Ltd

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

 Device Technologies Australia Pty Ltd

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

 vitreoretinal surgery

 IQ Medical

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

 Spectrum Surgical

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

 purified silicone oil

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.1.1 - Bare Metal Stents

 10.1.1.1 - Balloon Expandable

 Abbott Australasia Pty Ltd

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

 Peripheral Stent 58mm

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

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

  58mm length

 B Braun Australia Pty Ltd

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

 Bard Australia Pty Ltd

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

 Peripheral Stent length

 Biotronik Australia Pty Ltd

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

 15, 25, 38, 56mm

 Boston Scientific Australia Pty Ltd

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

 Vascular SD Stent and lengths up to 60mm

 Cook Medical Australia Pty Ltd

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

 135cm delivery system.

 Diameters 4-10mm, lengths 0.8

  - 4cm

 Johnson & Johnson Medical Pty Ltd

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

 30mm

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

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

 Delivery System on Slalom mounted on a slalom balloon 39mm

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

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

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 79mm

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

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

  7mm

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

 Stent System Expandable Stent 6, 7mm diameter

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

 (on Aviator Plus)                                 40, 50,

 60, 70mm diameters                

                    80, 142cm shaft

 lengths

 Medical Specialties Australia Pty Ltd

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

 Implantation System 58mm

 Medical Vision Australia Pty Ltd

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

 length

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

 balloon length

 Medtronic Australasia Pty Ltd

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

 &18mm

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

 20 - 80mm

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

 Stainless Steel Stent system, 5F sheath,  Length: 10mm - 24mm

 0.014" guide wire compatible

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

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

 compatable stent

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 10.1.1.2 - Self Expandable, <150mm

 Abbott Australasia Pty Ltd

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

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

 9-7, 10-8mm Length 20 +

 30mm Tapered

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

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

 stent, used to treat peripheral vessel  80mm in length

 disease, Xpert is a low profile system

 designed for small vessels and is 4 french.

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

 length

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

 <150mm  120mm

 Bard Australia Pty Ltd

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

 12cm lengths

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

 to treat peripheral disease 120mm

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

 120mm length

 Biotronik Australia Pty Ltd

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

 stent 30 - 100mm

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

 vessel disease. Stent is 4Fr compatible and  20-200mm

  a rapid exhange delivery system

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

 Nitinol stent system system 120mm Catheter length: 90-

 135mm

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Boston Scientific Australia Pty Ltd

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

 and lengths up to 100mm

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

 and lengths up to 40mm

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

 20 to 120mm

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

 and lengths up to 120mm

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

 expanding stent and lengths up to 100mm

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

 Superalloy Wire, Braided Mesh, Stainless

 Steel Stent with Unistep Delivery System

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

 diameter

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

 less than 150mm

 Cook Medical Australia Pty Ltd

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

 14mm diameter, 2 - 8cm length

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

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

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

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

 self-expandable stent made of nitinol.  The   available in the following sizes:

 special laser-cut pattern of the nitinol tube  stent outer diameters of 5 -

 provides a construction with a strong radial 10mm and stent lengths of 20 -

  force and high flexibility.  The stent has  140mm.

 radiopaque markers at both ends.  The

 stent is supplied preloaded in a 6.0 French

 inducer catheter. A radiopaque marker on

 the distal tip of the sheath is used to

 visualize deployment of the stent. Stent

 deployment is controlled by means of a

 hand held device.

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

 self-expanding, flexible, slotted-tube nitinol and 60mm/100mm/140mm

  stent. Post-deployment, the stent is  lengths.

 designed to impart an outward radial force

 upon the inner lumen of the vessel,

 establishing patency in the stented region.

 Endotherapeutics Pty Ltd

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

 ev3 Australia Pty Ltd

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

 60mm

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

 Nitinol stent premounted on an OTW

 delivery system.

 Johnson & Johnson Medical Pty Ltd

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

 System expanding stent, used to treat peripheral  100mm

 vessel disease.

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

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

 10mm

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

 length, 120cm delivery system

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

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

  Length:  20, 30, 40mm

 Medtronic Australasia Pty Ltd

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

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

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

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

 introducer sheath compatible, Rapid  6.0/9.0 - 7.0/10.0. Length

 Exchange design, .014" guide wire  20mm - 40 mm.

 compatible.

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

 Stent System system  30-120mm

 Pyramed Pty Limited

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

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

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

 Length: 40-100mm nominal;

 41-100 expanded.

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

 24mm, 26mm, 28mm, 30mm,

 32mm, 34mm. Length: 30-

 100mm nominal; 32-102

 expanded.

 10.1.1.3 - Self Expandable, ≥150mm

 Abbott Australasia Pty Ltd

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

  150mm, 170mm, 200mm

 Bard Australia Pty Ltd

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

  150mm - 200mm

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Biotronik Australia Pty Ltd

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

 Nitinol stent system system 200mm Catheter length: 90-

 135mm

 Boston Scientific Australia Pty Ltd

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

 greater than 150mm

 Cook Medical Australia Pty Ltd

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

 self-expandable stent made of nitinol.  The  Length:170mm and 200mm

 special laser-cut pattern of the nitinol tube

 provides a construction with a strong radial

  force and high flexibility.  The stent has

 radiopaque markers at both ends.

 ev3 Australia Pty Ltd

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

 Nitinol stent premounted on an OTW  200mm

 delivery system.

 Johnson & Johnson Medical Pty Ltd

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

 length, 120cm delivery system

 Medtronic Australasia Pty Ltd

MC760 Complete SE Stent Nitinol 150mm $2,970.00

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

 Stent System system  150mm

 Pyramed Pty Limited

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

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

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.1.2 - Drug Eluting Stents

 Cook Medical Australia Pty Ltd

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

 Stent is a self-expanding stent made of  diameters in 20, 30, 40, 60, 80,

 nitinol and coated with the drug Paclitaxel.   100, 120mm lengths

  The stent is preloaded in a 6.0 French

 delivery catheter.  Stent deployment is

 controlled by retraction of the handle while

  holding the metal cannula stationary.

10.10.1 - Peritoneal Dialysis, Long Term Implantable Catheters

 cu

 Kendall Australasia Pty Ltd TA Covidien Pty Ltd

KA001 Tenckhoff Peritoneal Dialysis Catheter Adult 2 cuff, Adult 1 cuff, Adult 0 Cuff 42cm to 47cm length. All  $175.00

 Peritoneal Catheters excluding

 the Swan Neck Fast Flow

 Catheter, have an internal

 diameter of 2.67mm and an

 external diameter of 4.95 mm.

KA002 Tenckhoff Peritoneal Dialysis Catheter Paediatric 2 cuff, Paediatric 1 cuff,  31cm to 37 cm length. All  $175.00

 Neonatal 1 cuff Peritoneal Catheters excluding

 the Swan Neck Fast Flow

 Catheter, have an internal

 diameter of 2.67mm and an

 external diameter of 4.95 mm.

KA003 Fast Flow Peritoneal Dialysis Catheter  Swan Neck, 2 cuff Int.diam: 3.2mm; ext diam  $175.00

 5.49mm.All Peritoneal

 Catheters excluding the Swan

 Neck Fast Flow Catheter, have

  an internal diameter of 2.67mm

  and an external diameter of

 4.95 mm.

Prostheses List by Category, Groups and Sponsor Page 35 of 944

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

KA004 Swan Neck Curl Peritoneal Dialysis  Adult 2 cuff, left 62 cm length. All Peritoneal  $175.00

 Catheter Catheters excluding the Swan

 Neck Fast Flow Catheter, have

  an internal diameter of 2.67mm

  and an external diameter of

 4.95 mm.

KA005 Swan Neck or Swan neck Tenckhoff  Adult-left, Adult-right, Adult, 2 cuff-left,  20 to 25cm external segment or $175.00

 Peritoneal Dialysis Catheter Adult, 2 cuff-right  43cm length. All Peritoneal

 Catheters excluding the Swan

 Neck Fast Flow Catheter, have

  an internal diameter of 2.67mm

  and an external diameter of

 4.95 mm.

KA006 Tenckhoff Peritoneal Dialysis Catheter,  Adult, 2 cuffs 57 to 62cm length. All  $175.00

 Curl Peritoneal Catheters excluding

 the Swan Neck Fast Flow

 Catheter, have an internal

 diameter of 2.67mm and an

 external diameter of 4.95 mm.

10.2.1 - Tube (Thoracic Aorta)

 10.2.1.1 - <180mm length

 Cook Medical Australia Pty Ltd

WC238 Zenith Thoracic Endovascular Graft Thoracic Proximal Graft 22mm to 42mm diameter,  $11,027.00

 115mm to 179mm Length

WC240 Zenith Thoracic Endovascular Graft Thoracic Distal Graft 26mm to 42mm diameter,  $11,027.00

 127mm to 179mm Length

WC275 Zenith TX2 TAA Endovascular Graft  Short Thoracic Proximal Graft Diameter 22mm - 42mm.  $11,027.00

 with Pro_Form and the Z-Trak Plus  Length 115mm - 162mm

 Introduction System - Short Proximal

 Component

 Medical Specialties Australia Pty Ltd

MS052 Relay Thoracic Stent Graft Duralloy Nitinol Surgical Graft Material  Diameter 22 - 46mm, Length  $11,027.00

 Braided Polyester PFTE impregnated  103 - 179mm

 Suture Dual Sheath Delivery System

Prostheses List by Category, Groups and Sponsor Page 36 of 944

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 Medtronic Australasia Pty Ltd

MC206 Talent Thoracic Stent Graft Talent Endoluminal Stent Graft - Thoracic  22 - 46mm x 130mm $11,027.00

 Stent Graft System

MC747 Valiant Endovascular Stent Graft Nitinol and polyester system 22-46mm diameter, 110mm  $11,027.00

 length

MC748 Valiant Endovasculat Stent Graft Nitinol and polyester system 22-46mm diameter, 150mm  $11,027.00

 length

MC809 Valliant Endovascular Stent Graft Nitinol and polyester system 24 - 46 diameter, up to 179mm $11,027.00

MC952 Valiant Captivia Valient Stent Graft with Captivia Delivery  22-46mm diameter, 150mm  $11,027.00

 System length

MC960 Valiant Captivia Valiant Stent Graft with captivia delivery  22 - 46 mm diameter: 100mm  $11,027.00

 system length

 W L Gore & Associates

GT191 Excluder Endovascular Prostheses Thoracic Stent Graft Nitinol & ePTFE Diameter 26-40mm x  10cm  $11,027.00

 Length

GT259 Conformable GORE TAG Thoracic  Conformable GORE TAG Straight Stent Grafts: $11,027.00

 Endoprosthesis Diameters (mm): 21, 26, 28,

 31, 34, 37, 40, 45

 Length (cm): 10

 Tapered Stent Grafts:

 Diameters (mm): 26x21; 31x26

 Lengths (cm): 10

GT260 Conformable GORE TAG Thoracic  Conformable GORE TAG Diameters (mm): 28, 31, 34,  $11,027.00

 Endoprosthesis 37, 40, 45

 Length (cm) 15

 paed

 Medical Vision Australia Pty Ltd

MF016 CP Stent CP Stent Covered 16, 22, 28, 24, 39 & 45mm  $3,000.00

 length

MF018 CP Stent CP Stent Covered, mounted on BIB  16, 22, 28, 24, 39 & 45mm  $3,000.00

 balloon length

Prostheses List by Category, Groups and Sponsor Page 37 of 944

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

 10.2.1.2 - ≥180mm length

 Cook Medical Australia Pty Ltd

WC239 Zenith Thoracic Endovascular Graft Thoracic Proximal Grft 22mm to 42mm diameter,  $14,500.00

 180mm to 216mm Length

WC241 Zenith Thoracic Endovascular Graft Thoracic Distal Graft 26mm to 42mm diameter,  $14,500.00

 180mm to 207mm Length

WC276 Zenith TX2 TAA Endovascular Graft  Long Thoracic Proximal Endovascular  Diameter 28mm-42mm Length  $14,500.00

 with Pro-Form and the Z-Trak Plus  Graft 197mm-216mm

 Introduction System - Long Proximal

 Component

 Medical Specialties Australia Pty Ltd

MS053 Relay Thoracic Stent Graft Duralloy Nitinol Surgical Graft Material  Diamter 22 - 46mm,  Length  $14,500.00

 Braided Polyester PFTE impregnated  180 - 271mm

 Suture Dual Sheath Delivery System

 Medtronic Australasia Pty Ltd

MC810 Valliant Endovascular Stent Graft Nitinol and polyester system 24 - 46 diameter, 180 -  $14,500.00

 227mm length

MC958 Valiant Captivia Valiant Stent Graft with Captivia Delivery  24-46mm diameter, 200mm  $14,500.00

 System length

 W L Gore & Associates

GT023 Excluder Endovascular Prostheses Thoracic Stent Graft Nitinol & ePTFE 34, 37 & 40mm Diameter x  $14,500.00

 20cm Lengths

GT261 Conformable GORE TAG Thoracic  Conformable GORE TAG Diameters (mm): 34, 37, 40, 45 $14,500.00

 Endoprosthesis 

 Length (cm): 20

10.2.10 - Tube, Peripheral, Balloon Expandable

 10.2.10.1 - ≤12mm diameter

 Atrium Australia - Pacific Rim Pty Limited

AC023 Advant PTFE V12 Stent Graft System Balloon Expandable PTFE Encapsulated  5mm - 12mm Diameter $4,185.00

 Stainless Steel Peripheral Vascular Stent

Prostheses List by Category, Groups and Sponsor Page 38 of 944

10 - VASCULAR

 Minimum  Maximum

Billing Code Product Name Description Size Benefit Benefit Condition

10.2.11 - Tube, Peripheral, Self Expandable

 10.2.11.1 - <150mm length

 Bard Australia Pty Ltd

BA219 Encapsulated Carbon Lined Stent Graft PTFE covered nitinol self-expanding stent 4mm - 13.5mm diameter, 2cm  $3,395.00

 - 12cm length

 W L Gore & Associates

GT020 Viabahn Endoprosthesis ePTFE & Nitinol Self Expanding  Viabahn 2.5mm - 13mm  $3,395.00

 Endoluminal Graft System Diameter, 5cm Length;

 Hemobahn 6 - 13mm Diameter,

  5cm Length

GT021 Viabahn/Hemobahn Endoprosthesis ePTFE & Nitinol Self Expanding  Viabahn 2.5mm - 13mm, 10cm $3,395.00