Description HCPCS Unit Unit Price Max Billable Units per Filling Quantity Guidelines Limited to 5 Refills? Covered Programs
Insulin Syringes (1 cc or less) A4206 EA $0.23000 100 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN, KHC
Insulin Needles A4215 EA $0.18000 100 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN, KHC
Blood Glucose Strips (for monitor) A4253 EA $0.56560 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN, KHC
Blood Glucose Test Strips with Disposable Monitor A9275 EA $0.56560 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN
Blood Glucose Monitor (Talking) E2100 EA $312.80000 1 Maximum: 1 unit per three rolling years. Only available for people with visual impairment. No Medicaid, CHIP, CSHCN
Lancets A4259 EA $0.11100 100 Maximum: 100 units every calendar month. Limited to a 30-day supply.

A person must use 100% of the product before refills are allowed.
Yes Medicaid, CHIP, CSHCN, KHC
Spring-powered Device for Lancets A4258 EA $14.65000 1 Maximum: 2 units per rolling year. No Medicaid, CHIP, CSHCN
Aerosol Holding Chamber (for use with a metered-dose inhaler) A4627 EA $27.60000 1 Maximum: 1 unit every 180 days. No Medicaid, CHIP, CSHCN
Oral Electrolyte Replacement Fluid B4103 ML $4.51000 per 500 ML or $0.00902 per ML 2000 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Hypertonic Saline Solution 7% T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Hypertonic Saline Solution 3% T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN
Nasal Saline Spray T1999 ML (AWP-10.5%) - 8% 1800 A person must use 75% of the product before refills are allowed. No Medicaid, CHIP, CSHCN