| Accessory | Description | Usual Maximum Replacement per month |
| A4357 | Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each | 2 every month |
| A4362 | Skin barrier; solid, 4 x 4 or equivalent; each | 20 every month |
| A4364 | Adhesive, liquid or equal, any type, per oz. | 4 every month |
| A4367 | Ostomy belt, each | 1 every month |
| A4369 | Ostomy skin barrier, liquid (spray, brush, etc.), per oz. | 2 every month |
| A4377 | Ostomy pouch, drainable, for use on faceplate, plastic, each | 10 every month |
| A4381 | Ostomy pouch, urinary, for use on faceplate, plastic, each | 10 every month |
| A4436 | Irrigation supply; sleeve, reusable, each | 4 every month |
| A4437 | Irrigation supply; sleeve disposable | 4 every month |
| A4402 | Lubricant, per ounce | 4 every month |
| A4404 | Ostomy ring, each | 10 every month |
| A4405 | Ostomy skin barrier, non-pectin based, paste, per ounce | 4 every month |
| A4406 | Ostomy skin barrier, pectin-based, paste, per ounce | 4 every month |
| A4414 | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each | 20 every month |
| A4415 | Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 44 inches, each | 20 every month |
| A4416 | Ostomy pouch, closed, with barrier attached, with filter (1 piece), each | 60 every month |
| A4417 | Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each | 60 every month |
| A4418 | Ostomy pouch, closed; without barrier attached, with filter (1 piece), each | 60 every month |
| A4419 | Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each | 60 every month |
| A4420 | Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each | 60 every month |
| A4423 | Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each | 60 every month |
| A4424 | Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each | 20 every month |
| A4425 | Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each | 20 every month |
| A4426 | Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each | 20 every month |
| A4427 | Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each | 20 every month |
| A4429 | Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each | 20 every month |
| A4431 | Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each | 20 every month |
| A4432 | Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (2 piece), each | 20 every month |
| A4433 | Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each | 20 every month |
| A4434 | Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each | 20 every month |
| A4450 | Tape, non-waterproof, per 18 square inches | 40 every month |
| A4452 | Tape, waterproof, per 18 square inches | 40 every month |
| A4456 | Skin barrier, wipes or swabs, each | 50 every month |
| A4481 | Tracheostoma filter, any type, any size, each | 62 every month |
| A4623 | Tracheostomy, inner cannula | 62 every month |
| A4625 | Tracheostomy care kit for new tracheostomy | 31 every month |
| A4626 | Tracheostomy cleaning brush, each | 2 every month |
| A4629 | Tracheostomy care kit for established tracheostomy | 31 every month |
| A5051 | Ostomy pouch, closed; with barrier attached (1 piece), each | 60 every month |
| A5052 | Ostomy pouch, closed; without barrier attached (1 piece), each | 60 every month |
| A5053 | Ostomy pouch, closed; for use on faceplate, each | 60 every month |
| A5054 | Ostomy pouch, closed; for use on barrier with flange (2 piece), each | 60 every month |
| A5055 | Stoma cap | 31 every month |
| A5056 | Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each | 40 every month |
| A5057 | Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each | 40 every month |
| A5061 | Ostomy pouch, drainable; with barrier attached, (1 piece), each | 20 every month |
| A5062 | Ostomy pouch, drainable; without barrier attached (1 piece), each | 20 every month |
| A5063 | Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each | 20 every month |
| A5071 | Ostomy pouch, urinary; with barrier attached (1 piece), each | 20 every month |
| A5072 | Ostomy pouch, urinary; without barrier attached (1 piece), each | 20 every month |
| A5073 | Ostomy pouch, urinary; for use on barrier with flange (2 piece), each | 20 every month |
| A5081 | Stoma plug or seal, any type | 31 every month |
| A5082 | Continent device; catheter for continent stoma | 1 every month |
| A5083 | Continent device, stoma absorptive cover for continent stoma | 150 every month |
| A5093 | Ostomy accessory; convex insert | 10 every month |
| A5121 | Skin barrier; solid, 6 x 6 or equivalent, each | 20 every month |
| A5122 | Skin barrier; solid, 8 x 8 or equivalent, each | 20 every month |
| A5126 | Adhesive or nonadhesive; disk or foam pad | 20 every month |
| A5131 | Appliance cleaner, incontinence and ostomy appliances, per 16 oz | 1 every month |
| A6216 | Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing | 60 every month |
| A7501 | Tracheostoma valve, including diaphragm, each | 1 every month |
| A7502 | Replacement diaphragm/faceplate for tracheostoma valve, each | 1 every month |
| A7504 | Filter for use in a tracheostoma heat and moisture exchange system, each | 62 every month |
| A7506 | Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each | 62 every month |
| A7507 | Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each | 62 every month |
| A7508 | Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each | 62 every month |
| A7509 | Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each | 62 every month |
| A7526 | Tracheostomy tube collar/holder, each | 31 every month |
| A7505 | Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each | 2 every month |
| A7520 | Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each | 1 every month |
| A7521 | Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each | 1 every month |
| A7524 | Tracheostoma stent/stud/button, each | 1 every month |
| A7527 | Tracheostomy/laryngectomy tube plug/stop, each | 2 every month |
| A4361 | Ostomy faceplate, each | 3 per 6 months |
| A4371 | Ostomy skin barrier, powder, per oz | 10 per 6 months |
| A4398 | Ostomy irrigation supply; bag, each | 2 per 6 months |
| A4399 | Ostomy irrigation supply; cone/catheter, with or without brush | 2 per 6 months |
| A4455 | Adhesive remover or solvent (for tape, cement or other adhesive), per oz | 16 per 6 months |
| A5102 | Bedside drainage bottle with or without tubing, rigid or expandable, each | 2 per 6 months |
| A5120 | Skin barrier, wipes or swabs, each | 150 per 6 months |
| A7503 | Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each | 1 per 6 months |
| A7522 | Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each | 1 per year |
