Incontinence Product List - 2016-05-12

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Manufacturer Product Name Size

ActivStyle Rely Breathable Briefs Small (HIP 20" - 32")
ActivStyle Rely Breathable Briefs Medium (HIP 34" - 44
ActivStyle Rely Breathable Briefs Large (HIP 44" - 58")
ActivStyle Rely Breathable Briefs X-Large (HIP 58" - 68
ActivStyle Rely Extra Underwear Medium (HIP 34" - 44
ActivStyle Rely Extra Underwear Large (HIP 44" - 58")
ActivStyle Rely Extra Underwear X-Large (HIP 58" - 68
ActivStyle Rely Maximum Underwear Medium (HIP 34" - 44
ActivStyle Rely Maximum Underwear Large (HIP 44" - 58")
ActivStyle Rely Maximum Underwear X-Large (HIP 58" - 68

Attends Attends Classic Briefs Medium/Regular (wa
Attends Attends Classic Briefs Large (waist 44" - 58
Attends Attends Classic Briefs X-Large (waist 58" - 6
Attends Attends Underwear Medium (waist 34" - 4
Attends Attends Underwear Large (waist 44" - 58
Attends Attends Underwear X-Large (waist 58" - 6
Attends Attends Underwear XX-Large
Attends Attends Extra Absorbent Breathable Briefs Small (waist 20" - 32
Attends Attends Extra Absorbent Breathable Briefs Medium (waist 32" - 4
Attends Attends Extra Absorbent Breathable Briefs Large (waist 44" - 58
Attends Attends Extra Absorbent Breathable Briefs X-Large (waist 58" - 6
Attends Attends Advanced Underwear Small (waist 22" - 36
Attends Attends Advanced Underwear Medium (waist 34" - 4
Attends Attends Advanced Underwear Large (waist 44" - 58
Attends Attends Advanced Underwear X-Large (waist 58" - 6
Attends Attends Care Underwear Medium (waist 32" - 4
Attends Attends Care Underwear Large (waist 44" - 58
Attends Attends Care Underwear X-Large (waist 58" - 6
Attends Attends Care Advanced Briefs Medium/Regular (wa
Attends Attends Care Advanced Briefs Large (waist 44" - 58

e Product List 5/12/2016
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Product codes Retention ROA Rewet HCPCS
Capacity 44 0.40 code
) RLY-B100
4") RLY-B110 1059 24 0.02 T4521
) RLY-B120 25 0.04 T4522
8") RLY-B130 521 39 0.39 T4523
4") RLY-PUW110 967 28 0.02 T4524
) RLY-PUW120 403 T4526
8") RLY-PUW130 352 38 0.10 T4527
4") RLY-PUW210 T4528
) RLY-PUW220 492 29 0.03 T4526
8") RLY-PUW230 33 0.02 T4527
473 34 0.73 T4528
aist 32" - 44") BRB20, BRB25 218
8") BRB30, BRB3096 389 T4522
63") BRB40, BRB4096 T4523
44") APO720, APO720100 T4524
8") APO730, APO730100 T4526
68") APO740, APO740100 T4527
T4528
AU50 T4544
2") BRBX10, BRBX15 T4521
44") BRBX20 T4522
8") BRBX30 T4523
63") BRBX40 T4524
6") APP0710 T4525
44") APP0720 T4526
8") APP0730 T4527
68") APP0740 T4528
44") APV20, APV20100 T4526
8") APV30, APV30100 T4527
68") APV40, APV40100 T4528
aist 32" - 44") BRBC20, BRBC25 T4522
8") BRBC30 T4523

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Attends Attends Care Advanced Briefs X-Large (waist 58" - 6
Attends Attends Care Briefs Medium (waist 32" - 4
Attends Attends Care Briefs Large (waist 44" - 58
Attends Attends Care Briefs X-Large (waist 58" - 6
Attends Attends Advanced Briefs Medium/Regular (wa
Attends Attends Advanced Briefs Large (waist 44" - 58
Attends Attends Advanced Briefs X-Large (waist 58" - 6
Attends Attends Briefs Medium/Regular (wa
Attends Attends Briefs Large (waist 44" - 58
Attends Attends Briefs X-Large (waist 58" - 6
Attends Attends Briefs XX-Large
Attends Attends Briefs XXX-Large
Attends Attends Derma Dry Plus Breathable Briefs Medium (waist 32" - 4
Attends Attends Derma Dry Plus Breathable Briefs Large (waist 44" - 58
Attends Attends Derma Dry Plus Breathable Briefs X-Large (waist 58" - 6

Covidien Simplicity Pad and Pant System, Heavy 12" X 24"
Covidien Simplicity Pad and Pant System, Night-time 14" X 30"
Covidien Sure Care Protective Underwear, Extra Heavy Medium (waist 34" - 4
Covidien Sure Care Protective Underwear, Extra Heavy Large (waist 44" - 54
Covidien Sure Care Protective Underwear, Extra Heavy X-Large (waist 48" - 6
Covidien Sure Care Protective Underwear, Heavy Medium (waist 34" - 4
Covidien Sure Care Protective Underwear, Heavy Medium (waist 34" - 4
Covidien Sure Care Protective Underwear, Heavy Large (waist 44" - 54
Covidien Sure Care Protective Underwear, Heavy X-Large (waist 48" - 6
Covidien Sure Care Protective Underwear, Heavy XX-Large (waist 60"
Covidien Sure Care Protective Underwear Medium (waist 34" - 4
Covidien Sure Care Protective Underwear Large (waist 44" - 54
Covidien Sure Care Protective Underwear X-Large (waist 48" - 6
Covidien Wings Adult Bariatric Brief extra heavy Bariatric (waist to 95"
Covidien Wings Adult Briefs XXL XXL (waist 65" - 69")
Covidien Wings Adult Quilted Briefs Heavy Small (waist 20" - 31
Covidien Wings Adult Quilted Briefs Heavy Medium (waist 32" - 4

e Product List 5/12/2016
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63") BRBC40 T4524
472 42 0.50 T4522
44") BRHC20
T4523
8") BRHC30 T4524
412 43 0.14 T4522
63") BRHC40 T4523
T4524
aist 32" - 44") DDC20, DDC25 416 45 0.10 T4522
T4523
8") DDC30 T4524
T4543
63") DDC40 T4543
373 41 0.12 T4522
aist 32" - 44") DDA20, DDA25 T4523
T4524
8") DDA30
394 26 0.48 T4521
63") DDA40 519 32 1.02 T4521
681 25 0.11 T4526
DD50
T4527
DD60 T4528
343 32 0.02 T4526
44") DDP20 381 31 0.13 T4526
T4527
8") DDP30 T4528
T4544
63") DDP40 452 34 0.02 T4526
T4527
1042 T4528
T4543
1046 T4543
T4521
46") 1205 403 54 0.08 T4522

4") 1215

66") 1225

46") 1605S

46") 1605

4") 1615

66") 1625

- 80") 1630

46") 1430

4") 1445

66") 1455

") 67095

) 67093

1") 66032

44") 66033

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Covidien Wings Adult Quilted Briefs Heavy Large (waist 45" - 58
Covidien
Covidien Wings Adult Quilted Briefs Heavy X-Large (waist 59" - 6
Covidien
Covidien Wings Adult Quilted Briefs Night-time Medium (waist 32" - 4
Covidien
Covidien Wings Adult Quilted Briefs Night-time Large (waist 45" - 58
Covidien
Covidien Wings Adult Quilted Briefs Night-time X-Large (waist 59" - 6
Covidien
Covidien Wings Ultra Quilted Briefs Medium (waist 32" - 4
Covidien
Covidien Wings Ultra Quilted Briefs Large (waist 45" - 58
Covidien
Covidien Wings Ultra Quilted Briefs X-Large (waist 59" - 6
Covidien
Covidien Wings Super Quilted Briefs Medium (waist 32" - 4
Covidien
Covidien Wings Super Quilted Briefs Large (waist 45" - 58
Covidien
Covidien Wings Super Quilted Briefs X-Large (waist 59" - 6
Covidien
Wings Hook & Loop Adult Briefs Heavy Small (waist 20" - 31
CVS Pharmacy
CVS Pharmacy Wings Hook & Loop Adult Briefs Heavy Medium (waist 32" - 4
CVS Pharmacy
CVS Pharmacy Wings Hook & Loop Adult Briefs Heavy Small (waist 20" - 31
CVS Pharmacy
CVS Pharmacy Wings Hook & Loop Adult Briefs Heavy Large (waist 45" - 58
CVS Pharmacy
CVS Pharmacy Wings Hook & Loop Adult Briefs Heavy X-Large (waist 59" - 6
CVS Pharmacy
CVS Pharmacy Wings Hook & Loop Ultra 3D Brief Small (waist 20" - 31

Wings Hook & Loop Ultra 3D Brief Medium (waist 32" - 4

Wings Hook & Loop Ultra 3D Brief Large (waist 45" - 58

Wings Hook & Loop Ultra 3D Brief X-Large (waist 59" - 6

Wings Pad and Pant System, Contoured Insert, He14" X 26"

Wings Pad and Pant System, Contoured Insert, Nig14" X 27"

Medium briefs Medium (waist 32" - 4

Large briefs Large (waist 45" - 58

Men's Maximum Absorbency Protective Underwea Small / Medium (wais

Men's Maximum Absorbency Protective Underwea Small / Medium (wais

Men's Maximum Absorbency Protective Underwea L/XL (waist 38" - 64"

Men's Maximum Absorbency Protective Underwea L/XL (waist 38" - 64"

Unisex moderate absorbency Protective UnderweaSmall / Medium (wais

Unisex moderate absorbency Protective UnderweaLarge (waist 38" - 50

Unisex moderate absorbency Protective UnderweaXlarge (waist 48" - 64

Women's Maximum Absorbecy Protective UnderweSmall / Medium (wais

e Product List 5/12/2016
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8") 66034 T4523
64") 66035 T4524
44") 67033 665 49 0.15 T4522
8") 67034 T4523
64") 67035 T4524
44") 77073 558 49 0.58 T4522
8") 77074 T4523
64") 77075 T4524
44") 87083 592 50 0.13 T4522
8") 87084 T4523
64") 87085 T4524
1") 63062 T4521
44") 63063 430 57 0.54 T4522
1") 66033S 425 57 0.12 T4522
8") 63064 T4523
64") 63065 T4524
1") 63072 T4521
44") 63073 501 57 0.05 T4522
8") 63074 T4523
64") 63075 T4524
6597B20 399 27 0.63 T4521
44") 6598B24 568 31 0.18 T4521
8")
st 28" - 40") 240333 372 37 0.04 T4522
st 28" - 40") 641431 T4523
489372
st 28" - 40") 830473 695 17 0.12 T4526
0") 489366 695 17 0.12 T4526
4") 842939
st 28" - 40") 846388 T4527
846387 T4527
849424 486 25 0.16 T4526
830476 T4527
T4528
706 20 0.10 T4526

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

CVS Pharmacy Women's Maximum Absorbecy Protective UnderweSmall / Medium (wais
CVS Pharmacy
CVS Pharmacy Women's Maximum Absorbecy Protective UnderweLarge (waist 38" - 50
CVS Pharmacy
CVS Pharmacy Women's Maximum Absorbecy Protective UnderweLarge (waist 38" - 50
CVS Pharmacy
CVS Pharmacy Women's Maximum Absorbecy Protective UnderweXlarge (waist 48" - 64
CVS Pharmacy
CVS Pharmacy Women's Maximum Absorbecy Protective UnderweXlarge (waist 48" - 64

First Quality Women's Moderate Absorbency Protective UnderwSmall / Medium (wais
First Quality
First Quality Women's Moderate Absorbency Protective UnderwLarge (waist 39" - 50
First Quality
First Quality Women's Moderate Absorbency Protective UnderwXlarge (waist 48" - 64
First Quality
First Quality Xlarge Briefs Xlarge (waist 59: - 64
First Quality
First Quality Nufit Protective Underwear Large (waist 44" - 58
First Quality
First Quality Nufit Protective Underwear Xlarge (waist 58" - 68
First Quality
First Quality Perfit Protective Underwear Large (waist 44" - 58
First Quality
First Quality Perfit Protective Underwear Xlarge (waist 58" - 68
First Quality
First Quality Prevail Bariatric Size A Brief waist 68" - 80"
First Quality
First Quality Prevail Bariatric Size B Brief Waist to 100"
First Quality
First Quality Prevail Breezers 360 Medium (waist 26" - 4
First Quality
First Quality Prevail Breezers 360 Large (waist 45" - 62

Prevail Breezers 360 X-Large (waist 58" - 7

Prevail Breezers Briefs Medium (waist 32 - 4

Prevail Breezers Briefs Large (waist 45 - 58"

Prevail Breezers Briefs Regular (waist 40 - 4

Prevail Breezers Briefs X-Large (waist 59" - 6

Prevail Nufit Protective Underwear Medium (waist 34" - 4

Prevail Perfit Medium (waist 32 - 4

Prevail Perfit Large (waist 45 - 58"

Prevail Perfit Regular (waist 40 - 4

Prevail Perfit X-Large (waist 59" - 6

Prevail Perfit Medium (waist 34" - 4

Prevail Perfit for Men Medium

Prevail Perfit for Men Large

Prevail Perfit for Men X-Large

Prevail Perfit for Women Medium

e Product List 5/12/2016
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st 28" - 40") 489330 706 20 0.10 T4526
0") 489350 T4527
0") 830475 T4527
4") 830474 T4528
4") 489362 T4528
st 28" - 40") 489339
0") 489342 489 24 0.16 T4526
4") 489356 T4527
4" 163094 T4528
8") T4524
8") NU-513
8") NU-514 T4527
8") PF-513 T4528
PF-514 T4527
48") PV-017 T4528
2") PV-094 T4543
70") PVBNG-012 T4543
44") PVBNG-013 397 32 0.18 T4522
") PVBNG-014 T4523
48") PVB-012 T4524
64") PVB-013 434 35 0.04 T4522
46") PVB-016 T4523
44") PVB-014 T4523
") NU-512 T4524
48") PF-012/1 382 25 0.17 T4526
64") PF-013/1 373 37 0.04 T4522
46") PF-016/1 T4523
PF-014/1 T4523
PF-512 T4524
PFM-512 382 25 0.17 T4526
PFM-513 364 25 0.11 T4526
PFM-514 T4527
PFW-512 T4528
364 26 0.11 T4526

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

First Quality Prevail Perfit for Women Large
First Quality Prevail Perfit for Women X-Large
First Quality Prevail Perfit 360 Medium (waist 26" - 4
First Quality Prevail Perfit 360 Large (waist 45" - 62
First Quality Prevail Perfit 360 X-Large (waist 58" - 7
First Quality Prevail PM Extended Wear Briefs Medium (waist 32 - 4
First Quality Prevail PM Extended Wear Briefs Large (waist 45 - 58"
First Quality Prevail PM Extended Wear Briefs X-Large (waist 59" - 6
First Quality Prevail Protective Underwear Small (waist 20 - 34"
First Quality Prevail Protective Underwear Small/Medium (waist
First Quality Prevail Protective Underwear Large (waist 44" - 58
First Quality Prevail Protective Underwear X-Large (waist 58" - 6
First Quality Prevail Protective Underwear XX-Large (waist 68"
First Quality Prevail Protective Underwear Refastenable Medium (waist 34" - 4
First Quality Prevail Protective Underwear Refastenable Large (waist 44" - 58
First Quality Prevail Simply Stretch Fit Size A Medium/Regular (wa
First Quality Prevail Simply Stretch Fit Size B Large/X-Large (waist
First Quality Prevail Stretch Fit Size A Medium/Regular (wa
First Quality Prevail Stretch Fit Size B Large/X-Large (waist
First Quality Prevail Protective Underwear Super Small/Medium (waist
First Quality Prevail Protective Underwear Super Large (waist 44" - 58
First Quality Prevail Protective Underwear Super X-Large (waist 58" - 6

Kimberly-Clark Depend Adjustable Underwear Small/Medium (waist
Kimberly-Clark Depend Adjustable Underwear Large/X-Large (waist
Kimberly-Clark Depend for Men Underwear Maximum Small/Medium (waist
Kimberly-Clark Depend for Men Underwear Maximum Large/X-Large (waist
Kimberly-Clark Depend for Women Underwear Maximum Small/Medium (waist
Kimberly-Clark Depend for Women Underwear Maximum Large (waist 38" - 50
Kimberly-Clark Depend for Women Underwear Maximum X-Large (waist 48" - 6
Kimberly-Clark Depend for Women Underwear Moderate Small/Medium (waist
Kimberly-Clark Depend for Women Underwear Moderate Large (waist 38" - 50
Kimberly-Clark Depend for Women Underwear Moderate X-Large (waist 48" - 6

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PFW-513 T4527
T4528
PFW-514 368 31 0.12 T4522
T4523
48") PFNG-012 T4524
675 35 0.04 T4522
2") PFNG-013 T4523
T4524
70") PFNG-014 T4525
422 23 0.09 T4526
44") NTB-012 T4527
T4528
") NTB-013 T4544
600 25 0.14 T4526
64") NTB-014 T4527
510 42 0.09 T4522
") PV-511 T4524
431 36 0.09 T4522
t 34" - 46") PV-512 T4524
603 25 0.13 T4526
8") PV-513 T4527
T4528
68") PV-514
460 21 0.32 T4526
- 80") PV-517 T4527

46") PVR-512 463 23 0.27 T4526
T4528
8") PVR-513
468 25 0.26 T4526
aist 32" - 54") SSF-A T4527
T4528
t 49" - 68") SSF-B
328 29 0.24 T4526
aist 32" - 54") SF-A T4527
T4528
t 49" - 68") SF-B

t 34" - 46") PVS-512

8") PVS-513

68") PVS-514

t 28" - 40") 19477, 19183

t 38" - 50") 19184, 19478,

t 28" - 40") 12539, 19840, 38533

t 38"-64") 13407, 19842, 38534

t 28" - 40") 12535, 19758, 38530

0") 12537, 19761, 38531

64") 13406, 19779, 38532

t 28" - 40") 19558, 38535

0") 19561, 38536

64") 19579, 38529

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Kimberly-Clark Depend Real Fit Briefs for Men (Maximum) Small/Medium (waist
Kimberly-Clark Depend Real Fit Briefs for Men (Maximum) Large/X-Large (waist
Kimberly-Clark Depend Silhouette Briefs for Women Small/Medium (waist
Kimberly-Clark Depend Silhouette Briefs for Women Large/X-Large (waist

Medline FitRight Ultra Adult briefs Small (waist 20" - 30

Medline FitRight Ultra Adult briefs Medium (waist 32" - 4
Medline FitRight Ultra Adult briefs Regular (waist 40 - 5
Medline FitRight Ultra Adult briefs Large (waist 48" - 58
Medline FitRight Ultra Adult briefs X-Large (waist 59" - 6
Medline FitRight Ultra Adult briefs XX-Large (waist 60"
Medline FitRight Stretch Ultra Adult briefs Medium / Regular

Medline FitRight Stretch Ultra Adult briefs Large / X-Large
Medline FitRight Stretch Ultra Adult briefs X-Large / XXL

Medline FitRight Restore Adult Briefs Medium (waist 32" - 4

Medline FitRight Restore Adult Briefs Regular (waist 40" - 5

Medline FitRight Restore Adult Briefs Large (waist 48" - 58

Medline FitRight Restore Adult Briefs X-Large (waist 59" - 6

Medline FitRight Restore Adult Briefs XXL (60" - 69")

Medline FitRight Super Protective Underwear Medium (waist 28" - 4

Medline FitRight Super Protective Underwear Large (waist 40 - 56"

Medline FitRight Super Protective Underwear X-Large (waist 56"-68

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t 28" - 40") 12778, 30814, 33995 514 19 0.46 T4526
t 38" - 50") 12779, 30815, 33992 530 T4527
t 28" - 40") 12776, 30816, 33993 350
t 38" - 50") 12777, 30817, 33994 17 0.49 T4526
0") FITULTRASM, 460 T4527
42") FITULTRASMZ
50") FITULTRAMD, 427 T4521
8") FITULTRAMDZ
66") FITULTRARGZ 51 0.03 T4522
- 69") FITULTRALGZ T4523
FITULTRAXLGZ T4523
42") FITULTRAXXLZ T4524
50") FITSTRETCHU1 T4543
8") FITSTRETCHU2, T4522
66") FITSTRETCHU2Z
FITSTRETCHU3 T4523
40") FITRESTOREMD, T4543
") FITRESTOREMDZ
8") FITRESTORERG, 54 0.02 T4522
FITRESTORERGZ
FITRESTORELG, T4523
FITRESTORELGZ
FITRESTOREXLG, T4523
FITRESTOREXLGZ
FITRESTOREXXL, T4524
FITRESTOREXXLZ
FIT33005, FIT33005A, T4543
FIT33005Z, FIT33005AZ
FIT33505, FIT33505A, 26 0.02 T4526
FIT33505Z, FIT33505AZ
FIT33600, FIT33600A, T4527
FIT33600Z, FIT33600AZ
T4528

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Medline FitRight Ultra Adult briefs Regular (waist 40" - 5
Medline FitRight Ultra Adult briefs Large (waist 48" - 58
Medline FitRight Ultra Adult briefs X-Large (waist 59" - 6
Medline FitRight Ultra Adult briefs XXL (60" - 69"
Medline Protection Plus Super Small (waist 20" - 28
Medline Protection Plus Super Small (waist 20" - 28
Medline Protection Plus Super XXL (waist 68: - 80")
Medline Protection Plus Super XXL (waist 68: - 80")
Medline Protection Plus Overnight Medium (waist 28" - 4
Medline Protection Plus Overnight Medium (waist 28" - 4
Medline Protection Plus Overnight Large (waist 40 - 56"
Medline Protection Plus Overnight Large (waist 40 - 56"
Medline Protection Plus Overnight X-Large (waist 56"-68
Medline Protection Plus Overnight X-Large (waist 56"-68
Medline Baribrief C Bariatric Brief XXXL (waist 65" - 94
Medline Baribrief C Bariatric Brief XXXL (waist 65" - 94

PBE ComfortCare Briefs Medium (waist 32" - 4
PBE ComfortCare Briefs Large (waist 45" - 58
PBE ComfortCare Briefs X-Large (waist 56" - 6
PBE Select Brief Small (waist 24" - 32
PBE Select Brief Medium (waist 32" - 4
PBE Select Brief X-Large (waist 56" - 6
PBE Select Soft n'Breathable Brief Medium (waist 32" - 4
PBE Select Soft n'Breathable Brief Large (waist 45" - 58
PBE Select Soft n'Breathable Brief X-Large (waist 56" - 6
PBE Select Underwear Small (waist 22" - 36
PBE Select Underwear Medium (waist 34" - 4
PBE Select Underwear Large (waist 45" - 58
PBE Select Underwear X-Large (waist 56 - 6
PBE Select Underwear XXL-Plus (waist 62" -
PBE Tranquility Air-Plus Bariatric 4XL (waist 70" - 106"
PBE Tranquility ATN Brief Small (waist 24" - 32

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50") FITULTRARG T4523
8") FITULTRALG T4523
66") FITULTRAXLG T4524
FITULTRAXXL T4543
8") MSC33255 T4525
8") MSC33255Z T4525
) MSC33700 T4544
) MSC33700Z T4544
40") MSC53005 874 25 0.02 T4526
40") MSC53005H T4526
") MSC53505 T4527
") MSC53505H T4527
8") MSC53600 T4528
8") MSC53600H T4528
4") BARIBRIEFC T4543
4") BARIBRIEFCZ T4543

44") 2965-100 378 92 0.73 T4522
8") 2966-100 T4523
64" 2967-100 T4524
2") 2620 T4521
44") 2624
64" 2635 488 54 0.10 T4522
44") 2627 T4524
8") 2628
64" 2629 381 76 0.09 T4522
6") 2604 T4523
48") 2605 T4524
8") 2606 T4525
64") 2607
- 80") 2608 532 38 0.10 T4526
") 2195 T4527
2") 2184 T4528
T4544
T4543
T4521

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

PBE Tranquility ATN Brief Medium (waist 32" - 4
PBE Tranquility ATN Brief Large (waist 45" - 58
PBE Tranquility ATN Brief X-Large (waist 56" - 6
PBE Tranquility Breathable Brief Medium (waist 32" - 4
PBE Tranquility Breathable Brief Large (waist 45" - 58
PBE Tranquility Breathable Brief X-Large (waist 56" - 6
PBE Tranquility Brief HI-Rise Bariatric 3XL (waist 64" - 96")
PBE Tranquility Premium Daytime Underwear Medium (waist 34" - 4
PBE Tranquility Premium Daytime Underwear Large (waist 45" - 58
PBE Tranquility Premium Daytime Underwear X-Large (waist 56" - 6
PBE Tranquility Premium Daytime Underwear 2XL (waist 62" - 80")
PBE Tranquility Premium Overnight Underwear Small (waist 22" - 36
PBE Tranquility Premium Overnight Underwear Medium (waist 34" - 4
PBE Tranquility Premium Overnight Underwear Large (waist 45" - 58
PBE Tranquility Premium Overnight Underwear X-Large (waist 56" - 6
PBE Tranquility Premium Overnight Underwear 2XL (waist 62" - 80")
PBE Tranquility Slimline Brief Small (waist 24" - 32
PBE Tranquility Slimline Brief Medium (waist 32" - 4
PBE Tranquility Slimline Brief Large (waist 45" - 58
PBE Tranquility Slimline Brief X-Large (waist 56" - 6
PBE Tranquility Smartcore Briefs Small (waist 24" - 32
PBE Tranquility Smartcore Briefs Medium (waist 32" - 4
PBE Tranquility Smartcore Briefs Large (waist 45" - 58
PBE Tranquility Smartcore Briefs X-Large (waist 56" - 6
PBE Tranquility Smartcore Briefs 2XL (waist 60" - 80")
PBE Tranquility Bariatric Disposable Brief 3XL (waist 64" - 96")

Presto Presto Breathable Brief Medium (waist 32" - 4
Presto Presto Breathable Brief Large (waist 45" - 58
Presto Presto Breathable Brief X-Large (waist 59" - 6
Presto Presto FlexRight Extended Use Underwear Medium (32" - 44")
Presto Presto FlexRight Extended Use Underwear Large (waist 44" - 58
Presto Presto FlexRight Extended Use Underwear X-Large (waist 58" - 6

e Product List 5/12/2016
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e underwear are only covered if included on this list.

44") 2185 801 53 0.15 T4522
8") 2186 567 T4523
64" 2187 589 T4524
44") 2305
8") 2306 659 54 0.16 T4522
64" 2307 T4523
2192 532 T4524
48") 2105 608 T4543
8") 2106
64" 2107 351 31 0.04 T4526
2108 506.2 T4527
6") 2114 T4528
48") 2115 T4544
8") 2116 T4525
64" 2117
2118 28 0.04 T4526
2") 2120 T4527
44") 2122 T4528
8") 2132 T4544
64" 2134 T4521
2") 2311
44") 2312 54 0.29 T4522
8") 2313 T4523
64") 2314 T4524
2315 T4521
44") 2190
8") 53 0.24 T4522
64") ABB11020 T4523
ABB11040 T4524
8") ABB11050 T4543
68") AUB44020 T4543
AUB44040
AUB44050 45 0.15 T4522
T4523
T4524

24 0.04 T4526
T4527
T4528

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Presto Presto FlexRight Extended Use Underwear XX-Large (waist 68"
Presto Presto FlexRight Premium Underwear Medium (waist 32" - 4
Presto Presto FlexRight Premium Underwear Large (waist 44" - 58
Presto Presto FlexRight Premium Underwear X-Large (waist 58" - 6
Presto Presto FlexRight Premium Underwear XX-Large (waist 68"
Presto Presto FlexRight Supreme Underwear Medium (waist 32" - 4
Presto Presto FlexRight Supreme Underwear Large (waist 44" - 58
Presto Presto FlexRight Supreme Underwear X-Large (waist 58" - 6
Presto Presto Premium Breathable Brief Small (waist 22" - 36
Presto Presto Premium Breathable Brief Medium (waist 32" - 4
Presto Presto Premium Breathable Brief Large (waist 45" - 58
Presto Presto Premium Breathable Brief X-Large (waist 59" - 6
Presto Presto Premium Breathable Brief XX-Large (waist 63"
Presto Presto Premium Underwear Small (waist 22" - 36
Presto Presto Stretch Breathable Brief Medium/Regular (wa
Presto Presto Stretch Breathable Brief Large/X-Large (waist
Presto Presto Supreme Breathable Brief Medium (waist 32" - 4
Presto Presto Supreme Breathable Brief Large (waist 45" - 58
Presto Presto Supreme Breathable Brief X-Large (waist 59" - 6

SCA TENA Bariatric 3XL Brief XXXL (waist 64" - 95
SCA TENA Classic Briefs Medium (waist 34" - 4
SCA TENA Classic Briefs Regular (waist 40" - 5
SCA TENA Classic Briefs Large (waist 48" - 59
SCA TENA Classic Briefs X-Large (waist 55" - 6
SCA TENA Classic Protective Underwear Medium (waist 34" - 4
SCA TENA Classic Protective Underwear Large (waist 45" - 58
SCA TENA Classic Protective Underwear X-Large (waist 55" - 6
SCA TENA Classic Protective Underwear XX-Large (waist 68"
SCA TENA Protective Underwear, Regular Medium (waist 34" - 4
SCA TENA Protective Underwear, Regular Large (waist 45" - 58
SCA TENA Protective Underwear, Regular Xlarge (waist 55"-66"
SCA TENA Protective Underwear, Regular XXL (waist 68" - 80")

e Product List 5/12/2016
Page 9
e underwear are only covered if included on this list.

- 80") AUB44060 T4528
353 34 0.04 T4526
44") AUB24020
T4527
8") AUB24040 T4528
T4528
68") AUB24050 452 28 0.13 T4526
T4527
- 80") AUB24060 T4528
T4521
44") AUB34020 394 45 0.15 T4522
T4523
8") AUB34040 T4524
T4524
68") AUB34050 T4525
417 52 0.02 T4522
6") ABB21010 T4523
460 46 0.07 T4522
44") ABB21020 T4523
T4524
8") ABB21040
T4543
64") ABB21050 425 52 3.07 T4522

- 69") ABB21060 T4523
T4523
6") AUB23010 T4524
363 35 0.18 T4526
aist 32" - 54") ABS21030 T4527
T4528
t 48" - 66") ABS21050 T4544
384 29 0.05 T4526
44") ABB30020 T4527
T4528
8") ABB30040 T4544
64") ABB30050

5") 61385

47") 67720

50") 67730

9") 67740

66") 67750

44") 72513

8") 72514

67") 72516

- 80") 72517

44") 72413

8") 72415

") 72416

) 72420

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

SCA TENA Stretch Ultra 2XL Brief XXL (waist 64" - 70")
SCA TENA Super Briefs Medium (waist 34" - 4
SCA TENA Super Briefs Regular (waist 40" - 5
SCA TENA Super Briefs Large (waist 48" - 59
SCA TENA Super Briefs X-Large (waist 55" - 6
SCA TENA Super Stretch Medium/Regular (wa
SCA TENA Super Stretch Lg/X-Large (waist 41
SCA TENA Ultra Briefs Small (waist 22" - 36
SCA TENA Ultra Briefs Medium (waist 34" - 4
SCA TENA Ultra Briefs Regular (waist 40" - 5
SCA TENA Ultra Briefs Large (waist 48" - 59
SCA TENA Ultra Briefs X-Large (waist 55" - 6
SCA TENA Ultra Stretch Brief Medium/Regular (wa
SCA TENA Ultra Stretch Brief Lg/X-Large (waist 41
SCA TENA Protective Underwear, Plus Medium (waist 34" - 4
SCA TENA Protective Underwear, Plus, discreet pkg Medium (waist 34" - 4
SCA TENA Protective Underwear, Plus Large (waist 45" - 58
SCA TENA Protective Underwear, Plus, discreet pkg Large (waist 45" - 58
SCA TENA Protective Underwear, Plus X-Large (waist 55" - 6
SCA TENA Protective Underwear, Plus, discreet pkg X-Large (waist 55" - 6
SCA TENA Protective Underwear, Extra Small (waist 25" - 35
SCA TENA Protective Underwear, Extra, discreet pkg Small (waist 25" - 35
SCA TENA Protective Underwear, Extra Medium (waist 34" - 4
SCA TENA Protective Underwear, Extra, discreet pkg Medium (waist 34" - 4
SCA TENA Protective Underwear, Extra Large (waist 45" - 58
SCA TENA Protective Underwear, Extra, discreet pkg Large (waist 45" - 58
SCA TENA Protective Underwear, Extra X-Large (waist 55" - 6
SCA TENA Protective Underwear, Extra, discreet pkg X-Large (waist 55" - 6
SCA TENA Dry Comfort Protective Underwear Medium (waist 34" - 4
SCA TENA Dry Comfort Protective Underwear Large (waist 45" - 58
SCA TENA Dry Comfort Protective Underwear X-Large (waist 55" - 6

Shopko Shopko Underwear Women's Maximum Medium (waist 32" - 4

e Product List 5/12/2016
Page 10
e underwear are only covered if included on this list.

) 61390 T4543
490 37 0.46 T4522
47") 67401
T4523
50") 67405 T4523
T4524
9") 67501 578 38 0.45 T4522
T4523
66") 68011 T4521
393 45 6.30 T4522
aist 33" - 52") 67902 T4523
T4523
1" - 64") 67903 T4524
477 38 0.56 T4522
6") 66100 T4523
T4526
47") 67200 343 22 0.22 T4526
T4527
50") 67201 T4527
T4528
9") 67300 T4528
T4525
66") 68010 T4525
439 27 0.07 T4526
aist 33" - 52") 67802 498 22 0.29 T4526
T4527
1" - 64") 67803 T4527
T4528
44") 72238 T4528
396 35 0.13 T4526
44") 72242 T4527
T4528
8") 72338
528 36 0.00 T4526
8") 72341

66") 72435

66") 72465

5") 72116

5") 72101

44") 72232

44") 72248

8") 72332

8") 72347

66") 72425

66") 72400

44") 72422

8") 72423

66") 72424

44") 36695

Incontinence

*Effective 7/1/2013, adult-size briefs and disposable

Shopko Shopko Underwear Men's Maximum Small / Medium (wais
Shopko Shopko Underwear Men's Maximum Large / X-large
Shopko Shopko Underwear Women's Maximum Large (waist 44" - 58
Shopko Shopko Underwear Women's Maximum Xlarge (waist 58" - 63

e Product List 5/12/2016
Page 11
e underwear are only covered if included on this list.

st 28" - 40") 37892 524 36 0.00 T4526
37893 T4528
8") 36696 T4527
3") 36697 T4528