Ordering Information - PolyMem

1 PolyMem Non-AdhesiveREFDIMENSIONSPER CASEPACKAGINGHCPCS x ( x )100 per case5 bx / 20 eaA620950333 x 3 (8cm x 8cm)60 per case4 bx / 15 eaA620950444 x 4 (10cm x 10cm)60 per case4 bx / 15 eaA620950555 x 5 (13cm x 13cm)30 per case2 bx / 15 x (17cm x 19cm)30 per case2 bx / 15 eaA621051244 x (10cm x 32cm)12 per case1 bx / 12 eaA621052444 x 24 (10cm x 61cm) Roll 8 per case2 bx / 4 eaA621158248 x 24 (20cm x 60cm) Roll 2 per case1 bx / 2 eaA6211 PolyMem Silver x ( x )100 per case5 bx / 20 x ( x )30 per case2 bx / 15 x (17cm x 19cm)15 per case1 bx / 15 x ( x 32cm)12 per case1 bx / 12 eaA6211 Ordering Information PolyMem and PolyMem Silver Non-Adhesive DressingsThe optimal choice when cutting dressings to size and tapeless attachment or roll taping, is your preferred method of application. Use as a primary, secondary or combined primary and secondary dressing.

2 Ferris Mfg. Corp. 5133 Northeast Parkway, Fort Worth, TX 76106-1822 Toll Free USA: 800-765-9636 International: +1 817-900-1301 MAXREFDIMENSIONSPER CASE PACKAGINGHCPCS Codes50353 x 3 ( x )40 per case4 bx / 10 x (11cm x 11cm)20 per case2 bx / 10 eaA621050888 x 8 (20cm x 20cm) 10 per case 2 bx / 5 eaA6211 PolyMem Max Silver10454 x 4 (10cm x 10cm)16 per case2 bx / 8 eaA620910888 x 8 (20cm x 20cm) 10 per case2 bx / 5 eaA6211 PolyMem WICREF DIMENSIONS PER CASEPACKAGINGHCPCS Codes57333 x 3 (8cm x 8cm) 4 grams40 per case4 bx / 10 eaA621557123 x 12 (8cm x 30cm) 16 grams12 per case1 bx / 12 eaA621557888 x 8 (20cm x 20cm) 28 grams10 per case2 bx / 5 eaA6215 PolyMem WIC Silver13311 x 3 ( x ) grams70 per case5 bx / 14 eaA621513333 x 3 (8cm x 8cm) 4 grams20 per case2 bx / 10 eaA621517888 x 8 (20cm x 20cm) 28 grams10 per case2 bx / 5 eaA6215 PolyMem WIC Silver x 14 (1cm x 35cm)

3 3 grams12 per case2 bx / 6 eaA6215 This configuration is a thicker PolyMem pad with high MVTR film for wounds with heavier drainage or when longer wear time is desired. Use as a primary, secondary or combined primary and secondary no film backing, WIC expands within the wound cavity to fill dead space, keeping the wound bed clean and moisturized while absorbing excess fluid. WIC Rope has a reinforced mesh to ensure one-piece Max and PolyMem Max Silver Non-Adhesive DressingsPolyMem WIC, PolyMem WIC Silver & PolyMem WIC Silver Rope Wound FillersPolyMem Film AdhesiveREFDIMENSIONSPER CASEPACKAGINGHCPCS Codes2031 x 1 ( x ) Pad2 x 2 (5cm x 5cm) Adhesive100 per case5 bx / 20 eaA62124052 x 3 (5cm x ) x ( x ) Adhesive60 per case 4 bx / 15 eaA6212 PolyMem MAX Film x 3 ( x ) x (7cm x ) Adhesive40 per case4 bx / 10 x (9cm x 9cm) x ( x ) Adhesive60 per case 4 bx / 15 eaA621234122 x 10 (5cm x 26cm) x ( x ) Adhesive 12 per case 1 bx / 12 eaA6213 The ultra-thin, adhesive-coated urethane film, together with the PolyMem membrane, provides a breathable yet tough, protective, water-resistant dressing of unsurpassed Film Adhesive DressingsPolyMem Cloth AdhesiveREFDIMENSIONSPER CASEPACKAGINGHCPCS Codes72031 x 1 ( x ) Pad2 x 2 (5cm x 5cm)

4 Adhesive100 per case5 bx / 20 eaA621274052 x 3 (5cm x 8cm) Pad4 x 5 (10cm x 13cm) Adhesive60 per case 4 bx / 15 x (9cm x 9cm) Pad6 x 6 (15cm x 15cm) Adhesive60 per case 4 bx / 15 eaA621270311 x 1 ( x ) Pad1 x 3 ( x 8cm) Adhesive 100 per case 5 bx / 20 eaA621270422 x (5cm x 4cm) Pad2 x 4 (5cm x 10cm) Adhesive100 per case5 bx / 20 eaA6212 PolyMem Silver Cloth x (9cm x 9cm) Pad6 x 6 (15cm x 15cm) Adhesive30 per case2 bx / 15 eaA6212 PolyMem Cloth Adhesive DressingsA breathable, adhesive-coated cloth backing that provides exceptional comfort for your by PolyMem TubeREFPAD DIMENSIONSPER CASEPACKAGINGHCPCS x (7cm x 7cm)30 per case2 bx / 15 x (9cm x 9cm)30 per case2 bx / 15 eaA6209 PolyMemSilverFinger / ToeREFREFDIMENSIONSPER CASE PACKAGINGHCPCS Codes44011401#1 small; circumference - ( x )30 per case5 bx / 6 eaA620944021402#2 medium; circumference - ( x )30 per case5 bx / 6 eaA620944031403#3 large; circumference - ( x )30 per case5 bx / 6 eaA620944041404#4 extra large; circumference - ( x )30 per case5 bx / 6 eaA620944051405#5 XXL.

5 Circumference - ( x )30 per case5 bx / 6 eaA6210 PolyMemSilverShapes by PolyMem SacralREFREFD imensionsPER CASEPACKAGINGHCPCS x ( x ) x ( x 20cm) Adhesive20 per case2 bx / 10 eaA6212 PolyMem Finger/Toe DressingsShapes by PolyMem Tube DressingsPolyMemSilverShapes by PolyMem OvalREFREFDIMENSIONSPER CASEPACKAGING HCPCS Codes802318231 x 2 ( x 5cm) Pad2 x 3 (5cm x ) Adhesive100 per case5 bx / 20 eaA6212805318533 x 2 ( x 5cm) Pad5 x ( x ) Adhesive30 per case2 bx / 15 eaA6212808618864 x ( x ) x ( x ) Adhesive20 per case2 bx / 10 eaA6213 Shapes by PolyMem Oval & Oval Silver DressingsShapes by PolyMem Sacral DressingsA variety of oval sizes offer a secure fit for wounds on elbows, knees and other contoured areas of the body where the dressing needs to bend and conform. This configuration is specially designed for use on fingers and toes. Appropriate for use as a combined primary and secondary dressing or as a secondary heart-shaped dressing is designed specifically for use in the sacral region.

6 This configuration is pre-cut to enhance patient comfort and help clinicians easily apply the dressing to tube sites. Unlike other dressings used on tube sites, PolyMem dressings do not shed document is meant for general Information . See individual product instructions for are owned by or licensed to Ferris. The marks may be registered or pending in several countries 2017-2018 Ferris Mfg. Corp. MKL-698 REV3 0318 MADE IN USAPolyMem wound care dressings are not made with natural rubber Mfg. Corp. and its representatives provide general Information as a courtesy and for the awareness of customers. Ferris does not guarantee coverage or payment for prod-ucts or accuracy of HCPCS codes associated with REF numbers (thought to be current 1-1-2016.) Ferris Information is not intended to increase or maximize reimbursement by any payor, and does not recommend how products should be billed to Medicare or other health care insurers.

7 The Provider bears responsibility for coding, satisfying requirements, and obtaining reimbursement. The Provider s records and billing should accurately describe the product and amount that was clinically necessary to treat the condition and the amount provided to the patient. Coverage, coding, and payment policies and guidelines are complex, can vary from one carrier or region to another, and change. Providers should consult with counsel, a reimbursement specialist, and CMS web pages. Providers should check with their local carriers or intermediaries often and consider the DME PDAC DMECS Application and calling the local DME MAC.