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Revised 02/13/04 - BG MaineCare Covered Asthma Supplies Drug Name NDC ACE AEROSOL CLOUD ENHANCE ACE SPACER AEROCHAMBER AEROCHAMBER AEROCHAMBER AEROCHAMBER AEROCHAMBER AEROCHAMBER MASK AEROCHAMBER MV AEROCHAMBER PLUS/FLOW SIG AEROCHAMBER PLUS/LARGE MA AEROCHAMBER PLUS/MEDIUM M AEROCHAMBER PLUS/SMALL MA AEROCHAMBER/FLOWSIGNAL AEROCHAMBER/MASK AEROCHAMBER/MASK AEROCHAMBER/MASK AEROCHAMBER/MASK AEROCHAMBER/MASK-LARGE AEROCHAMBER/MASK-LARGE AEROCHAMBER/MASK-SMALL AEROCHAMBER/MASK-SMALL AEROTRACH PLUS AEROVENT II ASTECH ADAPTER/USE WITH 1 BREATHERITE BREATHERITE BREATHERITE COLLAPSIBLE BREATHERITE COLLAPSIBLE BREATHERITE COLLAPSIBLE BREATHERITE COLLAPSIBLE BREATHERITE COLLAPSIBLE BREATHERITE RIGID SPACER BREATHERITE RIGID SPACER BREATHERITE RIGID SPACER BREATHERITE RIGID SPACER BREATHERITE RIGID SPACER BREATHERITE W/LARGE MASK BREATHERITE W/LARGE MASK BREATHERITE W/MEDIUM MASK BREATHERITE W/MEDIUM MASK BREATHERITE W/SMALL MASK BREATHERITE W/SMALL MASK BUBBLES THE FISH PEDI MAS E-Z SPACER E-Z SPACER MASK 49502020301 41353080100 00456315467 00456874513 52959100200 54569229400 54868451900 00456074513 04351098510 04351079710 04351080710 04351078710 04351088710 04351079510 04351078610 04351080510 04351088610 54569459800 00456074613 54569489300 00456074413 54569434400 04351052510 04351085750 49502020212 11391030100 11391030200 11391030201 11391030202 11391030203 11391030204 11391030205 11391030101 11391030102 11391030103 11391030104 11391030105 11391030110 11391030210 11391030120 11391030220 11391030130 11391030230 44229044044 59196000901 59196002001 1 of 4 Revised 02/13/04 - BG MaineCare Covered Asthma Supplies Drug Name NDC E-Z SPACER/MASK E-Z-V EASIVENT EASIVENT EASIVENT EASIVENT/MASK-LARGE EASIVENT/MASK-MEDIUM EASIVENT/MASK-SMALL ELLIPSE COMPACT SPACER INHAL-AID INHALER COMPANIONS INSPIREASE INSPIREASE INSPIREASE DRUG DELIVERY INSPIREASE DRUG DELIVERY INSPIREASE DRUG DELIVERY MICROCHAMBER/MASK MEDIUM MICROCHAMBER/MASK SMALL OPTICHAMBER ADVANTAGE OPTICHAMBER ADVANTAGE OPTICHAMBER ADVANTAGE/LAR OPTICHAMBER ADVANTAGE/MED OPTICHAMBER ADVANTAGE/SMA OPTICHAMBER FACE MASK/LAR OPTICHAMBER FACE MASK/MED OPTICHAMBER FACE MASK/SMA OPTIHALER OPTIHALER OPTIHALER OPTIHALER OPTIHALER MDI DRUG DELIVE PANDA MASK LARGE PANDA MASK LARGE PANDA MASK MEDIUM PANDA MASK MEDIUM PANDA MASK SMALL PANDA MASK SMALL PARI BABY CONVERSION PACK PARI BABY CONVERSION PACK PARI EXPIRATORY FILTER VA PARI LC MANUAL INTERRUPTE PARI LC MASK SET WITH Y P PARI LC NEB SET ADULT MAS PARI LC NEB SET PEDIATRIC PARI LC PLUS EXPIRATORY F PARI LC PLUS VALVE SET 59196002901 00173500601 49502020701 49502020725 54569474300 49502020803 49502020802 49502020801 00173500001 00085460001 47360017203 00085460370 00085460570 00085460201 00085460202 54569276600 47360017206 47360017205 08373080010 08373080050 08373080310 08373080210 08373080110 08373081310 08373081210 08373081110 08373076000 08373076510 08373076550 50486008420 08373076500 08439640105 08439640115 08439640103 08439640113 08439640102 08439640112 44229044003 44229044004 50486008284 44229022002 44229044006 44229022049 44229022050 44229041066 44229022011 2 of 4 Revised 02/13/04 - BG MaineCare Covered Asthma Supplies Drug Name NDC PARI MASK SET ADULT PP PARI MASK SET ADULT PVC PARI MASK SET PEDIATRIC PARI MASK SET PEDIATRIC PARI TREK PORTABLE POWER PEDIATRIC AEROSOL MASK PEDIATRIC MOUTHPIECE/DISP PEDIATRIC PANDA MASK PEDIATRIC PANDA MASK PFLEX SPACE CHAMBER ADULT MASK SPACE CHAMBER ADULT MASK SPACE CHAMBER INFANT MASK SPACE CHAMBER PEDIATRIC M THRESHOLD IMT ZOEY OPTICHAMBER ADAPTER PED MOUTHPIECE MW ADULT DISPOSABLE MOUTHPIE ADULT DISPOSABLE MOUTHPIE ASSESS DISPOSABLE MOUTHPI ASSESS DISPOSABLE MOUTHPI ASSESS DISPOSABLE MOUTHPI ASSESS DISPOSABLE MOUTHPI ASTECH DISPOSABLE MOUTHPI ASTECH DISPOSABLE MOUTHPI ASTECH DISPOSABLE MOUTHPI DISPOSABLE MOUTHPIECE FUL DISPOSABLE MOUTHPIECE LOW DISPOSABLE MOUTHPIECE/LOW DISPOSABLE MOUTHPIECE/UNI DISPOSABLE SAFETY MOUTHPI EXPIRATORY MOUTHPIECE INSPIREASE MOUTHPIECE 144 INSPIREASE REPLACEMENT MO KOKO PEAK PRO REPLACEMENT MICROCHAMBER MICROSPACER MICROSPACER MOUTHPIECE REUSABLE MW PARI LC PLUS MOUTHPIECE PARI MASK SET PARI NEBULIZER MOUTHPIECE PARI SOFT PLASTIC ADULT M PARI SOFT PLASTIC PEDIATR AIRZONE PEAK FLOW METER AIRZONE PEAK FLOW METER 44229014009 44229014010 44229012008 44229014006 83490046002 33413056203 08439123020 08439640101 08439640111 08373055300 44229044026 44229044027 44229044022 44229044023 08373073000 08373080030 44229031007 08439060026 08439122002 00585118403 00585118404 08373071100 08373071200 49502020101 49502020248 49502020299 50486008411 50486008412 50486008322 50486008323 08373071400 08439060030 00085460401 00085460402 08439393535 47360017202 47360001721 47360017201 44229031002 44229022006 50486008225 44229012004 50486008271 50486008270 08439130025 08439905094 3 of 4 Revised 02/13/04 - BG MaineCare Covered Asthma Supplies Drug Name NDC AIRZONE PEAK FLOW METER ASSESS FULL RANGE PEAK FL ASSESS FULL RANGE PEAK FL ASSESS LOW RANGE PEAK FLO ASSESS LOW RANGE PEAK FLO ASSESS PEAK FLOW METER ASSESS PEAK FLOW METER ASSESS PEAK FLOW METER FU ASSESS PEAK FLOW METER FU ASSESS PEAK FLOW METER LO ASSESS PEAK FLOW METER LO ASTECH PEAK FLOW METER ASTECH PEAK FLOW METER ASTHMA CHECK METER-ZONE S ASTHMAMENTOR INCHECK INSPIRATORY FLOW MINI WRIGHT AFS LOW RANGE MINI WRIGHT AFS PEAK FLOW MINI WRIGHT PEAK FLOW MET MINI WRIGHT PEAK FLOW MET MINI WRIGHT STD PEAK FLOW MINI WRIGHT STD PEAK FLOW PEAK AIR PEAK FLOW METER PEAK FLOW METER PERSONAL BEST FULL RANGE PERSONAL BEST FULL RANGE PERSONAL BEST LOW RANGE PERSONAL BEST LOW RANGE PIKO 1 PIKO 1 PIKO 1 PIKO 1 POCKET PEAK FLOW METER POCKET PEAK FLOW METER POCKETPEAK PEAK FLOW METE POCKETPEAK PEAK FLOW METE POCKETPEAK PEAK FLOW METE POCKETPEAK PEAK FLOW METE TRUZONE PEAK FLOW METER TRUZONE PEAK FLOW METER ZOEY PERSONAL BEST FULL R ZOEY PERSONAL BEST LOW RA 83490031024 08373071000 08373071800 08373071900 08373075000 00585118401 00585118402 08373071812 50486008410 08373071912 50486008415 41353070100 49502020001 08373074000 08373074200 08439109750 08439905093 08439104001 44229031001 44229031008 08439103001 08439905092 73796069940 50486008320 08373075500 54569488700 08373075600 54569488600 08439345010 08439345011 08439345012 08439345013 08439600101 08439600112 31253060207 50486008321 65845001800 65845001801 04351096510 44229031017 08373075530 08373075630 4 of 4