2.4.2 Benefit Coverage
Comparable To The Extended Care Health Option (ECHO) For Seriously
Ill Or Injured Service Members
2.4.2.1 Under 10
USC 1074(c)(4)(A) and (B), seriously ill/injured Service members shall receive services
comparable to those provided to dependents of Service members under
10 USC 1079(d) and (e), the TRICARE ECHO Program. Statutory authority
for these benefits for retirees ended December 31, 2012. Former
Service members that utilized this benefit will continue to be covered
by this provision for benefits received before December 31, 2012
(e.g., anti-rejection medication for a limb transplant). The contractors
shall ensure all TED requirements outlined in the TRICARE Systems
Manual (TSM),
Chapter 2 are
met including appropriate use of
SPC PF to
identify TED records for care rendered under the ECHO benefit for
seriously ill or injured Service members.
2.4.2.2 There are
no cost-shares, copayments, or financial caps for any of these ECHO-like
benefits when these services are authorized. There is no requirement
to register in the Exceptional Family Member Program (EFMP). There
is no time limit with disability/illness requirement. These benefits
shall be preauthorized, to include documentation of Category II/III
designation per Department of Defense Instruction (DoDI) 1300.24;
and, documentation that the Service member has been referred to
a Medical Evaluations Board (MEB).
2.4.2.3 The following
categories of care listed under 10 USC 1079(e) are authorized (see
10 USC 1079(e)(1-7):
2.4.2.3.1 Diagnosis.
2.4.2.3.2 Inpatient,
outpatient, and comprehensive Home Health Care (HHC) supplies and services
which may include cost effective and medically appropriate services
other than part-time or intermittent services, as these terms are
currently used under the TRICARE ECHO Program.
2.4.2.3.3 Training,
rehabilitation, special education, and assistive technology devices.
2.4.2.3.4 Institutional
care in private nonprofit, public, and state institutions and facilities
and, if appropriate, transportation to and from such institutions
and facilities.
2.4.2.3.5 Home health services, including custodial care
in conjunction with authorized home health services.
2.4.2.3.6 Seriously
ill or injured Service members are defined as Category II or III
per DoDI 1300.24.
2.4.2.3.6.1 Category
II:
• Has
a serious injury or illness.
• Is unlikely to return
to duty within a time specified by his or her military department.
• May be medically separated
from the military.
2.4.2.3.6.2 Category III:
• Has a severe or catastrophic
injury or illness.
• Is highly unlikely
to return to duty.
• Will most likely
be medically separated from the military.
2.4.2.4 The Service
member’s primary care provider or primary specialty care provider
shall document and provide the Service member’s category status
on a referral as well as documentation of a referral to an MEB.
Preauthorization is required. If the documentation supports the
category designation of Category II/III, the Service member is eligible
for benefits comparable to ECHO. Using the Government furnished
web-based enrollment application, the contractor shall apply the
ECHO Health Care Delivery Plan (HCDP) code of 400 to the Service
member. The provider’s documentation of Category II/III status is
the authorizing document allowing the contractor to apply the ECHO
HCDP code to the Service member. The contractor shall ensure all
TED requirements outlined in the TSM,
Chapter 2 are
met, including appropriate use of
SPC PF to
identify TED records for care rendered under the ECHO benefit for
seriously ill or injured Service members.
2.4.2.5 The contractor
shall collaborate with all DVA/VHA case managers along with the
Service member’s healthcare team to ensure continuity of care and
transition to DVA/VHA care and management upon retirement or separation.
2.4.2.6 As much
as practical, these benefits should mirror the ECHO Program and
be coordinated between the contractor and the health care team.
Benefits for these Service members arise from any physiological
disorder or condition or anatomical loss affecting one or more body
system and which precludes the person with the disorder, condition,
or anatomical loss from unaided performance of at least one of the
following major life activities: breathing, cognition, hearing,
seeing, and ability to bathe, dress, eat, groom, speak, stair use,
toilet use, transferring, and walking. Benefits include services for
rehabilitative, habitative care as well as Durable Equipment (DE)
and Durable Medical Equipment (DME).
2.4.2.7 Designation
of comparable to ECHO benefits for Service members.
2.4.2.7.1 Requests
for benefits under the comparable to ECHO will come from the Service member’s
PCM or specialty provider with documentation of the category description
(II/III) along with documentation to support that category description.
2.4.2.7.2 Documentation
of a referral to an MEB must be provided.
2.4.2.8 Provision
Of Respite Care
2.4.2.8.1 The eligibility
rules and exclusions contained in
32 CFR 199.5(b)(3) and
(5) do not apply to the provision of respite
benefits for a Service member. See
Appendix A for
definitions, terms, and limitations applicable to the respite care
benefit.
2.4.2.8.2 Seriously
ill or injured Service members shall qualify for respite care benefits
regardless of their enrollment status. Service members in the 50
U.S. and the District of Columbia shall qualify if they are enrolled
in TRICARE Prime, TPR, or not enrolled and receiving services in
accordance with the non-enrolled/non-referred provisions for the
use of SHCP funds. Service members outside the 50 U.S. and the District
of Columbia shall qualify if they are enrolled to
TOP
Prime
(with enrollment to an MTF/eMSM), TOP Prime Remote, or not enrolled
and receiving services in accordance with the non-enrolled/non-referred
provisions for Service member care overseas (see TPM,
Chapter 12, Section 1.1).
Note: Respite care benefits must be performed by a TRICARE-authorized
Home Health Agency (HHA), regardless of the Service member’s location
(see
32 CFR 199.6(b)(4)(xv) for HHA definition).
2.4.2.8.3 There are
no cost-shares or copays for Service member respite benefits when
those services are approved by the Service member’s Direct Care
System (DCS) case manager or other appropriate DCS authority (i.e.,
SAS, the enrolled or referring MTF/eMSM, TRICARE Area Office (TAO),
or Community Care Units (CCUs)).
2.4.2.8.4 All SHCP requirements and provisions of
Chapters 16 and
17 apply to
this benefit unless changed or modified by this paragraph. The appropriate
chapter for the status of the Service member shall apply. Contractors
shall follow the requirements and provisions of these chapters,
to include:
• MTF/eMSM
or SAS referrals and authorizations;
• Receipt and control
of claims;
• Authorization,
verification, reimbursement and payment mechanisms to providers;
• Reimbursement specifying
no cost-share, copay, or deductible to be paid by the Service member
or their lawful spouse; and
• Use of CHAMPUS Maximum
Allowable Charges (CMACs)/Diagnosis Related Groups (DRGs) when applicable.
2.4.2.8.5 Contractors
shall follow the provisions of the TSM,
Chapter 2, Sections 2.8 and
6.4 regarding the TED SPC for the Service
member respite benefit. Claims should indicate an appropriate procedure
code for respite care (CPT 99600 or HCPCS S9122-S9124) and shall
be reimbursed based upon the allowable charge or the negotiated
rate.
2.4.2.8.6 Respite
care services and requirements are as follows:
2.4.2.8.6.1 Respite care is authorized for a Service member
of the Uniformed Services on active duty and has a qualifying condition
as defined in
Appendix A.
2.4.2.8.6.2 Respite care is available if a Service member’s
plan of care includes frequent interventions by the primary caregiver(s).
2.4.2.8.6.3 Service
members receiving respite care are eligible to receive a maximum
of 40 respite hours in a calendar week, no more than five days per
calendar week and no more than eight hours per calendar day. No
additional benefit caps apply.
2.4.2.8.6.4 Respite benefits shall be provided by a TRICARE-authorized
HHA and are intended to mirror the benefits under the TRICARE ECHO
Home Health Care (EHHC) program described in the TPM,
Chapter 9, Section 15.1.
Note: Contractors are not required to enroll Service
members in the ECHO program (or a comparable program) for this respite
benefit.
2.4.2.8.6.5 Authorized
respite care does not cover care for other dependents or others
who may reside in or be visiting the Service member’s residence.
2.4.2.8.6.6 In addition,
consistent with the requirement that respite care services shall
be provided by a TRICARE-authorized HHA, services or items provided
or prescribed by a member of the patient’s family or a person living
in the same household are excluded from respite care benefit coverage.
2.4.2.8.6.7 The contractor
shall follow the reimbursement methodology for the similar respite
care benefit found in the TPM,
Chapter 9,
as modified by Service member SHCP reimbursement methodology contained
in
Chapters 16 and
17 (for Service
members located in the 50 U.S. and the District of Columbia) or
TOP reimbursement methodology contained in the TPM,
Chapter 12 (for Service members located outside
the 50 U.S. and the District of Columbia).
2.4.2.8.7 Should
other services or supplies not outlined above, or those otherwise
available under the TRICARE program, be considered necessary for
the care or treatment of a Service member, a request shall be submitted
to the SAS, MTF/eMSM, or TAO for authorization of payment. When preauthorization
is possible it shall be done.
2.4.2.9 Customized
Hand Crank Bikes
2.4.2.9.1 There is
a cap of $5,500.
2.4.2.9.2 Bike must
be custom fitted for the Service member’s unique injury.
2.4.2.9.3 Must be
preauthorized and evidence of a Category II/III illness or injury
must accompany the request. No request should be for more than the
$5,500 cap.
2.4.2.10 Custodial Care
2.4.2.10.1 Limited to 30 days if Service member has not
been referred to an MEB.
2.4.2.10.2 At the MTF/eMSM case manager’s request, the
appropriate regional Medical Director, Clinical Operations Division
(COD), TRICARE Health Plans may extend an additional 30 days if
Service member is due to return to duty at the end of the additional
30 days.
2.4.2.10.3 Any additional
extensions must be with a waiver from the Director, DHA for those Service
members that have not been referred to a MEB.
2.4.2.10.4 For Service
members who have been referred to an MEB, authorization is valid
until Service member retires, separates, or returns to duty. No
waiver is required.
2.4.2.10.5 May be provided in the home or authorized provider/facility.
Use of an unauthorized provider/facility would require a waiver.
2.4.2.10.6 Custodial
care services may be provided up to 24/7. The health care team will periodically
review Service member’s care plan to revise amount of custodial
care required.
2.4.2.10.7 The Service
member’s health care team will determine the requirements of the
Service member for Custodial Care, including the number of hours
and duration of the service and will adjust these requirements accordingly
as the Service member’s requirements change.
2.4.2.10.8 As required the contractors shall collaborate
with DoD and DVA/VHA case managers along with the Service member’s
health care team to ensure continuity of care and transition to
DVA/VHA care and management upon retirement or separation.
2.4.2.10.9 Care must
be preauthorized with documentation of Category II/III illness or
injury and other inclusion criteria in this section accompanying
the request.
2.4.2.11 Cryopreservation
And Reproductive Services
2.4.2.11.1 Policy Guidelines For Cyropreservation
Of Sperm/Oocytes/Embryos For Service Members With A Diagnosis Of
Cancer
2.4.2.11.1.1 Service
member must be either Category II or III as a result of their cancer
at the time of retrieval. The Service member must be scheduled to
undergo a gonadotoxic treatment for their cancer.
2.4.2.11.1.1.1 For females cyropreservation of eggs at age
49 or under at the time of retrieval.
2.4.2.11.1.1.2 For males cyropreservation of sperm at 61 or
under at time of retrieval.
2.4.2.11.1.2 Are on a period of active duty greater than
30 days and are scheduled to remain on active duty for the duration
of the retrieval and freezing process.
2.4.2.11.1.3 Have capacity to provide informed consent (i.e.,
third party consent is not authorized).
Note: Prior surgical sterilization does not disqualify
a Service member from participating.
2.4.2.11.1.4 Mature Oocyte
Retrieval
2.4.2.11.1.4.1 Referral
by PCM (or referral by primary care provider for TPR enrollees)
or specialist involved in a Service member’s cancer care is required
for each cycle. No more than three completed retrieval cycles are
covered. Services and supplies covered for mature oocyte retrieval
include the following.
2.4.2.11.1.4.1.1 Consultation
and subsequent office visits as indicated.
2.4.2.11.1.4.1.2 Laboratory tests and ultrasound imaging as
indicated.
2.4.2.11.1.4.1.3 Provider-administered
medications as indicated for oocyte retrieval.
2.4.2.11.1.4.1.4 Self-administered medications as indicated
for oocyte retrieval are covered under
Chapter 23.
2.4.2.11.1.4.1.5 Surgical retrieval and anesthesia.
2.4.2.11.1.4.1.6 Medically necessary services and supplies associated
with complications.
2.4.2.11.1.4.2 The benefit
is limited to the retrieval of 20 oocytes or three completed cycles, whichever
occurs first. There may be a total of four attempts to accomplish
three completed cycles.
2.4.2.11.1.4.3 Additional
retrieval beyond one cycle shall be authorized by the contractor
only if the cumulative number of oocytes retrieved of all previous
cycles is less than 20. For instance, if 12 oocytes are retrieved
in the first cycle, the contractor may approve a second cycle. If
11 more oocytes are retrieved in the second cycle, the contractor
shall not approve a third cycle.
2.4.2.11.1.5 Sperm
Collection And Retrieval
2.4.2.11.1.5.1 Referral
by PCM (or referral by primary care provider for TPR enrollees)
or specialist involved in a Service member’s cancer care is required.
If indicated, invasive procedures for sperm retrieval beyond simple
collection of semen (or urine for retrograde ejaculation) must be
specified in the referral. Services and supplies covered for sperm
collection and retrieval includes the following.
2.4.2.11.1.5.1.1 Consultation and subsequent office visits as
indicated.
2.4.2.11.1.5.1.2 Laboratory
tests as indicated including semen analysis.
2.4.2.11.1.5.1.3 Provider-administered medications as indicated
for sperm retrieval.
2.4.2.11.1.5.1.4 Self-administered
medications indicated for sperm retrieval are covered under
Chapter 23.
2.4.2.11.1.5.1.5 Invasive procedures for sperm retrieval (e.g.,
electro-ejaculation, epididymal aspiration) likely to produce viable
sperm.
2.4.2.11.1.5.1.6 Medically
necessary services and supplies associated with complications.
2.4.2.11.1.5.2 The benefit is limited to either two simple
specimen collections or one invasive procedure for sperm retrieval.
2.4.2.11.1.6 Cryopreservation
2.4.2.11.1.6.1 Services and supplies associated with cryopreservation
of all mature oocytes and sperm retrieved, and embryos.
2.4.2.11.1.6.2 Storage
Of Retrieved/Collected Oocyte/Sperm And Embryos
2.4.2.11.1.6.2.1 Storage is covered for 36 months from date
of first retrieval of all mature oocytes and sperm. The cost of
storage is incurred on the first day of the initial period of storage
and the first day of any subsequent year of storage.
2.4.2.11.1.6.2.2 The Service member is responsible for all costs
incurred after 36 months or when the Service member separates/retires
(whichever comes first). Arrangements for disposition are the responsibility
of Service members subject to state regulation on disposal and abandonment
of frozen specimens.
2.4.2.11.1.6.2.3 The contractor
shall ensure that oocytes, sperm, and embryos shall be stored at facilities
listed and registered in accordance with 21 CFR 1271.
2.4.2.11.1.6.3 Ownership
And Disposition
Issues regarding ownership,
future use, donation, and/or destruction shall be governed by applicable
state law and shall be the responsibility of the Service member
and their lawful spouse and the facility storing the cryopreserved
oocytes/sperm/embryos. DoD’s role is limited to paying for this
benefit when requested by the consenting Service member. DoD will
not have ownership or custody of cryopreserved oocytes/sperm/embryos.
DoD will not be involved in the ultimate disposition of excess cryopreserved
oocytes/sperm/embryos. Ultimate disposition or destruction of excess
cryopreserved oocytes/sperm/embryos is not separately reimbursed.
2.4.2.11.2 Policy
Guidelines For Assisted Reproductive Technology (ART)
2.4.2.11.2.1 The policy provides for the provision of ART which
includes embryo cryopreservation and storage, to assist in the reduction
of the disabling effects of the Service member’s qualifying condition.
The authority for this policy for care outside of the basic medical
benefit is derived from Section 1633 of the 2008 National Defense
Authorization Act (NDAA). This section allows the Service member
to receive services that are outside the definition of “medical
care.” This benefit is provided through the authorization of the
expenditure of SHCP funds and delivery of the needed services in either
MTFs/eMSMs that offer assisted reproductive technologies or in the
purchased care sector that are outside the medical benefit. Although
purchased care is available for this benefit depending on the Service
member’s circumstances not allowing him or her to travel, the use
of MTFs/eMSMs shall be encouraged, with Service members eligible
for this benefit given priority for care at MTFs/eMSMs if there
is a waiting list. If the Service member receives care or medications
in the civilian sector, participating network providers shall be
used if available. Preauthorization for every IVF cycle is required.
2.4.2.11.2.2 Assisted reproductive services, including sperm
retrieval, oocyte retrieval, IVF, artificial insemination, and blastocyst
implantation is offered based on the condition of the seriously
or severely ill/injured Service member not the spouse; therefore,
the use of the SHCP is authorized.
2.4.2.11.2.3 The benefit is limited to permitting a qualified
Service member to procreate with their lawful spouse, as defined
in federal statute and regulation.
2.4.2.11.2.4 Consent must be able to be given by the Service
member and his or her lawful spouse. Third party consent is not
authorized under this policy.
2.4.2.11.2.5 Third party
donations and surrogacy are not covered benefits. The benefit is
designed to allow the Service member and their spouse to become
biological parents through reproductive technologies.
2.4.2.11.3 Cancer
2.4.2.11.3.1 The policy applies to Service members, regardless
of gender, who are seriously or severely ill (Category II, III)
as a result of their cancer and will or have undergone cancer therapy
that may have effected their fertility. The Service member will
use their cryopreserved sperm/oocytes or embryos for the ART services
such as IVF.
2.4.2.11.3.2 The ART
benefit will be available for 36 months from the date of sperm or
oocyte retrieval.
2.4.2.11.3.3 If the
Service member proceeds with embryo cryopreservation and storage
during this 36 month period, these services will be covered only
during the 36 month period.
2.4.2.11.4 Transportation, shipping and handling costs
of oncocryopreserved sperm and oocytes shall be covered when:
2.4.2.11.4.1 Relocating the specimen from a local cryobank
to a local fertility clinic; or
2.4.2.11.4.2 Relocating the specimen from a cryobank to
a distant fertility clinic closer to where the Service member currently
resides.
2.4.2.11.5 Urogenital Trauma
2.4.2.11.5.1 The policy applies to Service members, regardless
of gender, who have sustained a serious or severe illness/injury
while on active duty that led to the loss of their natural procreative ability.
It is the intent of this policy to provide ART services, including
embryo cryopreservation and storage without limitation while on
active duty, only to consenting male Service members whose illness
or injury to their urogenital system prevents the successful delivery
of their sperm to their spouse’s egg and to consenting female Service
members whose illness or injury to their urogenital system prevents
their egg from being successfully fertilized by their spouse’s sperm,
but who maintain ovarian function and have a patent uterine cavity.
This includes, but is not limited to, those suffering neurological,
physiological, and/or anatomical injuries.
2.4.2.11.5.2 Male Service members must be able to produce
sperm, but need alternative sperm collection technologies as they
can no longer ejaculate in a way that allows for egg fertilization.
Ill/injured female Service members require ovarian function and
a patent uterine cavity that would allow them to successfully carry
a fetus even if unable to conceive naturally (e.g., thorough damage
to their fallopian tubes).
2.4.2.11.5.3 Embryo
cryopreservation and storage will be covered as long as the Service
member remains on active duty.
2.4.2.11.5.4 The Service member is responsible for all storage
costs when the Service member separates/retires. Arrangements for
disposition are the responsibility of Service members subject to state
regulation on disposal and abandonment of frozen specimens.
2.4.2.11.6 Procedures
2.4.2.11.6.1 Prediction of fertility potential (Ovarian
Reserve) shall be conducted in accordance with the provider clinic’s
practice guidelines. (This may include a Clomiphene Citrate Challenge
Test (CCCT) and evaluation of the uterine cavity.) Beneficiaries
with a likelihood of success, based on the specific clinic’s guidelines, shall be
provided IVF cycles under this benefit. Infertility testing and
treatment, including correction of the physical cause of infertility,
are covered in accordance with the TPM,
Chapter 4, Section 17.1.
2.4.2.11.6.2 Three completed
IVF cycles shall be provided for the seriously or severely ill/injured female
Service member or lawful spouse of the seriously or severely ill/injured
male Service member. No more than six IVF cycles shall be initiated
for the seriously or severely ill/injured female Service member
or legal spouse of the seriously or severely ill/injured male Service
member. There may be a total of six attempts to accomplish three
completed IVF cycles. If the ill/ injured Service member has used
initiated IVF cycles, subsequently remarries and desires this benefit
with the new spouse, the number of cycles available is dependent
on prior cycles used.
2.4.2.11.6.3 Assisted reproductive service centers with
capability to provide full services including alternative methods
of sperm aspiration will be invited to participate and accept payment
at the network discount rate. (Membership in the American Society
for Reproductive Medicine (ASRM), with associated certification(s),
is highly recommended for network providers. Reporting outcomes
to the Centers for Disease Control and Prevention (CDC) is mandatory.)
When a network provider is not available, the benefits provided
under this policy may be provided by any TRICARE-authorized provider,
including those authorized pursuant to
32 CFR 199.6(e).
2.4.2.11.6.4 IVF cycles
shall be accomplished in accordance with the practice guideline
for the provider clinic using gonadotropins which are concentrated
mixtures of Follicle Stimulating Hormone (FSH) or FSH and Luteinizing
Hormone (LH) given as an injection to stimulate the ovary to produce multiple
oocytes in preparation for egg retrieval. These medications shall be
purchased through the TPharm contract (to include home delivery,
non-network retail pharmacy, and network retail pharmacy options)
or MTF/eMSM.
2.4.2.11.6.5 Anesthesia
or conscious sedation will be provided for the oocyte retrieval
and sperm aspiration in accordance with the TPM,
Chapter 3, Section 1.1 and
1.2. For males, sperm aspiration through Microsurgical
Epididymal Sperm Aspiration (MESA), Percutaneous Epididymal Sperm Aspiration
(PESA), or non-surgical fine needle aspiration will be accomplished
in conjunction with egg retrieval. Vibratory stimulation or electro-ejaculation
may be used if appropriate for the seriously or severely ill/injured
Service member.
2.4.2.11.6.6 Intracytoplasmic
sperm injection will be accomplished for all viable oocytes.
2.4.2.11.6.7 Embryo
transfer in accordance with guidelines provided by the ASRM shall
be accomplished in accordance with specific clinic practices at
either cleavage stage or blastocyst stage of the embryo.
2.4.2.11.6.8 Healthy
embryos that progress to an appropriate stage, as assessed by the embryologist,
in excess of those used for the fresh embryo transfer may be cryopreserved.
2.4.2.11.6.9 In the
event that frozen embryos are available for transfer, TRICARE will
authorize frozen embryo transfer cycles to facilitate the utilization
of these embryos. Frozen embryo transfers may be accomplished in
fresh ovulatory cycles or in medicated transfer cycles in order
to provide the optimal uterine environment for embryo implantation.
2.4.2.11.7 Process For Participating
In Assisted Reproductive Services Program
2.4.2.11.7.1 For a Service member to be eligible, there
must be documentation of Category II or III illness or injury designation
as defined in DoDI 1300.24.
2.4.2.11.7.2 The referral to the contractor will contain the
following information:
• Service member’s qualifying
diagnosis(es);
• Category
(II or III);
• Summary
of relevant medical information supporting category designation;
• Name of provider
of reproductive services requested to be used;
• Number of initiated
IVF cycles; and
• Number of cancelled
IVF cycles.
2.4.2.11.7.3 All TED records for this benefit shall include
Enrollment/Health Plan Code “
SR SHCP - Referred Care”
regardless of the enrollment status returned by DEERS. The contractor
shall follow all applicable TED coding requirements in accordance
with TSM,
Chapter 2.
2.4.2.11.7.4 All SHCP requirements and provisions of
Chapters 16 and
17 apply to
this benefit unless changed or modified by this paragraph. The appropriate
chapter for the status of the Service member shall apply. Contractors
shall follow the requirements and provisions of these chapters,
to include MTF/eMSM or SAS referrals and authorizations, receipt
and control of claims, authorization verification, reimbursement
and payment mechanisms to providers, reimbursement specifying no cost-share,
copay, or deductible to be paid by the Service member or their lawful
spouse, and use of CMACs/DRGs when applicable.
2.4.2.11.8 Exclusions
2.4.2.11.8.1 Third party donations or surrogacy cannot be
cost-shared.
2.4.2.11.8.2 Cryopreservation
of gametes in anticipation of deployment.
2.4.2.11.8.3 Services related to gender selection will NOT
be cost-shared.
2.4.2.12 Incontinence Supplies
Personal incontinence supplies (i.e., diapers)
that support skin integrity and prevent deterioration of skin due
to incontinence are covered. Also covered are other types of incontinence supplies
such as diaper creams, bed pads, etc. that are necessary for skin
protection.