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North East CCAC Regional Approved Medical Supplies List
North East CCAC Regional Approved Medical Supplies List APRIL 01 2016 The NE CCAC Regional Medical Supplies List identifies all the CCAC-funded products available to patients. If different products are ordered, an automatic substitution policy will be initiated to provide the equivalent product approved by the CCAC as identified on the list. Table of Contents (Click on the desired section or page number): Medical supplies depot/drop-off locations 1 Wound Care Absorptives Alginates Antimicrobials & Silvers Clear Acrylic Composite Dressings Foams Hydrocolloids Hydrogel Films & Membranes Odour Absorbent Dressings Non-adherent Other & Specialty 8 8 9 10 10 11 11 12 12 12 13 13 Negative Pressure Wound Therapy (NPWT) 15 Dressings, Bandages, Compression & Wraps 17 Cleansers & Solutions 21 Feed, Ostomy, Respiratory 23 Urinary & Continence 26 IV, Needles, Syringes 31 Medical Supply Kits 37 Protective Wear 40 Miscellaneous 42 ______________________________________________________________________________ Searching the Medical Supplies Catalogue Electronically BOOKMARKS: Make sure the Navigation Pane is showing on the left hand side. If it is not press <F4> and then click on the second Navigation Pane option that looks like a ribbon. This will display the bookmarks. Click on the bookmark you want to view. PRODUCTS: Click on the Edit menu> Find> or press <Ctrl + F > and type in any word pertaining to product such as product code, description, manufacturer or manufacturer code and then press Enter. To navigate within the document, click the arrows or enter in a specific page number Please report any errors or feedback to [email protected] NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS SAULT STE. MARIE (Questions or issues call: 705-949-1808 / 1-800-668-7705 Ext: 3269) Service Depot/Drop-Off Area Location URBAN Sault Ste. Marie SSM01 Branch Office Pick-Up Location 390 Bay Street, Suite 103, Sault Ste. Marie, ON P6A 1X2 705-949-1650/800-668-7705 Fax: 705-949-3844 Availability For Regular Scheduled Pick-up* MON-FRI 8:30AM - 4:30PM Service Type CCAC Medical Supplies Infusion (IV) Equipment & Supplies URBAN SSM02 The Medicine Shoppe 316 Second Line West Sault Ste. Marie, ON P6C 2J5 705-253-7656/877-374-6938 Fax: 705-256-7656 MON-FRI 9:00AM– 6:00PM SAT 9:00AM–2:00PM Medicine Shoppe’s Infusion (IV) Equipment & Supplies URBAN SSM03 ParMed Clinic 477 Queen Street East Suite 100 Sault Ste. Marie, ON, P6A 1Z5 705-759-0110 MON-FRI 8:00AM– 8:00PM SAT-SUN 8:00AM– 8:00PM For Clinic patients only CCAC Medical Supplies RURAL SSM04 Matthews Memorial Hospital 1180 Richards Street, Richards Landing, ON P0R 1J0 705-246-2570 Orders arrive weekly on Thursdays Open 24 hrs CCAC Medical Supplies RURAL SSM05 Nugget Food Store c/o Copper Bay Shell 9153 Hwy 17 East Bruce Mines P0R 1C0 705-785-3713 RURAL SSM06 Thessalon Hospital 135 Dawson Street Thessalon, ON P0R 1L0 705-842-2014 RURAL SSM07 Pit Stop Gas Bar & Confectionary 3245 Hwy 17 East, Echo Bay, ON P0S 1C0 705-248-3333 Orders arrive weekly on CCAC Medical Supplies Fridays MON-SUN 6:00AM – 11:00PM RURAL SSM08 Goulais River Country Store 2771 Hwy 17 North Goulais River, ON P0S 1E0 705-649-3811 CCAC Medical Supplies Orders arrive weekly on Fridays MON-SUN 6:00AM -11:00PM RURAL SSM09 McCauley’s Village Store 5235 Hwy 17 North Haviland Bay, ON P0S 1E0 705-649-5813 CCAC Medical Supplies Orders arrive weekly on Fridays MON-SUN 8:30AM – 10:00PM RURAL SSM10 Elliot Lake PharmaChoice 267 Hillside Drive South Elliot Lake, ON P5A 1N7 705-848-0004 RURAL SSM11 Home Hardware 275 Imperial St Massey, ON P0P 1P0 705-865-2135 MON-THUR 8:00AM-6:00PM FRI 8:00AM-8:00PM SAT 8:00AM-5:30PM RURAL SSM12 Wawa Satellite Office 17 Government Road Wawa, ON P0S 1K0 705-856-7018 Fax: 705-856-1776 MON-FRI 8:30AM-4:30PM Orders arrive weekly on CCAC Medical Supplies Fridays MON-SUN 5:30AM – 10:00PM Orders arrive weekly on Thursdays Open 24 hrs MON-FRI 9:00AM–5:00PM SAT 9:00AM – 1:00PM CCAC Medical Supplies Robinson’s Medical Supplies & Infusion (IV) Equipment & Supplies Robinson’s Medical Supplies CCAC Medical Supplies Deliveries during extended hours: Only available for New Patients or Patient Resumes/ Hospital Discharges/End of Life Private-Pay Patient Deliveries: IN SSM PROPER $5.00, OUTLYING AREAS $6.00-20.00(STILL WITHIN CITY LIMITS), In ELLIOT LAKE & BLIND RIVER AREA - Call Robinson’s for price NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 1 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS NORTH BAY (Questions or issues call: 705-476-2220 / 1-888-533-2222 Ext: 2235) Service Depot/Drop-Off Pick-Up Location Area Location 1164 Devonshire Ave. URBAN North Bay Branch Office North Bay, ON P1B 6X7 NB01 705-476-2222 Fax: 705-474-2369 Availability For Regular Scheduled Pick-up* MON-FRI 8:30AM - 4:30PM Service Type CCAC Medical Supplies & IV Supplies URBAN NB02 VON Clinic 180 Shirreff Avenue Unit #195 North Bay, ON P1B 7K9 705-472-8050 Fax: 705-495-6691 MON-SUN 8:00AM – 8:00PM For Clinic patients only CCAC Medical Supplies URBAN NB03 Robinson’s Pharmasave 2547 Trout Lake Road North Bay, ON P1B 7S8 705-495-4515 MON-FRI 9:00AM - 6:00PM SATURDAY 9:00AM - 5:00PM SUNDAY 10:00AM - 2:00PM Robinson’s Infusion (IV) Equipment & Supplies RURAL NB04 Burks Falls Satellite Office 150 Huston Street, Suite 122 Burk's Falls, ON P0A 1C0 705-476-2222/888-533-2222 Fax: 705-382-2498 MON-FRI 8:30AM - 4:30PM CCAC Medical Supplies & Robinson’s Infusion (IV) Equipment & Supplies RURAL NB05 ParaMed Clinic 725 Coursol Road Sturgeon Falls, ON P2B 2Y6 705-753-3110 For Clinic Patients only RURAL NB06 Mattawa IDA 300 Main Street Mattawa, ON P0H 1V0 705-744-2625 MON-THUR 9:00AM – 5:30PM FRIDAY 9:00AM – 8:00PM SATURDAY 9:00AM – 5:00PM CCAC Medical Supplies & Robinson’s Infusion (IV) Equipment & Supplies RURAL NB07 South River Pharmacy 22 Marie St. South River, ON P0A 1X0 705-386-0636 MON-FRI 9:00AM – 5:30PM SATURDAY 9:00AM - 2:00PM CCAC Medical Supplies & Robinson’s Infusion (IV) Equipment & Supplies RURAL NB08 Argyle Nursing Station 11851 Hwy 522 Port Loring, ON P0H 1Y0 705-757-1717 CCAC Medical Supplies MONDAY 10:00AM – 6:00PM CCAC Medical Supplies & Robinson’s Infusion (IV) TUESDAY 8:00AM - 4:00PM WEDNESDAY 8:00AM – 8:00PM Equipment & Supplies THURSDAY 8:00AM - 4:00PM Closed daily between 12:00PM – 1:00PM as well as WEDNESDAY 4:30PM – 5:30PM 12035 Hwy #17 MON-FRI 8:00AM – 8:00PM Sturgeon Falls, ON P2B 2S6 SATURDAY 8:00AM – 6:00PM 705-753-5850 SUNDAY 9:00AM - 5:00PM RURAL NB09 Loblaws No Frills Pharmacy RURAL NB10 Glenn’s Pharmacy 496 Main St Powassan, ON 705-724-2741 MON-FRI 9:00AM – 6:00PM SATURDAY 9:00AM – 3:30PM CCAC Medical Supplies RURAL NB11 Clement’s IDA 497 Main St Powassan, ON P0H 1Z0 705-724-3523 MON-FRI 9:00AM – 6:00PM SATURDAY 9:00AM – 3:00PM Robinson’s Infusion (IV) Equipment & Supplies RURAL NB12 Caswell Resort 77 Main St. Sundridge, ON P0A 1Z0 705-384-7600 Robinson’s Medical Supplies & Infusion (IV) Equipment & Supplies MON – SUN 8:00AM – 11:00PM Robinson’s Infusion (IV) Equipment & Supplies Deliveries during extended hours: Only available for New Patients or Patient Resumes/ Hospital Discharges/End of Life Private-Pay Patient Deliveries: U-Need-A-Cab Phone: 705-497-7777 ($11 - $12 delivery charge). For Supplies and IV from Robinson’s – Call for price. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 2 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS TIMMINS (Questions or issues call: 705-267-2234/888-668-2222) Service Depot/Drop-Off Area Location URBAN Timmins Branch TIM01 Office URBAN TIM02 Bayshore Home Health Clinic Pick-Up Location 330 Second Avenue, Suite 101 Timmins, ON P4N 8A4 705-267-2234/888-668-2222 Fax: 705-267-7795 204-119 Pine Street S Timmins, ON P4N 2K3 705-268-6088/866-227-3661 Fax: 705-268-9085 URBAN/ RURAL TIM03 Bayshore Specialty Rx 70 Esna Park Drive Unit 11 Markham, ON L3R 6E7 905-474-0822/888-313-6988 RURAL TIM04 Matheson/ Iroquois Falls Satellite Office Anson General Hospital 58 Anson Drive Iroquois Falls, ON P0K 1E0 1-888-668-2222 Fax: 705-258-2296 RURAL TIM05 Bingham Hospital Bingham Hospital 507 Eight Avenue (Basement) Matheson, ON P0K 1N0 705-273-4500 RURAL TIM06 Smooth Rock Falls 101 Kelly Road Smooth Rock Falls, ON P0L 2B0 Medical 705-338-2788 Clinic Fax:705-338-2933 Availability For Regular Scheduled Pick-up* MONDAY – FRIDAY 8:30 AM – 4:30PM MONDAY – SUNDAY 8:00 AM – 8:00PM Service Type CCAC Medical Supplies CCAC Medical Supplies For clinic patients only Next day delivery from Markham Bayshore Rx IV Supplies MON 9:00AM – 5:00PM (Only if & Equipment order sent on previous Friday) TUES-FRI 9:00 AM – 5:00PM MONDAY – FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies (Bayshore Rx BodyGuard IV pump available at clinic) For clinic patients only CCAC Medical Supplies (Bayshore Rx BodyGuard IV pump available at clinic) MON 9:00AM – 4:15PM WED/TUES/THURS 9:00AM – 2:00PM FRI 9:00AM – 12:30PM CCAC Medical Supplies RURAL TIM07 Kapuskasing Satellite Office Sensenbrenner Hospital 101 Progress Crescent Kapuskasing, ON P5N 3H5 888-668-2222 Fax: 705-337-4080 MONDAY – FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies RURAL TIM08 Cochrane Satellite Office P.O Box 1750, 22E 5th Street Cochrane, ON P0L 1C0 877-513-2626 Fax: 705-272-2600 MONDAY – FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies RURAL TIM09 Hearst Satellite Office PO Box 547 1403B Edward Street Hearst ON P0L 1N0 705-362-6633 Fax: 705-362-6635 MONDAY – FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies (Bayshore Rx BodyGuard IV pump available at clinic and office). RURAL TIM10 Moosonee Satellite Office PO Box 57, 48 Revillion St. Moosonee ON, P0L 1Y0 705-336-2233 Fax: 705-336-2919 MONDAY – FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies RURAL TIM11 Honger Redwood Inn Chapleau 12 Birch St. West Chapleau, ON POM 1K0 705-864-1311 MONDAY – FRIDAY 9:00AM – 7:00PM CCAC Medical Supplies Private-Pay Patient Deliveries for CCAC Supplies: C&G delivery ($2 - $3). Note: All IV orders from Bayshore Rx are delivered directly to the patient’s treatment location NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 3 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS KIRKLAND LAKE (Questions or issues call: 705-567-2222) Ext: 7622 Service Area Depot/Drop-Off Location Pick-Up Location RURAL KL01 Kirkland Lake Branch Office 53 Government Rd W Kirkland Lake, ON P2N 2E5 705-567-2222/888-602-2222 Fax: 705-567-9407 RURAL KL02 Haileybury Satellite Office 240 Georgina Avenue, Suite 112 Haileybury, ON POJ 1KO 705-672-2222/888-602-2222 Fax: 705-672-3887 ext:7622 RURAL KL03 Findlay’s Drug Store 25-247 Whitewood Ave. New Liskeard, ON P0J 1P0 705-647-8186 RURAL KL04 Latchford Town Office RURAL KL05 RURAL KL06 Availability For Regular Scheduled Pick-up* Weekly supplies available for patient pick-up each Wednesday MONDAY - FRIDAY 8:30AM – 4:30PM Service Type CCAC Medical Supplies MONDAY - FRIDAY 8:30AM – 4:30PM CCAC Medical Supplies MON-FRI 8:00AM – 8:00PM SATURDAY 8:00AM – 5:30PM SUNDAY 10:00AM – 5:00PM CCAC Medical Supplies 10 Main St. Latchford, ON P0J 1N0 MONDAY - FRIDAY 8:30AM – 4:00PM CCAC Medical Supplies Temagami Family Health Team 17 O’Connor Dr. Temagami, ON P0H 2H0 705-569-3244 MONDAY – FRIDAY 8:30AM – 5:00PM CCAC Medical Supplies Garlin’s Gift Gallery 56 4th Ave. Englehart, ON P0J 1H0 705-544-8050 MONDAY – THURSDAY 8:00AM – 5:30PM CCAC Medical Supplies FRIDAY 8:00AM – 8:00 PM SATURDAY 8:00AM – 5:30PM RURAL KL07 J&S Variety Store 91 Pine Street Elk Lake, ON P0J 1G0 RURAL KL08 Larder Lake Co-Op RURAL KL09 MONDAY – SUNDAY 5:00AM – 11:00PM CCAC Medical Supplies 25 Godrey Street Larder Lake, ON P0K 1L0 705-643-2327 MONDAY – SATURDAY 10:00AM – 8:00PM SUNDAY 11:00AM – 4:00PM CCAC Medical Supplies Chez Lucie 1-42 Connell Ave Virginiatown, ON P0K 1X0 705-634-2228 MONDAY – SATURDAY 9:00AM – 9:00PM CCAC Medical Supplies RURAL KL10 Cote’s Variety Store 16 Tenth St. E Earlton, ON P0J 1E0 705-563-2022 MONDAY – SUNDAY 7:00AM – 10:00PM CCAC Medical Supplies RURAL KL11 Matachewan Nursing Station 1 Moyneur Ave Matachewan, ON P0K 1M0 705-565-2351 MONDAY – THURSDAY 9:00AM – 3:00PM (Closed 12:00-1:00PM) CCAC Medical Supplies FRIDAY 9:00AM-11:30PM RURAL KL12 Bayshore Specialty Rx 70 Esna Park Drive Unit 11 Markham, ON L3R 6E7 905-474-0822/888-313-6988 Next day delivery from Markham Bayshore Rx IV Supplies & Equipment MON 9:00AM – 5:00PM(Only if order sent on previous Friday) TUES-FRI 9:00 AM – 5:00PM Note: All IV orders from Bayshore Rx are delivered to the patient’s treatment location. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 4 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS SUDBURY (Questions or issues call: Robinson’s / HealthCare Pharmasave) Service Area URBAN SUD01 Depot/Drop-Off Pick-Up Location Location Health Care 1276 Lasalle Blvd. Pharmacy Sudbury, ON P3A 1Y8 Pharmasave URBAN SUD02 NE CCAC Clinic URBAN SUD03 Corner Clinic 865 Regent Sudbury, ON P3E 3Y9 344 Elgin, Sudbury, ON P3E 3N9 705-673-3721 Availability For Regular Scheduled Pick-up* MON-FRI 9:00AM-9:00PM SATURDAY 9:00AM-6:00PM SUNDAY 9:00-6:00PM Service Type Medical Supplies Infusion Equipment & Infusion Supplies MONDAY – SUNDAY 7:00AM – 10:00PM For clinic patients only Medical Supplies MON-WED 8:00AM-2:30PM THURSDAY 8:00AM-2:00PM FRIDAY 8:00AM-2:30PM Medical Supplies Infusion Equipment & Infusion Supplies Closed between 12:00-1:00PM URBAN SUD04 Daffodil Lodge 41 Ramsey Lake Rd. Sudbury, ON P3E 5J1 MONDAY – FRIDAY 9:00AM-5:00PM Medical Supplies URBAN SUD05 ICAN (Haig) 765 Brennan Road Sudbury, ON P3C 1C4 MONDAY – FRIDAY 9:00AM-5:00PM Medical Supplies URBAN SUD06 ICAN (Mont Adam) 117 Mont Adam Sudbury, ON P3B 1E1 MONDAY – FRIDAY 9:00AM-5:00PM Medical Supplies URBAN SUD07 Sudbury Maison Vale Hospice 1028 South Bay Sudbury, ON P3E 6J7 705-674-9252 MONDAY – SUNDAY 8:00AM – 6:00PM Medical Supplies URBAN SUD08 Health Sciences North 41 Ramsey Lake Rd Sudbury, ON P3E 5J1 CCAC use only - Distributed by the CCAC as required to facilitate hospital discharges only URBAN SUD09 NE CCAC Sudbury 40 Elm St. Suite 41-C Sudbury, ON P3C 1S8 705-522-3460 For CCAC clinicians use only – Not for patient pick-up Medical Supplies URBAN SUD10 Chelmsford Guardian Pharmacy 46 Main St. Chelmsford, ON P0M 1L0 705-855-2371 MON – FRI 9:00AM – 9:00PM SATURDAY 9:00AM – 5:30PM Medical Supplies URBAN SUD11 Wellness Shoppe 1769 Regent St. Sudbury, ON P3E 3Z7 705-522-9159 MON – FRI 9:30AM – 7:00PM SATURDAY 9:00AM – 5:00PM Medical Supplies URBAN SUD12 Coniston Guardian 24 Amanda St. Coniston, ON P0M 1M0 705-694-5346 MON – WED 9:00AM – 6:00PM THURS-FRI 9:00AM – 9:00PM SATURDAY 9:00AM – 5:30PM Medical Supplies URBAN SUD13 Wilson Pharmacy Pharmasave Nickel Centre Pharmacy, Pharmasave 10 Serpentine St. Copper Cliff, ON P0M 1N0 705-682-2841 3098 Falconbridge Hwy, Garson, ON P3L 1P5 705-693-2738 MONDAY – FRIDAY 9:00AM – 5:30PM Medical Supplies MON – FRI 9:00AM – 9:00PM SATURDAY 9:30AM – 5:30PM SUNDAY 11:00AM – 5:00PM Medical Supplies URBAN SUD15 Val Est Pharmacy, Pharmasave 3140 Hwy 69 N Val Caron, ON P0M 1E0 705-897-1867 MON – FRI 9:00AM – 9:00PM SATURDAY 9:30AM – 5:30PM SUNDAY 11:00AM – 4:00PM Medical Supplies URBAN SUD16 Walden Medicine Shoppe Lalonde Pharmacy 135 Regional Rd. 24 Walden Plaza 705-692-5868 23 Yonge St. Capreol, ON 705-858-1231 MON – FRI 9:00AM – 6:00PM SATURDAY 9:00AM – 5:00PM Medical Supplies URBAN SUD14 URBAN SUD17 Infusion Equipment & Infusion Supplies Medical Supplies Infusion Equipment & Infusion Supplies SUNDAY 11:00AM – 4:00PM Infusion Equipment & Infusion Supplies MON-THURS 9:00AM – 5:30PM Medical Supplies FRIDAY 9:00AM – 6:00PM SATURDAY 10:00PM – 3:00PM NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 5 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS SUDBURY (Questions or issues call: Robinson’s / HealthCare Pharmasave) Service Area URBAN SUD18 Depot/Drop-Off Pick-Up Location Location Dowling 30 Main St. Pharmacy Dowling, ON 705-855-4562 URBAN SUD19 Levack Pharmacy 2 – 1st Ave North Onaping Falls, ON 705-966-3612 RURAL SUD20 Hagar General Store 7147 Hwy 17 E, Hagar, ON 705-599-2060 RURAL SUD21 Noelville Pharmacy 27 St David N, Noelville, ON P0O 2N0 705-898-2999 RURAL SUD22 St. Charles Cooperative Store 25 Main St. St. Charles, ON 705-867-2000 RURAL SUD23 Pitfield General Store 7 Channel Killarney, ON P0M 2A0 705-287-2872 RURAL SUD24 Robinsons Pharmasave RURAL SUD25 Home Hardware 119 Tudhope Espanola, ON 705-869-1561 275 Imperial St Massey, ON P0P 1P0 705-865-2135 MON-FRI 9:00AM – 5:00PM Medical Supplies SATURDAY 10:00AM – 2:00PM Infusion Equipment & Infusion Supplies MON-THURS 8:00AM – 6:00PM Medical Supplies FRIDAY 8:00AM – 8:00PM SATURDAY 8:00AM – 5:30PM RURAL SUD26 Little Current Guardian 41 Meredith St Little Current, ON P0P 1K0 705-368-2530 MON-THURS 9:00AM – 5:30PM Medical Supplies Infusion Equipment & FRIDAY 9:00AM – 7:00PM Infusion Supplies SATURDAY 9:00AM – 5:30PM SUNDAY 11:00AM – 3:00PM RURAL SUD27 Manitowaning Pharmacy 1 Wellington Manitowaning, ON P0P 1N0 705-859-2323 RURAL SUD28 Mindemoya Pharmacy 705-377-5411 Guardian Pharmacy 11 Yonge St. Mindemoya, ON P0P 1S0 RURAL SUD29 Robertson IDA 39 Meredith Street Gore Bay, ON P0P 1H0 705-282-2147 MONDAY – SATURDAY 9:00AM – 5:30PM Medical Supplies RURAL SUD30 Central Guardian Pharmacy Meredith Street Gore Bay, ON P0P 1H0 705-282-2409 MONDAY – SATURDAY 9:00AM – 5:30PM Medical Supplies Availability For Regular Scheduled Pick-up* MON – FRI 9:00AM – 6:00PM SATURDAY 9:00AM – 5:30PM Service Type Medical Supplies MONDAY – FRIDAY 9:00AM - 5:00PM Medical Supplies MON – FRI 7:00AM – 7:00PM SATURDAY 9:00AM – 7:00PM SUNDAY 9:00AM – 5:00PM MON-THURS 9:00AM – 5:30PM FRIDAY 9:00AM – 6:00PM SATURDAY 9:00AM – 4:00PM Medical Supplies Medical Supplies Infusion Equipment & Infusion Supplies MON-THURS 8:00AM – 7:00PM Medical Supplies FRIDAY 8:00AM – 8:00PM SATURDAY 8:00AM – 7:00PM SUNDAY 8:00AM – 6:00PM MON-FRI 8:00AM – 6:00PM SATURDAY 8:00AM – 6:00PM SUNDAY 8:00AM – 6:00PM MONDAY – SATURDAY 9:00AM – 5:30PM Medical Supplies Medical Supplies MON-THURS 9:00AM – 6:00PM Medical Supplies Infusion Equipment & FRIDAY 9:00AM – 7:00PM Infusion Supplies SATURDAY 9:00AM – 6:00PM SUNDAY 11:00AM – 3:00PM Deliveries during extended hours: Only available for New Patients or Patient Resumes/ Hospital Discharges/End of Life Private-Pay Patient Deliveries: Call Robinson’s for current price. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 6 of 42 NORTH EAST CCAC MEDICAL SUPPLIES DEPOT/DROP-OFF LOCATIONS PARRY SOUND (Questions or issues call: Robinson’s / HealthCare Pharmasave) Service Depot/Drop-Off Pick-Up Location Area Location RURAL Britt Nursing Box 97 PS01 Station Parry Sound, ON P0G 1A0 705-383-2375 Availability For Regular Service Type Scheduled Pick-up* MON - THURS 8:00AM-4:00PM Medical Supplies FRIDAY 8:00AM-12:00PM RURAL PS02 Duck Rock General Store 2093 124 Hwy Dunchurch, ON P0A 1G0 705-389-3322 MONDAY – SUNDAY 8:00AM – 7:00PM Medical Supplies RURAL PS03 Lane Family Pharmasave 4 Pine Parry Sound Parry Sound, ON P2A 3B8 705-746-2187 MONDAY – SATURDAY 9:00AM – 6:00PM Medical Supplies RURAL PS04 Rosseau General Store 1 Rice Parry Sound, ON P2A 2W9 705-732-4479 RURAL PS05 NE CCAC Parry Sound Office 70 Joseph St. Parry Sound, ON P2A 2G5 705-773-4602 For CCAC clinicians use only Not for patient pick-up RURAL PS06 Parry Sound Hospital 6 Albert Street Parry Sound, ON P2A 3A4 Distributed by the CCAC as Medical Supplies required to facilitate hospital Infusion Equipment & discharges only Infusion Supplies Infusion Equipment & Infusion Supplies Winter (Sep-June) Medical Supplies MON-FRI 7:30AM – 6:00PM SATURDAY 8:00AM – 6:00PM SUNDAY 9:00AM – 4:00PM Medical Supplies Deliveries during extended hours: Only available for New Patients or Patient Resumes/ Hospital Discharges/End of Life Private-Pay Patient Deliveries: Call Robinson’s for current price. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 7 of 42 NE CCAC Regional Approved Medical Supplies List Wound Care Weekly Maximum Notes Qty Absorptives: Multi-layer wound covers that provide either a semi-adherent quality or a non-adherent layer, combined with highly absorptive layers of fibers, such as cellulose, cotton or rayon. Designed to minimize adherence to the wound and manage exudate. They may be used as a primary or secondary dressing to manage surgical incisions, lacerations, abrasions, burns, donor or skin graft sites, or any exudating wound. Mölnlycke 5" x 6" SWC-0107 Absorbent Dressing 5"x6" Mesorb 7 677201 13 x 15 cm Mölnlycke 6" x 9" SWC-0108 Absorbent Dressing 6"x9" Mesorb 7 677601 15 cm x 23 cm Mölnlycke 9" x 12" SWC-0109 Absorbent Dressing 9"x12" Mesorb 7 677801 23 x 30 cm Smith & Nephew 4" x 6" SWC-0110 Anti-Sheer Absorbent Dressing 4"x6" Exu-Dry 7 For malignant wounds or fungating wounds and burns only 5999004120 10 x 15 cm Smith & Nephew 6" x 9" SWC-0111 Anti-Sheer Absorbent Dressing 6"x9" Exu-Dry 7 For malignant wounds or fungating wounds and burns only 5999006 15 x 23 cm CCAC Code Description Brand Name Manufacturer Code Size Alginates: Non-woven, non-adhesive pads and ribbons composed of natural polysaccharide fibers or xerogel derived from seaweed. On contact with exudate these dressings form a moist gel through a process of ion exchange. They are soft and conformable, easy to pack, tuck or apply over irregular-shaped wounds. Indicated for wounds with moderate to heavy exudate, such as pressure ulcers, infected wounds, diabetic ulcers and venous insufficiency ulcers. Alginates generally require a secondary dressing. SWC-0025 Hydrofiber Dressing 4"x4" Aquacel SWC-0026 Hydrofiber Dressing 6"x6" Aquacel SWC-0106 Hydrofiber Ribbon 1"x18" Aquacel Kaltostat SWC-0036 Calcium Alginate Dressing 4"x4" Biatain NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Convatec 177902 Convatec 177903 Convatec 403770 Convatec 168212 Coloplast 3710 4" x 4" 10 x 10 cm 6" x 6" 15 x 15 cm 1" x 18" 2 x 45 cm 3" x 5" 7 x 12 cm 4" x 4" 10 x 10 cm 4 4 4 4 Either product may be provided depending on the inventory on hand 4 Page 8 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Antimicrobials & Silvers: Broad spectrum topical antimicrobials to reduce localized bacteria. Indicated to help reduce the risk of infection in partial- and full-thickness wounds, over percutaneous line sites and surgical incisions, or around tracheostomies. The ability to handle exudate depends on the characteristics and composition of the product. Does not replace systemic antibiotics for deeper tissue infections. Not to be used if known hypersensitivities to any product components. SWC-0029 Hydrofiber Silver Impregnated Dressing 4"x4" Aquacel Ag SWC-0031 Hydrofiber Silver Impregnated Dressing 8"x12" Aquacel Ag SWC-0032 Hydrofiber Silver Impregnated Ribbon 1"x18" Aquacel Ag SWC-0034 Non-adherent Antiseptic Impregnated Gauze 4"x4" Bactigras SSP-0003 Ointment with Iodine 10Gr Tube Iodasorb SDR-0078 Non-adhesive Povidone-Iodine Dressing 2"x2" SDR-0079 Non-adhesive Povidone-Iodine Dressing 3.7"x3.7" SWC-0112 Antimicrobial Gauze Sponges 12 Ply 4"x4" SWC-0113 Antimicrobial Rolled Gauze Roll 6 Ply SWC-0115 Antimicrobial Packing Strips 1/4" x 1 yard SWC-0116 Antimicrobial Packing Strips 1/2" x 1 yard SWC-0117 Antimicrobial Packing Strips 1" x 1 yard SWC-0118 Gentian Violet Antibacterial Dressing 4"x4" SWC-0137 Gentian Violet Antibacterial Dressing 6"x6" SWC-0138 Gentian Violet Antibacterial Tunneling Dressing SWC-0119 Silver Antimicrobial Barrier Dressing Non-Absorbent 4"x4" Convatec 403708 Convatec 403711 Convatec 403771 Smith & Nephew 66003650 4" x 4" 10 x 10 cm 8" x 12" 19 x 29 cm 1" x 18" 2 x 45 cm 4" x 4" 10 x 10 cm Smith & Nephew 66060630 10 Gram Tube Systagenix P01481 Systagenix Inadine P01512 Covidien Curity AMD 2533 Covidien Kerlix AMD 3332 Covidien Curity AMD 7831AMD Covidien Curity AMD 7832AMD Covidien Curity AMD 7833AMD Hollister Hydrofera Blue HB4414 Hollister Hydrofera Blue HB6614 Hollister Hydrofera Blue HBT0906 Acticoat Smith & Nephew Flex 3 66800399 Inadine NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 2" x 2" 5 x 5 cm 3.75 x 3.75" 9.5 x 9.5 cm 4" x 4" 10 x 10cm 4.5" x 4 1/8 yd 11.4cm x 3.7m 1/4" x 3' 0.6 x 91.4 cm 1/2" x 3' 1.3 x 91.4 cm 1" x 3' 2.5 x 91.4 cm 4" x 4" 10 x 10 cm 6" x 6" 15 x 15 cm 9 mm (Pack of 2) 4" x 4" 10 x 10cm 4 4 4 4 For adjunctive treatment and prevention of infection in skin loss lesions, including wounds, burns and ulcers 1 Should not be used in patients with known or suspected Iodine sensitivity, history of any thyroid disorder, or pregnant or lactating women 3 10% Povidone Iodine; equivalent to 1.0% available iodine 3 10% Povidone Iodine; equivalent to 1.0% available iodine 7 Impregnated with 0.2% PHMB 7 Impregnated with 0.2% PHMB 7 Impregnated with 0.2% PHMB 7 Impregnated with 0.2% PHMB 7 Impregnated with 0.2% PHMB 3 Non-border, Sterile 3 Non-border, Sterile 3 Sterile 3 Not compatible with oil-based products, such as petrolatum Page 9 of 42 CCAC Code Description Brand Name SWC-0120 Silver-Coated Antimicrobial Calcium Alginate Absorbent Dressing 4"x5" Acticoat Absorbent SWC-0131 Antimicrobial Gel with Silver 0.25 oz SilvaSorb SWC-0132 Antimicrobial Gel with Silver 1.5 oz SilvaSorb SWC-0133 Textile Antimicrobial Silver 10”x36” InterDry AG SWC-0134 Textile Antimicrobial Silver (Custom size) InterDry AG Manufacturer Code Smith & Nephew 20381 Medline MSC93025EP Medline MSC9301EP Coloplast 7912 Coloplast 7910 Size Weekly Maximum Qty 4" x 5" 10 x 12.5 cm 3 0.25 oz Tube Notes As required For clinic patients only 1.5 oz Tube 1 Community patients 10" x 36" 1 If larger than 36" required, order custom size 10" x Custom 4 Custom order per 12" lengths Composite Dressings: Multilayered, combination dressings to provide multiple functions, such as a bacterial barrier, absorption and adhesion. Usually, they are comprised of multiple layers and incorporate a semi- or non-adherent pad that covers the wound. Some are appropriate for autolysis. May also include an adhesive border of non-woven fabric tape or transparent film. Composite dressings can function as either a primary or a secondary dressing on a wide variety of wounds and may be used with topical medications. Use with wounds that have moderate to large amounts of exudate. SVS-0008 Non-Elastic Zinc Paste Bandage Viscopaste SWC-0090 Protease inhibitor dressing with Collagen (‡) Promogran Smith & Nephew 4948 Systagenix M772028 7.5 cm x 6 m 2 28 cm2 Hexagonal 2 Woven cloth impregnated with a paste containing 10 % Zinc Oxide BP rolled onto a plastic core Contraindicated for: • Malignant wounds • Eschar in wounds • Untreated Wound Infection • Wounds less than 12 weeks old • Diabetic Ulcer not offloaded/uncontrolled diabetes – HbA1C more than 7.9% • Pressure Ulcer not offloaded • Extensive burns • Hypersensitivity • Acute vasculitis • Venous Ulcer not in a compression system of at least 20mmHg Protease Inhibitor should be discontinued if there is no progression towards wound healing (less than 10% healing in 3 weeks). Clear Acrylic: Transparent film contact layer and clear, acrylic polymer pad, topped with breathable, waterproof film. Enables clinicians to monitor small to moderately exuding wounds without changing the dressing • Supports autolytic debridement • Extended wear time • Skin graft donor sites • Skin tears and pre-tibial lacerations • Post-operative wounds • First (superficial thickness) and second (partial thickness) degree burns and abrasions • Do not cut acrylic pad SWC-0139 Absorbent Clear Acrylic Small Oval 7.6x9.5cm Tegaderm SWC-0140 Absorbent Clear Acrylic Medium Oval 11x12cm Tegaderm NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 3M 90800 3M 90801 3 in. x 3-3/4 in. 7.6 x 9.5 cm 4-3/8 in. x 5 in. 11.1 x 12.7 cm 1 1 For pressure ulcers, skin tears and other low to moderately exuding wounds. Dressing should overlap the wound margins by at least 3/8" (1 cm). Page 10 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Foams: Foam dressings are sheets and other shapes of foamed polymer solutions (most commonly polyurethane) with small, open cells capable of holding fluids. They may be impregnated or layered in combination with other materials. Absorption capability depends on thickness and composition. The area in contact with the wound surface is non-adhesive for easy removal. Available with an adhesive border and/or a transparent film coating that acts as a bacterial barrier. Indicated for partial- and full-thickness wounds. Used on lightly- to heavily-exudating wounds, depending on product. Occlusive foams without silver should not be used on infected wounds. SWC-0099 Foam Non-Adhesive Regular or similar 4"x4" Mepilex XT SWC-0100 Foam Non-Adhesive Regular or similar 8"x8" Mepilex XT SWC-0101 Foam Non-Adhesive Lite or similar 6"x6" Mepilex Lite SWC-0102 Foam Adhesive Regular or similar 3"x3" Mepilex Border SWC-0103 Foam Adhesive Regular or similar 4"x4" Mepilex Border SWC-0104 Foam Adhesive Regular or similar 6"x6" Mepilex Border SWC-0105 Foam Adhesive Lite or similar 6"x6" Mepilex Border Lite SWC-0129 Foam Non-Adhesive with Ibuprofen 4"x4" Biatain IBU SWC-0130 Foam Non-Adhesive with Ibuprofen 6"x6" Biatain IBU Mölnlycke 211100 Mölnlycke 211400 Mölnlycke 284300 Mölnlycke 295200 Mölnlycke 295300 Mölnlycke 295400 Mölnlycke 281300 Coloplast 4110 Coloplast 4115 4" x 4" 10 x 10 cm 8" x 8" 20 x 20 cm 6" x 6" 15 x 15 cm 3 "x 3" 7.5 x 7.5 cm 4" x 4" 10 x 10 cm 6" x 6" 15 x 15 cm 4" x 4" 10 x 10 cm 4" x 4" 10 x 10 cm 6" x 6" 15 x 15 cm 4 4 4 4 4 4 4 4 4 Hydrocolloids: Wafers, powders or pastes composed of gelatin, pectin or carboxymethylcellulose. Moisture-retentive dressing, contributes to autolytic debridement. Creates occlusive barrier against bacterial invasion. Absorption capability depends on thickness and composition. Useful on areas that require contouring, such as heels and sacral ulcers. Powders and pastes require a secondary dressing. Indicated for partial- and full-thickness wounds with or without necrotic tissue. Characteristic odour may accompany dressing change and should not be confused with infection. Caution when used on fragile skin and should not be used on heavily draining or infected wounds. SWC-0045 Hydrocolloid Thin 4x4" Tegaderm SWC-0047 Hydrocolloid Thin Oval With Border 10x12cm Tegaderm SWC-0048 Hydrocolloid Thin Oval With Border 13x15cm Tegaderm SWC-0051 Hydrocolloid Regular 4x4" Tegaderm SWC-0052 Hydrocolloid Regular 6x6" Tegaderm NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 3M 90022 3M 90021 3M 90023 3M 90002 3M 90005 4" x 4" 10 x 10 cm 4" x 4.75" 10 x 12 cm 5.25" x 6" 13 x 15 cm 4" x 4" 10 x 10 cm 6" x 6" 15 x 15 cm 3 3 3 3 3 Page 11 of 42 CCAC Code Description Brand Name SWC-0053 Hydrocolloid Regular With Border 10x12cm Tegaderm SWC-0055 Hydrocolloid Regular With Border 17x20cm Tegaderm SWC-0056 Hydrocolloid Sacral Tegaderm SWC-0080 Hydrocolloid Regular 8"x8" Duoderm CGF Manufacturer Code Size 3M 90001 3M 90004 3M 90007 Convatec 187662 4" x 4.75" 10 x 12 cm 6.75" x 7.75" 17 x 20 cm 6 3/4" x 6 3/8" 17 cm x 16 cm 8"x8" 18.9 x 18.9cm Weekly Maximum Qty Notes 3 3 3 3 Hydrogel: Polymers with high water content designed to absorb a small amount of exudate, prevent drying of the wound bed and maintain a moist healing environment. The high moisture content serves to rehydrate wound tissue. Available in gels, solid sheets or embedded into gauze. Can decrease pain. Indicated for partial and full-thickness wounds, wounds with necrosis, minor burns and radiation tissue damage. May require a secondary dressing. Solid sheets should not be used on infected wounds. SWC-0023 Hydrogel (Low Pectin, Low Saline) Intrasite Gel Smith & Nephew 7311 15 g 3 Films & Membranes: Transparent film dressings are polymer membranes of varying thickness coated on one side with an adhesive. They are impermeable to liquid, water and bacteria but permeable to moisture vapor and atmospheric gases. Moisture vapour transmission rate (MVTR) varies from film to film. Can help reduce friction to susceptible skin (e.g. heels). Transparency allows visualization of the wound. Indicated for partial-thickness wounds with little or no exudate, wounds with necrosis, and as both a primary or secondary dressing. Also used to cover IV sites, donor sites, lacerations, abrasions and second-degree burns. Available in a wide variety of sizes, both sterile and in bulk. Should not be used on draining or infected wounds. SWC-0072 Transparent Film Dressing 10x12cm Tegaderm SWC-0128 Transparent Film Dressing 15x20cm Tegaderm 3M 1626W 3M 1628 4" x 4.75" 10 x 12 cm 6" x 8" 15 x 20 cm 3 3 Odour Absorbent Dressings: Odour absorbent charcoal contained within product that masks the odour. Ensure that dressing edges are sealed to control odour and treat the cause if possible. SWC-0037 Activated Charcoal Dressing with Silver 4"x4" SWC-0135 Activated Charcoal Dressing with Silver 2.5 x 3.75" SWC-0136 Activated Charcoal Dressing with Silver 4" x 7.5" Actisorb Plus Silver 220 Actisorb Plus Silver 220 Actisorb Plus Silver 220 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 KCI Systagenix MAS105 KCI Systagenix MAS065 KCI Systagenix MAS190 4" x 4" 10.5 x 10.5 cm 2.5" x 3.75" 6.5 x 9.5 cm 4" x 7.5" 10.5 x 19 cm 2 2 Silver is not released into the wound, so can be use on silver-sensitive patients. Remains effective to reduce odour when wet or dry and can be left in place for up to 7 days. NOTE: This product should not be cut 2 Page 12 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Non-adherent: Porous sheets of dressings with low adherence to tissue. Serves as a contact layer that allows the transfer of exudate to secondary dressing. May be composed of silicone or tulles. Facilitates application of topical preparations. Use with wounds that are painful or friable. May require a secondary dressing. SWC-0003 Non Adherent Sterile Impregnated Gauze 3"x3" Adaptic SWC-0076 Non Adherent Sterile Impregnated Gauze 3"x8" Adaptic SWC-0081 Non Adherent Sterile Silicone Dressing 2"x3" Mepitel SWC-0086 Non Adherent Sterile Impregnated Gauze 4"x4" Jelonet Systagenix 2012 Systagenix 2015 Mölnlycke 290510 Smith & Nephew 7404 3" x 3" 7.6 x 7.6 cm 3" x 8" 7.6 x 20.3 cm 2"x 3" 5 x 7.5 cm 4"x4" 10 x 10 cm 4 7 3 4 Other & Specialty SCM-0019 Blue Absorbent Pads 24cm x 26cm Each 1/Visit In-Home: 1 per Week Sharp/Blunt Clinic: 1 / Visit In-Home: 3 per Week Clinic: 1 / Visit SDR-0011 Sterile Single Use Scissors MED-Rx CHS 85-4202 SDR-0012 Sterile Plastic Thumb Forceps MED-Rx CHS 85-4200 SDR-0024 Suture Removal Kit Each 1 SDR-0025 Staple Remover Each 1 SDR-0062 Wound irrigation tip for syringe MED-RX 1 Tip 7 SDR-0080 Tissue Forceps Metal Sterile Disposable MED-Rx 1 x 2 teeth 4-3/4" 1/Visit SDR-0081 Curved Iris Scissors Sterile MED-Rx 4 1/2" 1/Visit SMK-0042 Initial Wound Care Kit SWC-0059 Wound Culture Swab MED-RX 20-1104 CHS 85-9000 CHS 85-9411 4 1/2" Each 1 Various NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Each Authorized for clinic patients for containment of drainage or for methotrexate administration in home/clinic ONLY. Approved clinics may order in bulk. Single use. Syringe must be ordered separately For sharp/surgical debridement and should only be performed by clinicians with this expertise. For sharp/surgical debridement and should only be performed by clinicians with this expertise See Medical Supply Kits for description 1 Page 13 of 42 CCAC Code Description Brand Name SWC-0064 Single Use Safety Scalpel - Size 10 Miltex SWC-0066 Flexible Silver Nitrate Caustic 6" Applicator Stick AMG SWC-0141 Flexible Silver Nitrate Applicator Stick AMG SWC-0121 Protective Barrier Wipe SWC-0122 Dermal Curette with 4mm tip SDR-0006 Cotton Tipped Applicator Plastic Sterile 2/pk SDR-0010 Sterile Tongue Depressor SWC-0123 Minor Laceration Tray Kit - Sterile Manufacturer Code Integra 4-510 AMG Medical 118-395 AMG Medical 118-395 Size Weekly Maximum Qty Notes Size 10 3 Sharp/surgical debridement should only be performed by clinicians with this expertise. Each 3 Silver Nitrate 75%, Potassium Nitrate 25% Pack of 100 1 For approved ETs nurses and clinic bulk orders only. Skin-Prep Smith & Nephew 59420425 Each 3 Helps reduce friction during removal of tapes and films. Can also be used to prepare skin attachment sites for drainage tubes, external catheters, surrounding ostomy sites and adhesive dressings. Miltex Integra 33-54 Each 1 For sharp/surgical debridement and should only be performed by clinicians with this expertise. Medline MDS202095 1 Pack of 2 7 AMG Medical 118-425 Adult 3 Adult size Individually wrapped, single patient use. Busse Cardinal Health 312-751 Each 1 See Medical Supply Kits for description NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 14 of 42 NE CCAC Regional Approved Medical Supplies List Negative Pressure Wound Therapy (NPWT) CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Negative Pressure Wound Therapy (NPWT): A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds. The therapy involves the controlled application of subatmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump (pump rental required in addtion to the dressings). SNP-0001 VAC Adhesive Drape V.A.C. SNP-0007 T.R.A.C. Y Connector V.A.C. SNP-0008 VAC GranuFoam Standard Dressing Kit Small V.A.C. SNP-0009 VAC GranuFoam Standard Dressing Kit Medium V.A.C. SNP-0010 VAC GranuFoam Standard Dressing Kit Large V.A.C. Special Order Only (SYY) VAC GranuFoam Standard Dressing Kit XL V.A.C. SNP-0017 VAC GranuFoam Silver Dressing Kit Small V.A.C. SNP-0018 VAC Granufoam Silver Dressing Kit Medium V.A.C. SNP-0019 VAC Granufoam Silver Dressing Kit Large V.A.C. SNP-0020 VAC WhiteFoam Dressing Kit Small V.A.C. SNP-0022 VAC WhiteFoam Dressing Kit Large V.A.C. SNP-0058 VAC WhiteFoam Small (Foam Only) V.A.C. SNP-0059 VAC WhiteFoam Large (Foam Only) V.A.C. SNP-0046 VAC Simplace Dressing Kit Small V.A.C. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 KCI M6275009 KCI M6275066 KCI M8275051 KCI M8275052 KCI M8275053 KCI M8275065 KCI M8275098 KCI M8275096 KCI M8275099 KCI M8275068 KCI M8275067 KCI M6275033 KCI M6275034 KCI M8275041 30.5 x 26 cm 1 Each 3 10 x 7.5 x 3.3 cm 3 18 x 12.5 x 3.3 cm 3 26 x 15 x 3.3 cm 3 60 x 30 x 1.5 cm 3 10 x 7.5 x 3.3 cm 3 18 x 12.5 x 3.3 cm 3 26 x 15 x 3.3 cm 3 10 x 7.5 x 1 cm 3 10 x 15 x 1 cm 3 10 x 7.5 x 1 cm 3 1 polyvinyl alcohol (PVA) foam dressing (10 x 7.5 x 1 cm) 10 x 15 x 1 cm 3 1 polyvinyl alcohol (PVA) foam dressing (10 x 15 x 1 cm) Each 3 Includes 1 small Spiral-cut VAC GranuFoam Dressing, 2 adhesive drapes, 1 SensaT.R.A.C. Pad Y-connector to connect two or more dressings Includes 1 small black foam dressing, 1 adhesive drape,1 SensaTRAC Pad Includes 1 medium black foam dressing, 2 adhesive drapes,1 SensaTRAC Pad Includes 1 large black foam dressing, 2 adhesive drapes,1 SensaTRAC Pad Includes 1 large black foam dressing, 5 adhesive drapes,1 SensaTRAC Pad Includes 1 small silver foam dressing, 1 adhesive drape,1 SensaTRAC Pad Includes 1 medium silver foam dressing, 2 adhesive drapes,1 SensaTRAC Pad Includes 1 large silver foam dressing, 2 adhesive drapes,1 SensaTRAC Pad Less adherent material helps promote graft take. Includes 1 small PVA foam dressing, 1 adhesive drape, 1 SensaT.R.A.C. Pad Less adherent material helps promote graft take. Includes 1 large PVA foam dressing,1 adhesive drape, 1 SensaT.R.A.C. Pad Page 15 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Negative Pressure Wound Therapy (NPWT): A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds. The therapy involves the controlled application of subatmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump (pump rental required in addtion to the dressings). SNP-0048 VAC Simplace Dressing Kit Medium V.A.C. SNP-0052 300 mL ActiVAC Canister with Gel V.A.C. SNP-0060 VAC SensaT.R.A.C. Pad V.A.C. SNP-0061 T.R.A.C Tubing Cap V.A.C. VAC GranuFoam Bridge Dressing Kit V.A.C. VAC GranuFoam Bridge XG Dressing Kit V.A.C. SWC-0124 Single Use Negative Pressure System 4x8" PICO SWC-0125 Single Use Negative Pressure System 4x12" PICO Special Order Only (SYY) Single Use Negative Pressure System 4x16" PICO SWC-0126 Single Use Negative Pressure System 6x8" PICO SWC-0127 Single Use Negative Pressure System 6x6" PICO Single Use Negative Pressure System 6x12" Special Order Only (SYY) Special Order Only (SYY) Special Order Only (SYY) Special Order Only (SYY) Special Order Only (SYY) KCI M8275040 KCI M8275058 KCI M8275057 KCI M6275069 Includes 1 medium Spiral-cut VAC GranuFoam Dressing, 2 adhesive drapes, 1 SensaT.R.A.C. Pad 1 canister with gel, tubing, clamp and connector; May be authorized for more than 1/week if the canister is full. Each 3 Each 1 Each 1 Includes 1 SensaT.R.A.C. Pad with tubing, clamp and connector Each 1 Cap to secure end of tubing when not in use KCI M8275042 Each 3 Each kit includes black foam, bridge dressing; sensa TRAC pad and adhesive drape KCI M8275044 Each 3 Each kit includes black foam, bridge dressing; sensa TRAC pad and adhesive drape Smith & Nephew 66800951 Smith & Nephew 66800952 4" x 8" 10 x 20 cm 4" x 12" 10 x 30 cm Smith & Nephew 66800953 4" x 16" 15 x 20 cm Smith & Nephew 66800955 Smith & Nephew 66800954 6" x 8" 15 x 20 cm 6" x 6" 15 x 15 cm PICO Smith & Nephew 66800956 6" x 12" 15 x 30 cm 1 Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Single Use Negative Pressure System 8x8" PICO Smith & Nephew 66800957 8" x 8" 20 x 20 cm 1 Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Single Use Negative Pressure System 10x10" PICO Smith & Nephew 66800958 10" x 10" 25 x 25 cm 1 Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 1 1 1 1 1 Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Each kit contains 2 units. Dressings may be left in place for up to seven days depending on the amount of fluid from the wound. Page 16 of 42 NE CCAC Regional Approved Medical Supplies List Tape, Dressings, Bandages, Compression & Wraps CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Dressings, Bandages, Compression & Wraps: Materials that are dry woven or non-woven and may stretch and conform to body contours. Fabric composition may include cotton, polyester, rayon or nylon. They function for cleansing, packing or to provide absorption as a second layer or dressing, to hold a wound cover in place, to apply pressure or to cushion a wound. Some are sterile or non-sterile in bulk and may be adhesive. Other uses include securing IVs and splints and providing mild compression/support for strains, sprains and edema. SDR-0086 White Surgical Tape 1" Single Use Roll SDR-0087 Blue Silicone Tape 1" Single Use Roll SDR-0037 Wound Closure Strip 1/2" (6 strips) Sterile SDR-0038 Wound Closure Strip 1/4" (3 strips) Sterile SDR-0039 Non Allergenic Self Adhesive Surgical Tape 2" SDR-0040 Non Allergenic Self Adhesive Surgical Tape 4" SDR-0048 Montgomery Straps and Ties SDR-0017 Sterile Packing Plain 1/4" (Bottle) SDR-0018 Sterile Packing Plain 1/2" (Bottle) SDR-0019 Sterile Packing Plain 1" (Bottle) SDR-0088 Sterile Gauze Packing Cotton Single Use 1/4" SDR-0089 Sterile Gauze Packing Cotton Single Use 1/2" SDR-0090 Sterile Gauze Packing Cotton Single Use 2" SDR-0020 Sterile 2" Small Woven Gauze Roll for Packing Transpore White 3M 1534S-1 3M Kind Removal 2770S-1 3M Steri-Strip R1547 3M Steri-Strip R1541 Derma Sciences Ultrafix DUP62036 Derma Sciences Ultrafix DUP62037 Derma Sciences Montgomery DUP97991 Derma Sciences PAK-ITS DUP59120 Derma Sciences PAK-ITS DUP59220 Derma Sciences PAK-ITS DUP59320 Derma Sciences PAK-ITS DUP561036 Derma Sciences PAK-ITS DUP4853 Derma Sciences PAK-ITS DUP4856 Derma Sciences Gazetex DUP9321 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 1" x 1-1/2 yard 2.5 cm x 1.3 m 1" x 54" 2.5 cm x 1.3m 1/2" x 4" 12 x 100 mm 1/4" x 3" 6 x 75 mm 2" x 1 yrd 5 cm x 1 m 4" x 1 yrd 10 cm x 1 m 18 cm x 28 cm 1/4" x 5 yards 0.635cm x 4.5m 1/2" x 5 yards 1.27cm x 4.5m 1" x 5 yards 2.54 cm x 4.5m 1/4" x 36" 0.635cm x 90cm 1/2" x 54" 1.3 cm x 137cm 2" x 54" 5 cm x 137 cm 2-1/4" x 3 yards 5.7 cm x 2.7 m 1 Universal hypoallergenic tape can be used for all applications 1 Only order for patients with very fragile at risk skin who react to Transpore White SDR-0086 2 2 7m 7m A non-sterile and non-woven fixative tape that is breathable and gentle to the skin. Custom cut by metre lengths A non-sterile and non-woven fixative tape that is breathable and gentle to the skin. Custom cut by metre lengths 1 2 2 2 Single-ply ribbon gauze strips that can be used dry to absorb drainage in exuding wounds or soaked with a medication of choice. A secondary dressing is needed to hold the strips in place and to protect the wound from outside contaminants. (Bottles not for use at clinic - See single use packs below). 3 3 3 7 100% Cotton, 6 Ply; Page 17 of 42 CCAC Code Description Brand Name Manufacturer Code Derma Sciences DUP9322 Derma Sciences DUP564036 Derma Sciences DUP4869 SDR-0021 Sterile 4" Large Woven Gauze Roll for Packing Gazetex SDR-0022 Sterile Gauze Packing Cotton 2x36" PAK-ITS SDR-0023 Sterile Gauze Packing Cotton Fan Folded 2x72" PAK-ITS SDR-0001 Abdominal Pad Sterile 5"x9" Medline NON21450 SDR-0002 Abdominal Pad Sterile 8"x10" Medline NON21454 SDR-0003 Gauze Sterile Woven 2"x2" AMD SDR-0004 Gauze Sterile Woven 4"x4" AMD SDR-0055 Drain Gauze Sponge Tracheostomy Sterile Woven 4"x4" AMD SDR-0058 Drain Sponge Sterile Non-woven 4"x4" AMD SDR-0064 Gauze Sterile Non-Woven 2"x2" AMD SDR-0065 Gauze Sterile Non-Woven 4"x4" AMD SDR-0076 Gauze Non-Sterile Non-Woven 4"x4" AMD SDR-0013 Oval Eye Pad Non-woven Sterile Surecare SDR-0007 Conforming Bandage Wrap Non-Sterile 2" (Roll) Duform SDR-0008 Conforming Bandage Wrap Non-Sterile 4" (Roll) Duform SDR-0060 Conforming Bandage Non-Sterile 4" (Roll) Dutex SDR-0027 Tubular Net Elastic Bandage - Fingers/Toes/Small Wrist SDR-0083 Tubular Net Elastic Bandage - Wrist & Elbow Medline Elastic Net Medline Elastic Net NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 AMD-Ritemed A2120 AMD-Ritemed A4800 AMD-Ritemed A4412T AMD-Ritemed A9210 AMD-Ritemed A2240 AMD-Ritemed A4440 AMD-Ritmed A2100-CH Derma Sciences DUP82911 Derma Sciences DUP75102 Derma Sciences DUP75104 Derma Sciences DUP76783 NONNET02 NONNET03 Size 4-1/2" x 4 yards 11.4 cm x 3.7m 2" x 36" 5 cm x 90 cm 2" x 72" 5 cm x 182 cm 5" x 9" 12.7 x 22.8 cm 8" x 10" 20 x 25 cm 2" x 2" 5 x 5 cm 4" x 4" 10 x 10cm 4" x 4" 10 x 10cm 4" x 4" 10 x 10cm 2" x 2" 5 x 5 cm 4" x 4" 10 x 10cm 4" x 4" 10.2 x 10.2 cm 1-5/8" x 2-5/8" 4 x 6.5 cm 2" x 4.1 yards 5 cm x 3.75 m 4" x 4.1 yards 10 cm X 3.75 m 4" x 4.1 yards 10 cm X 3.75 m 7 2/3" 19.5 cm 9 1/3" 23.7 cm Weekly Maximum Qty 7 Notes Used for wrapping or packing large deep wounds 3 3 7 7 28 Cotton, 12 Ply, Pack of 2 28 Cotton, 8 Ply, Pack of 2 14 7 Cotton, 12 Ply, Pack of 1 Pre-cut notches for use with IV lines, picc lines, drain tubes etc. Synthetic, 6 Ply, Pack of 2 Pre-cut notches for use with IV lines, picc lines, drain tubes etc. 25 Synthetic, 4 Ply, Pack of 2 25 Synthetic, 4 Ply, Pack of 3 1 Pack of 200 Synthetic, 4 Ply 7 7 Synthetic knitted stretch bandage ideal as a secondary dressing 7 7 2 2 Cotton, 2 ply woven bandage ideal as a secondary dressing (nonstretch) Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Page 18 of 42 CCAC Code Description Brand Name Medline Elastic Net Medline Elastic Net Medline Elastic Net Medline Elastic Net Medline Elastic Net Medline Elastic Net Medline Elastic Net Manufacturer Code Size 11 2/3" 29.6 cm 12 3/8" 31.4 cm 17" 61 cm 28 2/3" 72.8 cm 31 1/3" 79.6 cm 35" 88.9 cm 41" 93.1 cm 16 - 20cm L x 6.6 - 7.2 cm W 20 - 24 cm L x 7.3 - 7.9 cm W 24 - 28 cm L x 8.7 - 9.2 cm W 28 - 36 cm L x 9.7-10.3 cm W 36-46 cm L x 11.3-12.7 cm W Weekly Maximum Qty SDR-0028 Tubular Net Elastic Bandage - Elbow & Arm SDR-0029 Tubular Net Elastic Bandage - Knee & Thigh SDR-0084 Tubular Net Elastic Bandage - Shoulder Hip Thigh SDR-0030 Tubular Net Elastic Bandage - Chest Back Perineum Axilla SDR-0085 Tubular Net Elastic Bandage - Chest Region Large SYY-0687 Tubular Net Elastic Bandage - Chest Region XL SYY-0688 Tubular Net Elastic Bandage - Chest Region XXL SDR-0068 Multipurpose Tubular Elastic Bandage Size C Tubigrip SDR-0069 Multipurpose Tubular Elastic Bandage Size D Tubigrip SDR-0070 Multipurpose Tubular Elastic Bandage Size E Tubigrip SDR-0071 Multipurpose Tubular Elastic Bandage Size F Tubigrip SDR-0072 Multipurpose Tubular Elastic Bandage Size G Tubigrip SCM-0003 Mesh Pants XL Each 1 SCM-0004 Mesh Pants Large Each 1 SCM-0005 Mesh Pants Medium Each 1 SCM-0006 Mesh Pants Small Each 1 SCM-0017 Mesh Pants XXL Each 1 SVS-0003 High Stretch Elastic Stretch Bandage Non-Latex 4" 4" x 5 yards 1* Dusor NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 NONNET04 NONNET05 NONNET06 NONNET07 NONNET08 NONNET09 NONNET10 Mölnlycke 1443 Mölnlycke 1437 Mölnlycke 1434 Mölnlycke 1438 Mölnlycke 1439 Derma Sciences DUP71414LF 2 2 2 2 2 2 2 2 2 2 2 Notes Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Special Order SYY only Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Special Order SYY only - Limb sizes C through G available. Other sizes may available only as an exception item special order with approval. Sizes intended as a guideline only and should be used in conjunction with existing clinical protocols that consider physiological state and wound and skin condition. - Each box is 10 m. If unsure of size, order a 1 metre sample length - If overlapped, applies pressure of 10-15 mm Hg - Can be washed (gentle cycle & air dry) and reused multiple times 2 Mesh pants are only authorized only for patients requiring this product as a means of containing wound care dressings to coccyx, perineal area, etc. *May order 2 for initial order only. Non-Sterile Page 19 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Derma Sciences DUP71416LF 6" x 5 yards 1* *May order 2 for initial order only. Non-Sterile Notes SVS-0004 High Stretch Elastic Stretch Bandage Non Latex 6" Dusor SVS-0006 2 Layer Compression System - 35-40mmHg Coban 2 3M 2094N Each 2 2 Rolls - Comfort layer and compression layer. Ideal for majority of patients with venous leg ulcers, lymphedema and other conditions where compression bandage therapy is appropriate. SVS-0007 2 Layer Compression System - 25-30 mmHg Coban 2 Lite 3M 2794N Each 2 2 Rolls - Comfort layer and compression layer. Designed to be more comfortable for patients less tolerant of compression bandages. NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 20 of 42 NE CCAC Regional Approved Medical Supplies List Cleansers & Solutions CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Cleansers SSO-0001 Chlorhexidine 500mL 2% 500 mL 1 SSO-0002 Hydrogen Peroxide 3% 500mL 500 mL 1 SSO-0004 Povidone Iodine 1% 100mL bottle 100 mL 2 SSO-0006 Chlorhexidine Swabsticks with alcohol Each 8 SSO-0019 Normal Saline 500cc bottle (‡) 500 cc 1 SSO-0023 Normal Saline 118cc Irrigation Bottle Sterile 118 cc 7 SSO-0031 Sterile Water 500cc bottle (‡) 500 cc 1 SSO-0052 Alcohol Wipe Each 28 SSO-0053 Benzalkonium Chloride Wipe Each 28 SSO-0063 Chlorhexidine Wipe (Alcohol Free) Solu-I.V. Each 28 SSO-0054 Povidone Iodine Wipe Betadine Each 3 SSO-0067 Povidone Iodine Swabstick (Single) Betadine Each 8 SSO-0068 Povidone Iodine Swabstick (3 pack) Betadine Each 3 SSO-0011 Hygeol 1:20 500 mL (‡) Betadine Baxter (‡) Derma Baxter NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Baxter JF7633 Derma Sciences DUP48501N Baxter JF7624 3M S10108 500 mL Contraindicated for: • Malignant Wounds • Exposed Bone • Exposed Tendon • Patient with Extensive Burns • Hypersensitivity to iodine (Hyperthyroidism) The items are approved only for: 1) Immunocomprimised patient (i.e. BMT, Oncology, Organ Transplant patient); 2) Well water (untreated) or 3) Environmental considerations (i.e. concerns of hygiene) 7 per 2 wks Maximum 14/patient Page 21 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty BD 306572 10 cc 14 Notes Solutions SSO-0021 Normal Saline 10cc Pre-Filled Syringe PosiFlush SSO-0024 Normal Saline IV 100cc Bag 100 cc 7 SSO-0025 Normal Saline IV 250cc Bag 250 cc 7 SSO-0026 Normal Saline IV 500cc Bag 500 cc 7 SSO-0027 Normal Saline IV 1000cc Bag 1000 cc 7 SSO-0029 Normal Saline 10cc Vial 10 cc 7 SSO-0032 Sterile Water 10cc Vial 10 cc 7 SSO-0033 Dextrose 3%/0.3 saline IV 500cc Bag 500 cc 7 SSO-0034 Dextrose 3%/0.3 saline IV 1000cc Bag 1000 cc 7 SSO-0037 Dextrose 5% IV 50cc Bag 50 cc 7 SSO-0038 Dextrose 5% IV 100cc Bag 100 cc 7 SSO-0040 Dextrose 5% IV 500cc Bag 500 cc 7 SSO-0041 Dextrose 5% IV 1000cc Bag 1000 cc 7 SSO-0045 Ringers Lactate IV 500cc Bag 500 cc 7 SSO-0046 Ringers Lactate IV 1000cc Bag 1000 cc 7 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 22 of 42 NE CCAC Regional Approved Medical Supplies List Feed, Ostomy, Respiratory CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Feed, Ostomy, Respiratory: Initial supply authorization for four weeks for short-term treatment and to allow Patient to coordinate insurance or ADP applications. Supplies will only continue to be provided after 4 weeks if Patient continues to have nursing services AND is not eligible for any other funding program up to a maximum total period of six months. Feeding supplies are for the CCAC provided Kangaroo ePump or Joey Pump and may not be compatible with other pumps. SFS-0005 Enteral Feeding Gravity Bag Kangaroo SFS-0006 Enteral Feeding Pump Set 500 ml Kangaroo Joey SFS-0031 Enteral Feeding Pump Set 1000 ml Kangaroo Joey SFS-0035 Enteral Feeding Pump Set with Flush Set 1000ml Kangaroo Joey SFS-0010 Gastrostomy Tube with Y Port 16 Fr Kangaroo SFS-0036 Gastrostomy Tube with Y Port 20 Fr Kangaroo SFS-0012 Nasogastric Feeding Tube 5 Fr (Infant) Kangaroo SFS-0037 Nasogastric Feeding Tube PVC 5 Fr (Infant) Kangaroo SFS-0038 Nasogastric Feeding Tube 6.5 Fr (Infant) Kangaroo SFS-0015 Nasogastric Feeding Tube 12 Fr Kangaroo Entriflex SFS-0039 Nasogastric Tube Stabilization Device (Pediatric) Statlok SFS-0019 Nasogastric Tube Stabilization Device (Adult) Statlok SFS-0040 Adapter Y-Port-G-tube/P.E.G. 16 Fr Kangaroo SFS-0041 Adapter Y-Port-G-tube/P.E.G. 20 Fr Kangaroo SFS-0042 Purple Oral Syringe 3 ml Monoject NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Covidien 8884702500 Covidien 762055 Covidien 763656 Covidien 763662 Covidien 8884720163 Covidien 8884720205 Covidien 461412 Covidien 460802 Covidien 461438 Covidien 8884721252 Bard NG0100 Bard NG0120 Covidien 8884751622 Covidien 8884752042 Covidien 403S 1000 ml 2 500 ml 2 1000 ml 2 1000 ml 2 16 Fr x 9" 20 cc 20 Fr x 9" 20 cc 5 Fr x 20" 1.7 mm x 51 cm 5 Fr x 16" 1.7 mm x 41 cm 6.5 Fr x 36" 2.2 mm x 91 cm 12 Fr x 43" 4 mm x 109 cm 1/Patient Admission 1/Patient Admission Pediatric 1 Order for babies and small children For nasogastric tubes and feeding tubes Adult 1 For nasogastric tubes and feeding tubes Fits all G-Tubes 16 Fr or smaller Fits all G-Tubes 18 Fr or bigger 1/Patient Admission 1/Patient Admission 3 ml 3 1/month 2/week 1/month 1/month To be used in the absence of a feeding pump. Non-sterile For continuous overnight feeds ONLY Remains in situ for 30 days Purple Polyurethane Sterile Used only for patients who pull them out frequently PVC Sterile Remains in situ for 30 days Purple Polyurethane Sterile With stylet and rigid outlet port Non-Sterile. For use with the Kangaroo P.E.G. Kits and can be used as the replacement Y-port on all Kangaroo gastrostomy tubes. 1 per patient admission. CCAC will replace only if port is clogged or broken when patient still eligible for CCAC supplies. Non sterile; reusable, can be washed Page 23 of 42 CCAC Code Description Brand Name Manufacturer Code Covidien 410S Kimberly Clark 0121-12 Size Weekly Maximum Qty 10 ml 3 Non sterile; reusable, can be washed 12 inch 1 Includes right-angle connector, 2 Port "Y" and clamp SFS-0043 Purple Oral Syringe 10 ml Monoject SFS-0044 Feeding Tube Extension Set MIC-KEY Secur-Lok SOS-0001 Ostomy Flange and Pouch Specifiy Brand, Product Code, Type and Size when ordering SOS-0013 Nephrostomy Pouch Each 3 SOS-0014 Stomadhesive Paste (tube) Each 1/Patient SOS-0015 Stomadhesive Powder Each 1/Patient SOT-0032 Tracheostomy Tray Each 7 SOT-0033 Tracheostomy Brush Each 1 SOT-0034 Tracheostomy Ties Adult Each 1 SOT-0035 Tracheostomy Ties Pediatric Each 1 SOT-0036 Tracheostomy Drain Sponges 2x2 SOT-0037 Tracheostomy Drain Sponges 4x4 SOT-0051 Nebulizer Mask Kit Each 1 SOT-0052 Filter for Nebulizer Unit Each 1 SOT-0053 Suction Catheter 8 FR Each 7 SOT-0054 Suction Catheter 12Fr Each 7 SOT-0055 Suction Catheter 14Fr Each 7 SOT-0057 Yankauer Suction Bulb Tip Each 1 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 2" x 2" 5 x 5 cm 4" x 4" 10 x 10 cm Covidien 1180-851089 Covidien 1180-851121 Covidien 1180-851147 Notes Max. 4 week supply 14 14 Page 24 of 42 CCAC Code Description Brand Name SOT-0072 Connecting tubing to suction catheter Med-RX SOT-0073 Trach kit for compressor item ETM-1013 SOT-0077 Inner Cannula Disposable Size 4 Shiley SOT-0078 Inner Cannula Disposable Size 6 Shiley SOT-0079 Inner Cannula Disposable Size 8 Shiley SOT-0080 Fenestrated Inner Cannula Disposable Size 4 Shiley SOT-0081 Fenestrated Inner Cannula Disposable Size 6 Shiley SOT-0082 Fenestrated Inner Cannula Disposable Size 8 Shiley NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Manufacturer Code MED-RX 70-8072 Covidien 47800 Covidien 4DIC Covidien 6DIC Covidien 8DIC Covidien 4DICFEN Covidien 6DICFEN Covidien 8DICFEN Size Weekly Maximum Qty 1/4" X 72" 1 Each 1 Each 21 Each 21 Each 21 Each 21 For use with Tracheostomy Tubes 4DFEN, 4DCFN Each 21 For use with Tracheostomy Tubes 6DFEN, 6DCFN Each 21 For use with Tracheostomy Tubes 8DFEN, 8DCFN Notes For use with Tracheostomy Tubes 4DCT, 4DFEN, 4DCFS, 4DCFN For use with Tracheostomy Tubes 6DCT, 6DFEN, 6PERC, 6DCFS, 6DCFN For use with Tracheostomy Tubes 8DCT, 8DFEN, 8PERC, 8DCFS, 8DCFN Page 25 of 42 NE CCAC Regional Approved Medical Supplies List Urinary & Continence Weekly Maximum Notes Qty Urinary & Continence: Medical supplies may be authorized only while the patient is in need of nursing services. ODSP, social assistance, private insurance, DVA must be accessed as possible sources of funding on a long term basis. Individual supplies required to support percutaneous nephrostomy care may be ordered weekly when an entire PNT Kit SMK-0008 is not required. CCAC Code Description Brand Name MED-Rx Manufacturer Code Size CHS 85-4010 Each SDR-0005 Dressing Tray Kit - Disposable Single Use SUR-0001 Foley 2 way Latex 12Fr 5cc 2/month SUR-0002 Foley 2 way Latex 14Fr 5cc 2/month SUR-0003 Foley 2 way Latex 16Fr 5cc 2/month SUR-0004 Foley 2 way Latex 18Fr 5cc 2/month SUR-0005 Foley 2 way Latex 20Fr 5cc 2/month SUR-0006 Foley 2 way Latex 22Fr 5cc 2/month SUR-0013 Foley 2 way Latex 12Fr 30cc 2/month SUR-0014 Foley 2 way Latex 14Fr 30cc 2/month SUR-0015 Foley 2 way Latex 16Fr 30cc 2/month SUR-0016 Foley 2 way Latex 18Fr 30cc 2/month SUR-0017 Foley 2 way Latex 20Fr 30cc 2/month SUR-0018 Foley 2 way Latex 22Fr 30cc 2/month SUR-0027 Foley 2 way 100% Silicone 12 Fr 5/10cc 2/month NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 1 For catheter treatments only (PNT or PICC). Not for use in wound care. See Medical Supply Kits for description of contents Page 26 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty SUR-0028 Foley 2 way 100% Silicone 14Fr 5/10cc 2/month SUR-0029 Foley 2 way 100% Silicone 16Fr 5/10cc 2/month SUR-0030 Foley 2 way 100% Silicone 18Fr 5/10cc 2/month SUR-0031 Foley 2 way 100% Silicone 20Fr 5/10 cc 2/month SUR-0032 Foley 2 way 100% Silicone 16Fr 30cc 2/month SUR-0033 Foley 2 way 100% Silicone 18Fr 30cc 2/month SUR-0034 Foley 2 way 100% Silicone 20Fr 30cc 2/month SUR-0035 Foley 2 way 100% Silicone 22Fr 30cc 2/month SUR-0036 Foley 2 way 100% silicone 24 Fr 30cc 2/month SUR-0038 Foley 2 way Hydromer Coated 14Fr 5/10cc 2/month SUR-0039 Foley 2 way Hydromer Coated 16Fr 5/10cc 2/month SUR-0040 Foley 2 way Hydromer Coated 18FR 5/10cc 2/month SUR-0041 Foley 2 way Hydromer Coated 20Fr 5/10cc 2/month SUR-0042 Foley 2 way Hydromer Coated 22Fr 5/10cc 2/month SUR-0043 Foley 2 way hydromer Coated 16Fr 30cc 2/month SUR-0044 Foley 2 way hydromer Coated 18Fr 30cc 2/month SUR-0045 Foley 2 way Hydromer Coated 20Fr 30cc 2/month NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Notes Page 27 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty SUR-0048 Red Rubber Silicone 10 Fr 2/month SUR-0049 Red Rubber Silicone 12Fr 2/month SUR-0050 Red Rubber Silicone 14Fr 2/month SUR-0051 Red Rubber Silicone 16 Fr 2/month SUR-0052 Red Rubber Silicone 18 Fr 2/month SUR-0053 Red Rubber Silicone 20Fr 2/month SUR-0055 Intemittent 6" female 12Fr 2/month SUR-0056 Intermittent 6" Female 14Fr 2/month SUR-0057 Intemittent 6" female 16Fr 2/month SUR-0059 Intermittent Regular 12Fr 2/month SUR-0060 Intermittent Regular 14Fr 2/month SUR-0061 Intermittent Regular 16Fr 2/month SUR-0062 Intermittent regular 18Fr 2/month SUR-0074 Bladder Irrigation Tubing 5/week SUR-0075 Catheter Anchor Device 2/month SUR-0076 Catheter adapter 2/month SUR-0077 Catheter Clamp 2/month NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Notes Page 28 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty SUR-0078 Catheter Plug 2/month SUR-0079 Foley Catheter Tray 2/month SUR-0080 Irrigation Tray Kit with 60 cc Piston Syringe SUR-0081 Leg Bag Strap Large Reusable 1/month SUR-0082 Leg Bag Strap Medium Reusable 1/month SUR-0083 Leg Bag Strap Small Reusable 1/month SUR-0085 Leg Bag 500mL with drain and extension tubing 2/month SUR-0086 Leg Bag 500mL with drain, without extension tubing 2/month SUR-0087 Leg Bag 1000ml with extension tubing 2/month SUR-0089 Leg Bag 1000ml without extension tubing 2/month SUR-0090 Night Bag 2000ml 2/month SUR-0091 Sterile Lubricant Water Based 2/month SUR-0092 Xylocaine Jelly 2% 2/month SUR-0094 Urinary Extension Tubing with connector 18" SUR-0103 PNT Ext. Tube SUR-0104 SUR-0105 Statlock Universal Plus Catheter Stabilization Device Large 14-16 FR StatLock Universal Plus Catheter Stabilization Device Medium 10 - 12 FR MED-Rx CHS 85-5042 Each Covidien 8884731998 1/week Notes Disposible Single Use 2/month 2/month StatLock StatLock NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Bard VUPD1416 Bard VUPD1012 14 - 16 fr 2/month 10 - 12 fr 2/month Restricts catheter motion and fits virtually all catheter sizes. For biliary and nephrostomy drainage and peritoneal lavage catheters. Page 29 of 42 CCAC Code Description SUR-0106 StatLock Universal Plus Catheter Stabilization Device Small 6 - 8 FR SUR-0108 Specimen container Brand Name StatLock NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Manufacturer Code Size Weekly Maximum Qty Bard VUPD68 6 - 8 fr 2/month Starplex 00529 Notes 2 Page 30 of 42 NE CCAC Regional Approved Medical Supplies List IV, Needles, Syringes CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty BD 303345 Each 7 7" 7 Notes IV, Needles, Syringes Interlink For use with Baxter Interlink, Abbott LifeShield or McGaw SafeLine Systems SIV-0001 Blunt Plastic Cannula SIV-0002 Clave Extention Tubing 7" SIV-0003 Clave Multidose Vial Adapter Each 7 SIV-0004 Clave Needleless Connector Each 7 SIV-0005 Clave Port Male adapter Plug Each 7 SIV-0006 Clave Primary IV Administration Set Each 3 SIV-0007 Clave Secondary IV Administration Set Each 7 SIV-0008 Clave "Y" Connector Each 7 SIV-0009 Positive Displacement Device MaxPlus Clear Volume: 0.28ml 7 Clear needleless connector SIV-0010 Positive Displacement Catheter Extension Set MaxPlus Clear 8" / 20 cm 7 Extension set with removable needleless connector SIV-0012 Microbore Y Type Catheter Extension Set MaxPlus Clear Volume: 1.2ml Length: 13cm 3 Extension set with clear needleless connector SIV-0013 Dual Luer Lock Cap Baxter Baxter 2C6250 Each 3 Male / female port protector; No open fluid path SIV-0015 Interlink Universal Vial Adapter Interlilnk Baxter 2N3395 Each 7 SIV-0016 Interlink 20ml vial adapter 20 mL 7 SIV-0017 Interlink 3cc syringe with cannula 3cc 7 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Care Fusion MP1000-C Care Fusion MP9001-C Care Fusion MP2202-C Page 31 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty 85” (2.2 m) 3 37" 3 SIV-0018 Interlink Continuous Flow Primary IV Administration Set Interlink SIV-0019 Interlink Secondary Medication Set Interlink SIV-0020 Interlink PRN adapter Each 3 SIV-0021 Interlink IV Extension Tubing Each 3 SIV-0026 Hemostat Clamps untoothed Each 1 SIV-0027 Hemostat Clamps padded Each 1 SIV-0042 Ambulatory Infusion Pump Administration Set Each 7 SIV-0043 Ambulatory Infusion Pump High Volume Administration Set Each 7 SIV-0044 Ambulatory Infusion Pump Administration Set Filtered Each 7 SIV-0045 Ambulatory Infusion Pump Extension Tubing 30 inches 30 inches 3 SIV-0046 Ambulatory Infusion Pump Extension Tubing 45 inches 45 inches 3 SIV-0047 Ambulatory Infusion Pump Medication Cassette 50ml 50 mL 7 SIV-0048 Ambulatory Infusion Pump Medication Cassette 100ml 100 mL 7 SIV-0052 PRN Adapter Long Each 7 SIV-0079 Syringe Luer Lok 1cc 1 cc 7 SIV-0080 Syringe Luer Lok 3cc 3 cc 7 SIV-0081 Syringe Luer Lok 5cc 5 cc 7 SIV-0082 Syringe Luer Lock 10cc 10 cc 7 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Baxter JC6519 Baxter JC7451 Notes With Lever lock cannula (detached) and male Luer lock adapter, hanger Filtered for administration of Cephalosporins, Vancomycin, Ceftazidine Page 32 of 42 CCAC Code SIV-0083 Description Brand Name Manufacturer Code Syringe Luer Lok 20cc Size Weekly Maximum Qty 20 cc 7 Notes For IV: 7 / Patient / Week See Notes For Wound Care: 1 / Patient / Week In-Home or 1 / Visit in Clinic --> Also order Wound Irrigation Tip for syringe for each dressing change (SDR-0062) SIV-0084 Syringe Luer Lok 30cc 30 cc SIV-0085 Syringe Luer Lok 60cc 60 cc 7 SIV-0088 Syringe Catheter Tip 10cc 10 cc 7 SIV-0089 Syringe Catheter Tip 20cc 20 cc 7 SIV-0090 Syringe Catheter Tip 30cc 30 cc 7 SIV-0091 Syringe Catheter Tip 60cc 60 cc 7 SIV-0111 Vial Access Adapter for Interlink-single use 15 gauge 7 SIV-0113 IV Extension Tubing for use with Clave Port SIV-0114 Luer Lock Extension Tubing 8" SIV-0117 Blunt Fill Needle 18g 1.5" SIV-0120 PleurX Drainage Kit 1000ml Sterile SIV-0121 Bodyguard Tubing without filter 3 SIV-0123 Continuflo Extension Sets with 3 injection sites 7 SIV-0125 Inter cannula 3 SIV-0126 3cc syringe with cannula 3 cc 14 SIV-0127 5 cc syringe with cannula 5 cc 14 Interlink BD 303367 Designed for use with Interlink injection sites. Used for a one time access to 10 ml vials 3 PleurX NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 CareFusion 50-7510 8" 3 18g 1.5" 3 Each 3 For use with Pleurovac. Includes bottle and supplies Page 33 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes SIV-0131 Sharps Disposal Container 1 SIV-0132 Sterile non fenestrated drape 18x26" 2 SIV-0133 Statlock PICC II Cook Double Lumen 1 Specific catheter stabilization device for 6 7 Fr PICC lines SIV-0134 Sterile Universal IV Catheter Stabilization Device Statlock PICC Plus 1 PICC Sutureless, Tricot Anchor Pad SDR-0077 Catheter Ported Dressing 7 x 9 cm IV3000 3 For peripheral IVs SDR-0082 Catheter Central/PICC Dressing 10 x 12 cm IV3000 1-Hand 3 Indicated for peripheral and central venous catheter fixation and to keep the catheter site dry SWC-0067 Transparent Film IV Dressing with Border Tegaderm IV 3 For winged and ported peripheral catheters SIV-0135 Microclave connector 7 SIV-0137 Tourniquet 1 SIV-0138 IV Hook 1 SIV-0143 Butterfly Catheter 19g - BD Winged Infusion Set SIV-0144 Butterfly Catheter 21g - BD Winged Infusion Set SIV-0145 Butterfly Catheter 23g - BD Winged Infusion Set SIV-0146 Butterfly Catheter 25g - BD Winged Infusion Set SIV-0147 Butterfly Catheter 27g - BD Winged Infusion Set SIV-0148 IV Catheter 18g 1/16" - Smith Medical IV Protective VPoint SIV-0149 IV Catheter 20g - Smith Medical Protective V-Point SIV-0150 IV Catheter 22g - Smith Medical IV Protective V-Point NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Bard Limited PIC0220 Smith & Nephew 4006 Smith & Nephew 4008 3M 1633 Adult 2.75" x 3.5" 7 x 9 cm 4" x 4-3/4" 10 x 12 cm 2.75" x 3.25" 7 x 8.5 cm 3/4 " 12" tubing 3/4 " 12" tubing 3/4 " 12" tubing 3 3 3 3 3/8 " 12" tubing 3 3 Smiths Medical 3067 Smiths Medical 3060 3 3 Page 34 of 42 CCAC Code Description Brand Name SIV-0151 IV Catheter 24g - Smith Medical IV Protective V-Point SIV-0152 Subcutaneous Administration Needle 6 mm 24" Tubing CLEO 90 SIV-0201 Subcutaneous Administration Needle 9 mm 24" Tubing CLEO 90 SIV-0153 Needle 18g 1" Edge SIV-0154 Needle 18g 1-1/2" Edge SIV-0155 Needle 20g 1" Edge SIV-0156 Needle 21g 1" Edge SIV-0157 Needle 21g 1-1/2" Edge SIV-0158 Needle 22g 1" Edge SIV-0159 Needle 22g 1-1/2" Edge SIV-0160 Needle 23g 1" Edge SIV-0161 Needle 23g 1-1/2" Edge SIV-0162 Needle 25g 5/8" Edge SIV-0165 Needle 25g 1" Edge SIV-0166 Needle 25g 1-1/2" Edge SIV-0167 Needle 27g 1/2" Edge SIV-0172 Needle with Syringe 3cc 22g 1 1/2" Edge SIV-0173 Needle with Syringe 3cc 23g 1" Edge NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Manufacturer Code Smiths Medical 3063 Smiths Medical 21-7220-24 Smiths Medical 21-7230-24 Smiths Medical 401810 Smiths Medical 401815 Size Weekly Maximum Qty 3 6 mm cannula 24 inch tubing 9 mm cannula 24 inch tubing 3 7 18g 1-1/2" 7 Smiths Medical 20g 1" 7 Smiths Medical 21g 1" 7 21g 1-1/2" 7 22g 1" 7 22g 1-1/2" 7 23g 1" 7 23g 1-1/2" 7 25g 5/8" 7 25g 1" 7 Smiths Medical 25g 1-1/2" 7 Smiths Medical 27g 1/2" 7 3cc 22g 1 1/2" 7 3cc 23g 1" 7 Smiths Medical Smiths Medical 402558 Smiths Medical 402510 Smiths Medical 432215 Smiths Medical 432310 Compatible with any open system insulin pump 31" & 42" tubing may be available as exception item 3 18g 1" Smiths Medical 402115 Smiths Medical 402210 Smiths Medical 402215 Smiths Medical 402310 Notes Page 35 of 42 CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty SIV-0175 Needle with Syringe 1cc 25g 5/8" Edge Smiths Medical 1cc 25g 5/8" 7 SIV-0177 Needle with Syringe 1cc 27g 1/2" Edge Smiths Medical 1cc 27g 1/2" 7 SIV-0181 Needle with Syringe 3cc 25g 5/8" Edge Smiths Medical 432558 3cc 25g 5/8" 7 SIV-0182 Needle with Syringe 3cc 25g 1" Edge Smiths Medical 3cc 25g 1" 7 SIV-0186 Needle with Syringe Insulin 1cc 28g 1/2" Edge Smiths Medical 1cc 28g 1/2" 7 SIV-0187 Infusion Set - 22 Gauge x 0.75" Saf-T-Intima SIV-0203 Infusion Set - 24 Gauge x 0.75" Saf-T-Intima 22 gauge 0.75" 24 gauge 0.75" SIV-0189 Tubercullin 1cc slip tip syringe BD BD 383329 BD 383319 BD 309659 1 cc 14 SIV-0190 10cc syringe with 21g 1.5" needle Edge Smiths Medical 10 cc 14 SIV-0191 3cc syringe with 21g 1.5" needle Edge Smiths Medical 3 cc 14 SIV-0192 Gripper 22g x 3/4"- Portacath Gripper Plus Gripper Plus SIV-0193 Gripper 19g x 1.25" - Portacath Gripper Plus Gripper Plus SIV-0196 SIV-0199 SIV-0197 SIV-0200 SIV-0202 Heparin Lock Syringe 10 USP units/mL - 5 mL Fill in 10 mL Diameter Syringe Heparin Lock Syringe 10 USP units/mL - 3 mL Fill in 10 mL Diameter Syringe Heparin Lock Syringe 100 USP units/mL - 5 mL Fill in 10 mL Diameter Syringe Heparin Lock Syringe 100 USP units/mL - 3 mL Fill in 10 mL Diameter Syringe PosiFlush PosiFlush PosiFlush PosiFlush Antibiotic IV Medication Refill Solution Bag NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Smiths Medical 21-2766-24 Smiths Medical 212765-24 BD 306414 BD 306413 BD 306424 BD 306423 Notes 3 Safety system with wings, extension tubing and Y adapter 3 Safety system with wings, extension tubing and Y adapter 1 1 10 USP/mL 5 mL/mL 10 USP/mL 3 mL 100 USP/mL 5 mL 100 USP/mL 3 mL 3 3 3 3 7 For flushing Vascular Access Devices as per nursing guidelines and manufacturer’s recommendations. For flushing Vascular Access Devices as per nursing guidelines and manufacturer’s recommendations. For flushing Vascular Access Devices as per nursing guidelines and manufacturer’s recommendations. For flushing Vascular Access Devices as per nursing guidelines and manufacturer’s recommendations. Solution bag - not a cassette. For IV Med Refill orders only Page 36 of 42 NE CCAC Regional Approved Medical Supplies List Medical Supply Kits Medical Supplies Kits: Most items in each kit can be ordered individually if an entire kit is not required if an individual CCAC code is listed below. Additional items may also be ordered as needed. Description CCAC Code SMK-0003 Foley Catheter Kit SIV-0082 Syringe Luer Lock 10cc 2 SS0-0052 Alcohol wipe 6 SUR-0079 Foley Catheter Tray 2 SUR-0085 Leg Bag 500ml with drain and extension tubing 1 SUR-0090 Night Bag 2000mL 1 Description CCAC Code SMK-0008: Percutaneous Nephrostomy Kit Qty Per Kit SDR-0005 Dressing Tray 2 SDR-0055 Drain Gauze Sponge Tracheostomy Sterile Woven 4"x4" 2 SOT-0001 Disposable Procedural Mask 2 SOT-0021 Sterile Nitrile Gloves Medium (Pair) 2 SSO-0021 Normal Saline 10cc Pre-Filled Syringe 1 SSO-0052 Alcohol wipe 14 SUR-0086 Leg Bag 500mL with drain, without extension tubing 1 SWC-0128 Transparent Film Dressing 15x20cm 2 SUR-0103 PNT Ext. Tube 2 Description CCAC Code SMK-0029: PICC Dressing Kit Qty Per Kit Qty Per Kit SDR-0003 Gauze sterile woven 2"x2" 2 SDR-0005 Dressing Tray Kit 1 SDR-0028 Net Elastic Bandage 4 (arm, elbow) 1 SDR-0037 Wound Closure Strip 1/2" (Pkg) 1 SDR-0082 Catheter Central/PICC Dressing 10 x 12 cm 2 SIV-0009 Positive Displacement Device 1 SIV-0134 Sterile Universal IV Catheter Stabilization Device 1 SOT-0001 Disposable Procedural Mask 2 SOT-0021 Sterile Nitrile Gloves Medium (Pair) 1 SSO-0006 Chlorhexidine swabsticks with alcohol 4 SSO-0063 Chlorhexidine Wipes without alcohol 2 SSO-0021 Normal Saline 10cc Pre-Filled Syringe 2 For double lumen add: SIV-0009 Positive Displacement Device 1 SSO-0021 Normal Saline 10cc Pre-Filled Syringe 1 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Notes Maximum Quantity: 1 Kit/Week Order catheters separately Notes Maximum Quantity: 1 Kit/Week If a night bag is required, it may be ordered using the regular item code SUR-0090 Dressing Tray SDR-0005 may be ordered individually if an entire kit is not required If a Statlock is required add: SUR-0104 Statlock Universal Plus Catheter Stabilization Device Large 12 - 14 fr; or SUR-0105 StatLock Universal Plus Catheter Stabilization Device Medium 10 - 12 fr; or SUR-0106 StatLock Universal Plus Catheter Stabilization Device Small 6 - 8 fr Notes Maximum Quantity: 1 Kit/Week All PICC/central lines require pump for infusion therapy. A large Ambulatory Infusion Pump carrying bag may be required, if necessary. Add: 2 of Ambulatory Infusion Pump Administration Sets (SIV-0042) OR Ambulatory Infusion Pump Administration Sets Filtered for administration of Cephalosporins, Vancomycin, Ceftazidine (SIV-0044) and 2 Alcohol Wipes (SS0-0052) AND 2 Normal Saline Syringes (SSO-0021) per day of infusion Add: Portacath Gripper item SIV0192 or SIV-0193 as required. Add: Prefilled Heparin Lock Syringes as per nursing guidelines (See IV, Needles, Syringes ) Dressing Tray SDR-0005 may be ordered individually if an entire kit is not required Page 37 of 42 Medical Supplies Kits: Most items in each kit can be ordered individually if an entire kit is not required if an individual CCAC code is listed below. Additional items may also be ordered as needed. Description CCAC Code SMK-0039: Subcutaneous Administration of Pain Management Medications via Infusion Pump: Initial Start Up Kit SWC-0072 Transparent Film Dressing 10cm x 12cm 2 SDR-0086 White Surgical Tape 1" Single Use Roll 1 SIV-0020 Interlink PRN adapter 2 SIV-0152 Subcutaneous Administration Needle 6 mm 24" Tubing 3 SIV-0080 Syringe Luer Lok 3cc 10 SIV-0147 Butterfly Catheter 27g Winged Infusion Set 3 SIV-0158 Needle 22g 1" - Smith Medical Edge 4 SIV-0175 Needle with Syringe 1cc 25g 5/8" 20 SSO-0006 Chlorhexidine Swabsticks with alcohol 4 SSO-0029 Normal Saline Injectable 10cc Vial 1 SSO-0052 Alcohol Wipe 10 Description CCAC Code SMK-0040: Peripheral IV Start/Restart Qty Per Kit SDR-0003 Gauze sterile woven 2"x2" 2 SDR-0004 Gauze sterile woven 4"x4" 2 SDR-0008 Conform Wrap Non Sterile 4" (Roll) 1 SDR-0028 Net Elastic Bandage 4 (arm, elbow) (Mtr) 1 SDR-0086 White Surgical Tape 1" Single Use Roll 1 SIV-0009 Positive Displacement Device 1 SIV-0114 Extension Tubing Luer Lock 8" 1 SIV-0137 Tourniquet 1 SIV-0150 IV Catheter 22g - IV Protective V-Point 2 SIV-0151 IV Catheter 24g - IV Protective V-Point 2 SSO-0063 Chlorhexidine Wipes (Alcohol Free) 6 SWC-0067 Transparent Window Dressing 7.5cm x 8.5cm 2 SSO-0021 Normal Saline 10cc Pre-Filled Syringe 2 Description CCAC Code SMK-0041: Gravity IV Administration Kit Qty Per Kit Qty Per Kit SIV-0018 Interlink Continuous Flow Primary IV Administration Set 3 SIV-0019 Interlink Secondary Medication Set 3 SIV-0052 PRN Adapter Long 2 SSO-0025 Normal Saline IV 250cc Bag 3 SSO-0052 Alcohol Wipes 6 SSO-0021 Normal Saline 10cc Pre-Filled Syringe 6 NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Notes Maximum Quantity: 1 Kit/Week Add: 3 Extension tubing (SIV-0045 or SIV-0046) if being used with medication cassette. Notes Maximum Quantity: 3 Kit/Week For infusion via pump order: Ambulatory Infusion Pump Administration Set (SIV-0042) OR Ambulatory Infusion Pump Administration Set Filtered for administration of Cephalosporins, Vancomycin, Ceftazidine (SIV-0044) AND 2 Chlorhexidine Wipes (SS00063) AND 2 Normal Saline Syringes (SSO-0021) per day of infusion Notes Maximum Quantity: 3 Kit/Week Provides 3 days of infusion For increased frequency of medication administration beyond once daily, order additional Alcohol wipes (SSO-0052) and Prefilled Normal Saline Syringes (SSO-0021) per day of infusion Page 38 of 42 Medical Supplies Kits: Most items in each kit can be ordered individually if an entire kit is not required if an individual CCAC code is listed below. Additional items may also be ordered as needed. Description CCAC Code SMK-0042: Initial Wound Care Kit SWC-0023 Hydrogel 15g (Low Pectin, Low Saline) 1 SDR-0039 Non Allergenic Self Adhesive Surgical Tape 2" (Metre) 1 SDR-0003 Gauze sterile woven 2"x2" 4 SDR-0004 Gauze sterile woven 4"x4" 4 SDR-0006 Cotton Tipped Applicator Plastic Sterile 2/pk 1 SIV-0084 Syringe Luer Lok 30cc 1 SDR-0062 Wound irrigation tip for syringe 1 SWC-0107 Absorbent Dressing 5"x6" 2 Description CCAC Code SWC-0123: Minor Laceration Tray Kit - Sterile Qty Per Kit Plastic Tray 1 Gauze Sponges 5 Waterproof Sterile Field 1 Fenestrated Waterproof Drape 1 Absorbent Towels 2 Tissue Forceps 1 Needle Holder 1 Scissors 1 Notes Maximum Quantity: 1 Kit/Patient Admission Nurse to identify and order regular wound care supplies after initial visit Notes Maximum Quantity: 1 Kit/Week Disposable single use For sharp/surgical debridement and should only be performed by clinicians with this expertise. Qty Per Kit Notes 3 Compartment 1200 CC Outer Tray 1 For catheter treatments only (PNT or PICC). Not for use in wound care. Rayon Cotton Balls Large Absorbent 6 Gauze 4" x 4" - 8 Ply 4 4" Plastic Transfer Forcep 3 Absorbent Towel - 3 Ply 1 CSR Sterile Field Towel 1 Waste Bag with Tie 1 Description CCAC Code SDR-0005 Dressing Tray Kit Disposable Single Use Qty Per Kit NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 39 of 42 NE CCAC Regional Approved Medical Supplies List Protective Wear CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Protective Wear: Personal protective equipment (PPE) may be authorized for NE CCAC staff to protect employees from exposure to workplace hazards as per policy. Service Providers are expected to provide their own personal protective equipment to their own staff to protect from infectious diseases. Non-Sterile PPE may be authorized for contracted service providers by the CCAC only when the on-going patient-specific treatment requires protective wear be worn to minimize risk to patient or specialty PPE is required. Clean PPE is standard in community care, and sterile PPE supplies are only to be authorized when treatments require a sterile technique as per approved guidelines. SOT-0001 Disposable Ear Loop Surgical Face Mask Each 7 SOT-0003 Disposable Isolation Gown Small Each 1 per Visit SOT-0004 Disposable Isolation Medium Each 1 per Visit SOT-0005 Disposable Isolation Gown Large Each 1 per Visit SOT-0006 Disposable Isolation Gown Extra Large Each 1 per Visit SOT-0007 Non-Sterile Vinyl Gloves Small (Pair) Disposamed Each Pair 7 Non-latex, powder free, vinyl examination gloves SOT-0008 Non-Sterile Vinyl Gloves Medium (Pair) Disposamed Each Pair 7 Non-latex, powder free, vinyl examination gloves SOT-0011 Non-Sterile Vinyl Gloves Medium (Box) Disposamed Box of 100 1 Non-latex, powder free, vinyl examination gloves Bulk orders only available for ETs, NPs, Clinic, Hospice, RRNs SOT-0009 Non Sterile Vinyl Gloves Large (Pair) Disposamed Each Pair 7 Non-latex, powder free, vinyl examination gloves SOT-0019 Eye Protection Safety Glasses Each 1 For procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids SOT-0020 Sterile Nitrile Gloves Small (Pair) Flexam Each Pair 3 Non-latex, powder free, nitrile examination gloves SOT-0021 Sterile Nitrile Gloves Medium (Pair) Flexam Each Pair 3 Non-latex, powder free, nitrile examination gloves SOT-0022 Sterile Nitrile Gloves Large (Pair) Flexam Each Pair 3 Non-latex, powder free, nitrile examination gloves NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Cardinal Health MDS192474 Cardinal Health MDS192475 Cardinal Health MDS192475 Cardinal Health MDS192476 Cardinal Health N8830 Cardinal Health N8831 Cardinal Health N8832 Page 40 of 42 CCAC Code Description Brand Name SOT-0023 Sterile Nitrile Gloves Extra Large (Pair) Flexam SOT-0012 Sterile Nitrile Gloves Medium (Box) Flexam SOT-0013 Non-skid shoe covers (one size fits all) SOT-0085 N95 Respirator Surgical Small 3M SOT-0086 N95 Respirator Surgical Medium 3M SOT-0087 N95 Respirator Surgical Large SOT-0088 Surface Disinfectant Wipes (Flat Pack) Caviwipe SOT-0089 Alcohol-Based Hand Sanitizer Rub Purell Advanced Aura NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Manufacturer Code Cardinal Health N8833 Cardinal Health N8831 3M Healthcare 1860s 3M Healthcare 1860 3M Healthcare 1870+ Metrex 11-1224 Gojo 9651-24-CAN00 Size Weekly Maximum Qty Each Pair 3 Non-latex, powder free, nitrile examination gloves Box of 40 Pairs 1 Non-latex, powder free, nitrile examination gloves Bulk orders available for ETs, NPs, Clinic, Hospice only Each Pair 1 per Visit Small 1 PPE for CCAC employees only (Not provided to patients or SPOs) Medium 1 PPE for CCAC employees only (Not provided to patients or SPOs) Large 1 PPE for CCAC employees only (Not provided to patients or SPOs) 45 Wipes 1 PPE for CCAC employees only (Not provided to patients or SPOs) 118 mL Bottle 1 PPE for CCAC employees only (Not provided to patients or SPOs) Notes Page 41 of 42 NE CCAC Regional Approved Medical Supplies List Miscellaneous CCAC Code Description Brand Name Manufacturer Code Size Weekly Maximum Qty Notes Miscellaneous SOT-0038 9 Volt Batteries for Ambulatory Infusion Pump As needed As required for pumps SOT-0042 Forceps Locking SOT-0043 TENS Electrolodes Reusable 1.5 (pckg of 2) SOT-0044 TENS Electrolodes Reusable 3.5 (pckg of 2) SOT-0045 TENS Electrolodes Reusable 2x4 (pckg of 2) SOT-0083 Oral Swab sticks Latex-free Plain Untreated (Box 250) SOT-0084 Oral Swab sticks Latex-free Plain Untreated (Each) NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Dynarex 1217 Box of 250 Each 1/patient admission 1/patient admission 1/patient admission 1/patient admission Hospice Palliative patients only only 21 Palliative patients only Page 42 of 42
