North East CCAC Regional Approved Medical Supplies List APRIL 01 2016 Please report any errors or feedback to [email protected]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 Wound Care 1 Absorptives 8 Alginates 8 Antimicrobials & Silvers 9 Clear Acrylic 10 Composite Dressings 10 Foams 11 Hydrocolloids 11 Hydrogel 12 Films & Membranes 12 Odour Absorbent Dressings 12 Non-adherent 13 Other & Specialty 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
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North East CCAC Regional Approved Medical Supplies List
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):
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
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 Area
Depot/Drop-Off Location Pick-Up Location Availability For Regular
Scheduled Pick-up* Service Type
URBAN SSM01
Sault Ste. Marie Branch Office
390 Bay Street, Suite 103, Sault Ste. Marie, ON P6A 1X2 705-949-1650/800-668-7705 Fax: 705-949-3844
MON-FRI 8:30AM - 4:30PM
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
Orders arrive weekly on Fridays
MON-SUN 5:30AM – 10:00PM
CCAC Medical Supplies
RURAL SSM06
Thessalon Hospital
135 Dawson Street Thessalon, ON P0R 1L0 705-842-2014
Orders arrive weekly on Thursdays
Open 24 hrs
CCAC Medical Supplies
RURAL SSM07
Pit Stop Gas Bar & Confectionary
3245 Hwy 17 East, Echo Bay, ON P0S 1C0 705-248-3333
Orders arrive weekly on Fridays
MON-SUN 6:00AM – 11:00PM
CCAC Medical Supplies
RURAL SSM08
Goulais River Country Store
2771 Hwy 17 North Goulais River, ON P0S 1E0 705-649-3811
Orders arrive weekly on Fridays
MON-SUN 6:00AM -11:00PM
CCAC Medical Supplies
RURAL SSM09
McCauley’s Village Store
5235 Hwy 17 North Haviland Bay, ON P0S 1E0 705-649-5813
Orders arrive weekly on Fridays
MON-SUN 8:30AM – 10:00PM
CCAC Medical Supplies
RURAL SSM10
Elliot Lake PharmaChoice
267 Hillside Drive South Elliot Lake, ON P5A 1N7 705-848-0004
MON-FRI 9:00AM–5:00PM SAT 9:00AM – 1:00PM
Robinson’s Medical Supplies & Infusion (IV) Equipment & Supplies
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
Robinson’s Medical Supplies
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
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)
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.
Service Area
Depot/Drop-Off Location
Pick-Up Location Availability For Regular Scheduled Pick-up*
Service Type
URBAN NB01
North Bay Branch Office
1164 Devonshire Ave. North Bay, ON P1B 6X7 705-476-2222 Fax: 705-474-2369
MON-FRI 8:30AM - 4:30PM 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
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
Note: All IV orders from Bayshore Rx are delivered to the patient’s treatment location.
Service Area
Depot/Drop-Off Location
Pick-Up Location
Availability For Regular Scheduled Pick-up*
Weekly supplies available for patient pick-up each
Wednesday
Service Type
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
MONDAY - FRIDAY 8:30AM – 4:30PM
CCAC Medical Supplies
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
MONDAY - FRIDAY 8:30AM – 4:30PM
CCAC Medical Supplies
RURAL KL03
Findlay’s Drug Store
25-247 Whitewood Ave. New Liskeard, ON P0J 1P0 705-647-8186
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.
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-0036 Calcium Alginate Dressing 4"x4"
Either product may be provided depending on the inventory on hand
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 8 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SWC-0029 Hydrofiber Silver Impregnated Dressing 4"x4" Aquacel Ag Convatec403708
4" x 4" 10 x 10 cm 4
SWC-0031 Hydrofiber Silver Impregnated Dressing 8"x12" Aquacel Ag Convatec403711
8" x 12" 19 x 29 cm 4
SWC-0032 Hydrofiber Silver Impregnated Ribbon 1"x18" Aquacel Ag Convatec403771
1" x 18"2 x 45 cm 4
SWC-0034 Non-adherent Antiseptic Impregnated Gauze 4"x4" Bactigras Smith & Nephew66003650
4" x 4" 10 x 10 cm 4 For adjunctive treatment and prevention of infection in skin loss
lesions, including wounds, burns and ulcers
SSP-0003 Ointment with Iodine 10Gr Tube Iodasorb Smith & Nephew66060630
10 GramTube 1
Should not be used in patients with known or suspected Iodine sensitivity, history of any thyroid disorder, or pregnant or lactating women
4" x 4" 10 x 10cm 3 Not compatible with oil-based products, such as petrolatum
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.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 9 of 42
CCAC Code Description Brand Name ManufacturerCode Size
SWC-0131 Antimicrobial Gel with Silver 0.25 oz SilvaSorb MedlineMSC93025EP 0.25 oz Tube As required For clinic patients only
SWC-0132 Antimicrobial Gel with Silver 1.5 oz SilvaSorb MedlineMSC9301EP 1.5 oz Tube 1 Community patients
SWC-0133 Textile Antimicrobial Silver 10”x36” InterDry AG Coloplast7912 10" x 36" 1 If larger than 36" required, order custom size
SWC-0134 Textile Antimicrobial Silver (Custom size) InterDry AG Coloplast7910 10" x Custom 4 Custom order per 12" lengths
SVS-0008 Non-Elastic Zinc Paste Bandage Viscopaste Smith & Nephew4948 7.5 cm x 6 m 2 Woven cloth impregnated with a paste containing 10 % Zinc Oxide BP
rolled onto a plastic coreSWC-0090 Protease inhibitor dressing with Collagen (‡) Promogran Systagenix
M772028 28 cm2
Hexagonal2 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 20mmHgProtease Inhibitor should be discontinued if there is no progression towards wound healing (less than 10% healing in 3 weeks).
SWC-0139 Absorbent Clear Acrylic Small Oval 7.6x9.5cm Tegaderm 3M90800
3 in. x 3-3/4 in.7.6 x 9.5 cm 1
SWC-0140 Absorbent Clear Acrylic Medium Oval 11x12cm Tegaderm 3M90801
4-3/8 in. x 5 in.11.1 x 12.7 cm 1
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 withoutchanging 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
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).
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.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 10 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SWC-0099 Foam Non-Adhesive Regular or similar 4"x4" Mepilex XT Mölnlycke211100
4" x 4"10 x 10 cm 4
SWC-0100 Foam Non-Adhesive Regular or similar 8"x8" Mepilex XT Mölnlycke211400
8" x 8"20 x 20 cm 4
SWC-0101 Foam Non-Adhesive Lite or similar 6"x6" Mepilex Lite Mölnlycke284300
6" x 6"15 x 15 cm 4
SWC-0102 Foam Adhesive Regular or similar 3"x3" Mepilex Border Mölnlycke295200
3 "x 3"7.5 x 7.5 cm 4
SWC-0103 Foam Adhesive Regular or similar 4"x4" Mepilex Border Mölnlycke295300
4" x 4"10 x 10 cm 4
SWC-0104 Foam Adhesive Regular or similar 6"x6" Mepilex Border Mölnlycke295400
6" x 6"15 x 15 cm 4
SWC-0105 Foam Adhesive Lite or similar 6"x6" Mepilex Border Lite
Mölnlycke281300
4" x 4"10 x 10 cm 4
SWC-0129 Foam Non-Adhesive with Ibuprofen 4"x4" Biatain IBU Coloplast4110
4" x 4"10 x 10 cm 4
SWC-0130 Foam Non-Adhesive with Ibuprofen 6"x6" Biatain IBU Coloplast4115
6" x 6"15 x 15 cm 4
SWC-0045 Hydrocolloid Thin 4x4" Tegaderm 3M90022
4" x 4"10 x 10 cm 3
SWC-0047 Hydrocolloid Thin Oval With Border 10x12cm Tegaderm 3M90021
4" x 4.75"10 x 12 cm 3
SWC-0048 Hydrocolloid Thin Oval With Border 13x15cm Tegaderm 3M90023
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.
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.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 11 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SWC-0053 Hydrocolloid Regular With Border 10x12cm Tegaderm 3M90001
4" x 4.75"10 x 12 cm 3
SWC-0055 Hydrocolloid Regular With Border 17x20cm Tegaderm 3M90004
SWC-0023 Hydrogel (Low Pectin, Low Saline) Intrasite Gel Smith & Nephew7311 15 g 3
SWC-0072 Transparent Film Dressing 10x12cm Tegaderm 3M1626W
4" x 4.75"10 x 12 cm 3
SWC-0128 Transparent Film Dressing 15x20cm Tegaderm 3M1628
6" x 8"15 x 20 cm 3
SWC-0037 Activated Charcoal Dressing with Silver 4"x4" Actisorb Plus Silver 220
KCI Systagenix MAS105
4" x 4" 10.5 x 10.5 cm 2
SWC-0135 Activated Charcoal Dressing with Silver 2.5 x 3.75" Actisorb Plus Silver 220
KCI Systagenix MAS065
2.5" x 3.75"6.5 x 9.5 cm 2
SWC-0136 Activated Charcoal Dressing with Silver 4" x 7.5" Actisorb Plus Silver 220
KCI Systagenix MAS190
4" x 7.5"10.5 x 19 cm 2
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.
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.
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.
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
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 12 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SWC-0003 Non Adherent Sterile Impregnated Gauze 3"x3" Adaptic Systagenix2012
3" x 3"7.6 x 7.6 cm 4
SWC-0076 Non Adherent Sterile Impregnated Gauze 3"x8" Adaptic Systagenix2015
3" x 8"7.6 x 20.3 cm 7
SWC-0081 Non Adherent Sterile Silicone Dressing 2"x3" Mepitel Mölnlycke290510
2"x 3"5 x 7.5 cm 3
SWC-0086 Non Adherent Sterile Impregnated Gauze 4"x4" Jelonet Smith & Nephew7404
4"x4"10 x 10 cm 4
SCM-0019 Blue Absorbent Pads 24cm x 26cm Each 1/VisitAuthorized for clinic patients for containment of drainageor for methotrexate administration in home/clinicONLY. Approved clinics may order in bulk.
SDR-0011 Sterile Single Use Scissors MED-Rx CHS85-4202 4 1/2"
In-Home: 1 per Week
Clinic: 1 / Visit
Sharp/Blunt
SDR-0012 Sterile Plastic Thumb Forceps MED-Rx CHS85-4200 Each
In-Home: 3 per Week
Clinic: 1 / Visit
SDR-0024 Suture Removal Kit Each 1
SDR-0025 Staple Remover Each 1
SDR-0062 Wound irrigation tip for syringe MED-RX MED-RX20-1104 1 Tip 7 Single use. Syringe must be ordered separately
SDR-0080 Tissue Forceps Metal Sterile Disposable MED-Rx CHS85-9000
1 x 2 teeth4-3/4" 1/Visit For sharp/surgical debridement and should only be performed by
clinicians with this expertise.
SDR-0081 Curved Iris Scissors Sterile MED-Rx CHS85-9411 4 1/2" 1/Visit For sharp/surgical debridement and should only be performed by
clinicians with this expertise
SMK-0042 Initial Wound Care Kit 1 See Medical Supply Kits for description
SWC-0059 Wound Culture Swab Various Each 1
Other & Specialty
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.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 13 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SWC-0064 Single Use Safety Scalpel - Size 10 Miltex Integra4-510 Size 10 3 Sharp/surgical debridement should only be performed by clinicians with
SWC-0141 Flexible Silver Nitrate Applicator Stick AMG AMG Medical118-395 Pack of 100 1 For approved ETs nurses and clinic bulk orders only.
SWC-0121 Protective Barrier Wipe Skin-Prep Smith & Nephew59420425 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.
SWC-0122 Dermal Curette with 4mm tip Miltex Integra33-54 Each 1 For sharp/surgical debridement and should only be performed by
SDR-0010 Sterile Tongue Depressor AMG Medical 118-425 Adult 3 Adult size Individually wrapped, single patient use.
SWC-0123 Minor Laceration Tray Kit - Sterile Busse Cardinal Health312-751 Each 1 See Medical Supply Kits for description
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 14 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SNP-0001 VAC Adhesive Drape V.A.C. KCIM6275009 30.5 x 26 cm 1
SNP-0007 T.R.A.C. Y Connector V.A.C. KCIM6275066 Each 3 Y-connector to connect two or more dressings
SNP-0008 VAC GranuFoam Standard Dressing Kit Small V.A.C. KCIM8275051 10 x 7.5 x 3.3 cm 3 Includes 1 small black foam dressing, 1 adhesive drape,1 SensaTRAC
Pad
SNP-0009 VAC GranuFoam Standard Dressing Kit Medium V.A.C. KCIM8275052 18 x 12.5 x 3.3 cm 3 Includes 1 medium black foam dressing, 2 adhesive drapes,1
SensaTRAC Pad
SNP-0010 VAC GranuFoam Standard Dressing Kit Large V.A.C. KCIM8275053 26 x 15 x 3.3 cm 3 Includes 1 large black foam dressing, 2 adhesive drapes,1 SensaTRAC
PadSpecial Order Only (SYY)
VAC GranuFoam Standard Dressing Kit XL V.A.C. KCIM8275065 60 x 30 x 1.5 cm 3 Includes 1 large black foam dressing, 5 adhesive drapes,1 SensaTRAC
Pad
SNP-0017 VAC GranuFoam Silver Dressing Kit Small V.A.C. KCIM8275098 10 x 7.5 x 3.3 cm 3 Includes 1 small silver foam dressing, 1 adhesive drape,1 SensaTRAC
Pad
SNP-0018 VAC Granufoam Silver Dressing Kit Medium V.A.C. KCIM8275096 18 x 12.5 x 3.3 cm 3 Includes 1 medium silver foam dressing, 2 adhesive drapes,1
SensaTRAC Pad
SNP-0019 VAC Granufoam Silver Dressing Kit Large V.A.C. KCIM8275099 26 x 15 x 3.3 cm 3 Includes 1 large silver foam dressing, 2 adhesive drapes,1 SensaTRAC
Pad
SNP-0020 VAC WhiteFoam Dressing Kit Small V.A.C. KCIM8275068 10 x 7.5 x 1 cm 3 Less adherent material helps promote graft take. Includes 1 small PVA
foam dressing, 1 adhesive drape, 1 SensaT.R.A.C. Pad
SNP-0022 VAC WhiteFoam Dressing Kit Large V.A.C. KCIM8275067 10 x 15 x 1 cm 3 Less adherent material helps promote graft take. Includes 1 large PVA
foam dressing,1 adhesive drape, 1 SensaT.R.A.C. Pad
SNP-0058 VAC WhiteFoam Small (Foam Only) V.A.C. KCIM6275033 10 x 7.5 x 1 cm 3 1 polyvinyl alcohol (PVA) foam dressing (10 x 7.5 x 1 cm)
SNP-0059 VAC WhiteFoam Large (Foam Only) V.A.C. KCIM6275034 10 x 15 x 1 cm 3 1 polyvinyl alcohol (PVA) foam dressing (10 x 15 x 1 cm)
SNP-0046 VAC Simplace Dressing Kit Small V.A.C. KCIM8275041 Each 3 Includes 1 small Spiral-cut VAC GranuFoam Dressing, 2 adhesive
drapes, 1 SensaT.R.A.C. Pad
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 sub-atmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump (pump rental required in addtion to the dressings).
NE CCAC Regional Approved Medical Supplies List
Negative Pressure Wound Therapy (NPWT)
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 15 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
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 sub-atmospheric 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. KCIM8275040 Each 3 Includes 1 medium Spiral-cut VAC GranuFoam Dressing, 2 adhesive
drapes, 1 SensaT.R.A.C. Pad
SNP-0052 300 mL ActiVAC Canister with Gel V.A.C. KCIM8275058 Each 1 1 canister with gel, tubing, clamp and connector; May be authorized for
more than 1/week if the canister is full.
SNP-0060 VAC SensaT.R.A.C. Pad V.A.C. KCIM8275057 Each 1 Includes 1 SensaT.R.A.C. Pad with tubing, clamp and connector
SNP-0061 T.R.A.C Tubing Cap V.A.C. KCIM6275069 Each 1 Cap to secure end of tubing when not in use
Special Order Only (SYY)
VAC GranuFoam Bridge Dressing Kit V.A.C. KCIM8275042 Each 3 Each kit includes black foam, bridge dressing; sensa TRAC pad and
adhesive drape
Special Order Only (SYY)
VAC GranuFoam Bridge XG Dressing Kit V.A.C. KCIM8275044 Each 3 Each kit includes black foam, bridge dressing; sensa TRAC pad and
adhesive drape
SWC-0124 Single Use Negative Pressure System 4x8" PICO Smith & Nephew66800951
4" x 8"10 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.
SWC-0125 Single Use Negative Pressure System 4x12" PICO Smith & Nephew66800952
4" x 12"10 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. Special Order Only (SYY)
Single Use Negative Pressure System 4x16" PICO Smith & Nephew66800953
4" x 16"15 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.
SWC-0126 Single Use Negative Pressure System 6x8" PICO Smith & Nephew66800955
6" x 8"15 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.
SWC-0127 Single Use Negative Pressure System 6x6" PICO Smith & Nephew66800954
6" x 6"15 x 15 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. Special Order Only (SYY)
Single Use Negative Pressure System 6x12" PICO Smith & Nephew66800956
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.
Special Order Only (SYY)
Single Use Negative Pressure System 8x8" PICO Smith & Nephew66800957
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.
Special Order Only (SYY)
Single Use Negative Pressure System 10x10" PICO Smith & Nephew66800958
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 Page 16 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SDR-0086 White Surgical Tape 1" Single Use Roll Transpore White
3M 1534S-1
1" x 1-1/2 yard 2.5 cm x 1.3 m 1 Universal hypoallergenic tape can be used for all applications
SDR-0087 Blue Silicone Tape 1" Single Use Roll Kind Removal 3M 2770S-1
1" x 54"2.5 cm x 1.3m 1 Only order for patients with very fragile at risk skin who react to
SDR-0088 Sterile Gauze Packing Cotton Single Use 1/4" PAK-ITS Derma SciencesDUP561036
1/4" x 36"0.635cm x 90cm 3
SDR-0089 Sterile Gauze Packing Cotton Single Use 1/2" PAK-ITS Derma SciencesDUP4853
1/2" x 54"1.3 cm x 137cm 3
SDR-0090 Sterile Gauze Packing Cotton Single Use 2" PAK-ITS Derma SciencesDUP4856
2" x 54"5 cm x 137 cm 3
SDR-0020 Sterile 2" Small Woven Gauze Roll for Packing Gazetex Derma SciencesDUP9321
2-1/4" x 3 yards 5.7 cm x 2.7 m 7
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.
NE CCAC Regional Approved Medical Supplies List
Tape, Dressings, Bandages, Compression & Wraps
100% Cotton, 6 Ply;
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).
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 17 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SDR-0021 Sterile 4" Large Woven Gauze Roll for Packing Gazetex Derma SciencesDUP9322
4" x 4.1 yards10 cm X 3.75 m 7 Cotton, 2 ply woven bandage ideal as a secondary dressing (non-
stretch)
SDR-0027 Tubular Net Elastic Bandage - Fingers/Toes/Small Wrist
Medline Elastic Net NONNET02 7 2/3"
19.5 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SDR-0083 Tubular Net Elastic Bandage - Wrist & Elbow Medline Elastic Net NONNET03 9 1/3"
23.7 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
Used for wrapping or packing large deep wounds
Synthetic knitted stretch bandage ideal as a secondary dressing
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 18 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SDR-0028 Tubular Net Elastic Bandage - Elbow & Arm Medline Elastic Net NONNET04 11 2/3"
29.6 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SDR-0029 Tubular Net Elastic Bandage - Knee & Thigh Medline Elastic Net NONNET05 12 3/8"
31.4 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SDR-0084 Tubular Net Elastic Bandage - Shoulder Hip Thigh Medline Elastic Net NONNET06 17"
61 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SDR-0030 Tubular Net Elastic Bandage - Chest Back Perineum Axilla
Medline Elastic Net NONNET07 28 2/3"
72.8 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SDR-0085 Tubular Net Elastic Bandage - Chest Region Large Medline Elastic Net NONNET08 31 1/3"
79.6 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement.
SYY-0687 Tubular Net Elastic Bandage - Chest Region XL Medline Elastic Net NONNET09 35"
88.9 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Special Order SYY only
SYY-0688 Tubular Net Elastic Bandage - Chest Region XXL Medline Elastic Net NONNET10 41"
93.1 cm 2 Non-adhesive and holds dressing/devices securely in place while allowing freedom of movement. Special Order SYY only
SDR-0068 Multipurpose Tubular Elastic Bandage Size C Tubigrip Mölnlycke1443
16 - 20cm L x 6.6 - 7.2 cm W 2
SDR-0069 Multipurpose Tubular Elastic Bandage Size D Tubigrip Mölnlycke1437
20 - 24 cm L x7.3 - 7.9 cm W 2
SDR-0070 Multipurpose Tubular Elastic Bandage Size E Tubigrip Mölnlycke1434
24 - 28 cm L x8.7 - 9.2 cm W 2
SDR-0071 Multipurpose Tubular Elastic Bandage Size F Tubigrip Mölnlycke1438
28 - 36 cm L x9.7-10.3 cm W 2
SDR-0072 Multipurpose Tubular Elastic Bandage Size G Tubigrip Mölnlycke1439
36-46 cm L x11.3-12.7 cm W 2
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" Dusor Derma SciencesDUP71414LF 4" x 5 yards 1* *May order 2 for initial order only. Non-Sterile
- 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
Mesh pants are only authorized only for patients requiring this product as a means of containing wound care dressings to coccyx, perineal area, etc.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 19 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SVS-0004 High Stretch Elastic Stretch Bandage Non Latex 6" Dusor Derma SciencesDUP71416LF 6" x 5 yards 1* *May order 2 for initial order only. Non-Sterile
SVS-0006 2 Layer Compression System - 35-40mmHg Coban 2 3M2094N 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 3M2794N 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
Cleansers & SolutionsCCAC Code Description Brand Name Manufacturer
Code SizeWeekly
Maximum Qty
Notes
SSO-0001 Chlorhexidine 500mL 2% 500 mL 1
SSO-0002 Hydrogen Peroxide 3% 500mL 500 mL 1
SSO-0004 Povidone Iodine 1% 100mL bottle (‡) Betadine 100 mL 2Contraindicated for: • Malignant Wounds • Exposed Bone• Exposed Tendon • Patient with Extensive Burns • Hypersensitivity to iodine (Hyperthyroidism)
SSO-0006 Chlorhexidine Swabsticks with alcohol Each 8
SSO-0019 Normal Saline 500cc bottle (‡) Baxter BaxterJF7633 500 cc 1
SSO-0023 Normal Saline 118cc Irrigation Bottle Sterile (‡) Derma Derma Sciences DUP48501N 118 cc 7
SSO-0031 Sterile Water 500cc bottle (‡) Baxter BaxterJF7624 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. 3M S10108 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 500 mL 7 per 2 wks Maximum 14/patient
Cleansers
NE CCAC Regional Approved Medical Supplies List
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)
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 21 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SSO-0021 Normal Saline 10cc Pre-Filled Syringe PosiFlush BD306572 10 cc 14
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
Solutions
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 22 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SFS-0005 Enteral Feeding Gravity Bag Kangaroo Covidien8884702500 1000 ml 2 To be used in the absence of a feeding pump. Non-sterile
SFS-0006 Enteral Feeding Pump Set 500 ml Kangaroo Joey Covidien762055 500 ml 2
SFS-0031 Enteral Feeding Pump Set 1000 ml Kangaroo Joey Covidien763656 1000 ml 2
SFS-0035 Enteral Feeding Pump Set with Flush Set 1000ml Kangaroo Joey Covidien 763662 1000 ml 2 For continuous overnight feeds ONLY
SFS-0010 Gastrostomy Tube with Y Port 16 Fr Kangaroo Covidien 8884720163
16 Fr x 9"20 cc
1/Patient Admission
SFS-0036 Gastrostomy Tube with Y Port 20 Fr Kangaroo Covidien 8884720205
SFS-0042 Purple Oral Syringe 3 ml Monoject Covidien403S 3 ml 3 Non sterile; reusable, can be washed
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.
NE CCAC Regional Approved Medical Supplies List
Feed, Ostomy, Respiratory
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.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 23 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SFS-0043 Purple Oral Syringe 10 ml Monoject Covidien410S 10 ml 3 Non sterile; reusable, can be washed
SFS-0044 Feeding Tube Extension Set MIC-KEYSecur-Lok
Kimberly Clark0121-12 12 inch 1 Includes right-angle connector, 2 Port "Y" and clamp
SOS-0001 Ostomy Flange and Pouch Max. 4 week supply
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 2" x 2"5 x 5 cm 14
SOT-0037 Tracheostomy Drain Sponges 4x4 4" x 4" 10 x 10 cm 14
SOT-0051 Nebulizer Mask Kit Each 1
SOT-0052 Filter for Nebulizer Unit Each 1
SOT-0053 Suction Catheter 8 FR Covidien1180-851089 Each 7
SOT-0054 Suction Catheter 12Fr Covidien1180-851121 Each 7
SOT-0055 Suction Catheter 14Fr Covidien1180-851147 Each 7
SOT-0057 Yankauer Suction Bulb Tip Each 1
Specifiy Brand, Product Code, Type and Size when ordering
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 24 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SOT-0072 Connecting tubing to suction catheter Med-RX MED-RX70-8072 1/4" X 72" 1
SOT-0073 Trach kit for compressor item ETM-1013 Covidien47800 Each 1
SOT-0077 Inner Cannula Disposable Size 4 Shiley Covidien4DIC Each 21 For use with Tracheostomy Tubes 4DCT, 4DFEN, 4DCFS, 4DCFN
SOT-0078 Inner Cannula Disposable Size 6 Shiley Covidien6DIC Each 21 For use with Tracheostomy Tubes 6DCT, 6DFEN, 6PERC, 6DCFS,
6DCFN
SOT-0079 Inner Cannula Disposable Size 8 Shiley Covidien8DIC Each 21 For use with Tracheostomy Tubes 8DCT, 8DFEN, 8PERC, 8DCFS,
8DCFN
SOT-0080 Fenestrated Inner Cannula Disposable Size 4 Shiley Covidien4DICFEN Each 21 For use with Tracheostomy Tubes 4DFEN, 4DCFN
SOT-0081 Fenestrated Inner Cannula Disposable Size 6 Shiley Covidien6DICFEN Each 21 For use with Tracheostomy Tubes 6DFEN, 6DCFN
SOT-0082 Fenestrated Inner Cannula Disposable Size 8 Shiley Covidien8DICFEN Each 21 For use with Tracheostomy Tubes 8DFEN, 8DCFN
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 25 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SDR-0005 Dressing Tray Kit - Disposable Single Use MED-Rx CHS85-4010 Each 1 For catheter treatments only (PNT or PICC). Not for use in wound care.
See Medical Supply Kits for description of contents
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
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.
NE CCAC Regional Approved Medical Supplies List
Urinary & Continence
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 26 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
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 Page 27 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
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 Page 28 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SUR-0078 Catheter Plug 2/month
SUR-0079 Foley Catheter Tray 2/month
SUR-0080 Irrigation Tray Kit with 60 cc Piston Syringe MED-Rx CHS85-5042 Each 1/week Disposible Single Use
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" Covidien 8884731998 2/month
SUR-0103 PNT Ext. Tube 2/month
SUR-0104 Statlock Universal Plus Catheter Stabilization Device Large 14-16 FR StatLock Bard
VUPD1416 14 - 16 fr 2/month
SUR-0105 StatLock Universal Plus Catheter Stabilization Device Medium 10 - 12 FR StatLock Bard
VUPD1012 10 - 12 fr 2/monthRestricts catheter motion and fits virtually all catheter sizes.For biliary and nephrostomy drainage and peritoneal lavage catheters.
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 29 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SUR-0106 StatLock Universal Plus Catheter Stabilization Device Small 6 - 8 FR StatLock Bard
VUPD68 6 - 8 fr 2/month
SUR-0108 Specimen container Starplex 00529 2
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 30 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SIV-0001 Blunt Plastic Cannula Interlink BD303345 Each 7 For use with Baxter Interlink, Abbott LifeShield or McGaw SafeLine
Systems
SIV-0002 Clave Extention Tubing 7" 7" 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-0010 Positive Displacement Catheter Extension Set MaxPlus Clear Care Fusion MP9001-C 8" / 20 cm 7 Extension set with removable needleless connector
SIV-0012 Microbore Y Type Catheter Extension Set MaxPlus Clear Care FusionMP2202-C
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 Baxter2N3395 Each 7
SIV-0016 Interlink 20ml vial adapter 20 mL 7
SIV-0017 Interlink 3cc syringe with cannula 3cc 7
IV, Needles, Syringes
NE CCAC Regional Approved Medical Supplies List
IV, Needles, Syringes
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 31 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SIV-0018 Interlink Continuous Flow Primary IV Administration Set Interlink Baxter
JC6519 85” (2.2 m) 3
SIV-0019 Interlink Secondary Medication Set Interlink BaxterJC7451 37" 3 With Lever lock cannula (detached) and male Luer lock adapter,
hanger
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 Filtered for administration of Cephalosporins, Vancomycin, Ceftazidine
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 Page 32 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SIV-0083 Syringe Luer Lok 20cc 20 cc 7
SIV-0084 Syringe Luer Lok 30cc 30 cc See Notes-->
For IV: 7 / Patient / Week
For Wound Care: 1 / Patient / Week In-Home or 1 / Visit in ClinicAlso order Wound Irrigation Tip for syringe for each dressing change (SDR-0062)
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 Interlink BD 303367 15 gauge 7 Designed for use with Interlink injection sites. Used for a one time
access to 10 ml vials
SIV-0113 IV Extension Tubing for use with Clave Port 3
SIV-0114 Luer Lock Extension Tubing 8" 8" 3
SIV-0117 Blunt Fill Needle 18g 1.5" 18g 1.5" 3
SIV-0120 PleurX Drainage Kit 1000ml Sterile PleurX CareFusion50-7510 Each 3 For use with Pleurovac. Includes bottle and supplies
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
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 33 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
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
Bard Limited PIC0220 Adult 1 PICC Sutureless, Tricot Anchor Pad
SDR-0077 Catheter Ported Dressing 7 x 9 cm IV3000 Smith & Nephew4006
2.75" x 3.5"7 x 9 cm 3 For peripheral IVs
SDR-0082 Catheter Central/PICC Dressing 10 x 12 cm IV30001-Hand
Smith & Nephew 4008
4" x 4-3/4"10 x 12 cm 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 3M1633
2.75" x 3.25"7 x 8.5 cm 3 For winged and ported peripheral catheters
SUR-0086 Leg Bag 500mL with drain, without extension tubing 1
SWC-0128 Transparent Film Dressing 15x20cm 2
SUR-0103 PNT Ext. Tube 2
CCAC Code Qty Per Kit Notes
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
SIV-0009 Positive Displacement Device 1
SSO-0021 Normal Saline 10cc Pre-Filled Syringe 1
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.
SMK-0003Foley Catheter Kit
Maximum Quantity: 1 Kit/Week
Order catheters separately
SMK-0008:Percutaneous Nephrostomy Kit
Maximum Quantity: 1 Kit/WeekIf 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; orSUR-0105 StatLock Universal Plus Catheter Stabilization Device Medium 10 - 12 fr; orSUR-0106 StatLock Universal Plus Catheter Stabilization Device Small 6 - 8 fr
SMK-0029:PICC Dressing Kit
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 SIV-0192 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
Description
For double lumen add:
NE CCAC Regional Approved Medical Supplies List
Medical Supply Kits
Description
Description
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 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.
CCAC Code Qty Per Kit Notes
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
CCAC Code Qty Per Kit Notes
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
CCAC Code Qty Per Kit Notes
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
SMK-0041:Gravity IV Administration Kit
SMK-0040:Peripheral IV Start/Restart
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 (SS0-0063) AND 2 Normal Saline Syringes (SSO-0021) per day of infusion
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
SMK-0039:Subcutaneous Administration of Pain Management Medications via Infusion Pump: Initial Start Up Kit
Maximum Quantity: 1 Kit/Week
Add: 3 Extension tubing (SIV-0045 or SIV-0046) if being used with medication cassette.
Description
Description
Description
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 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.
CCAC Code Qty Per Kit Notes
SWC-0023 Hydrogel 15g (Low Pectin, Low Saline) 1
SDR-0039 Non Allergenic Self Adhesive Surgical Tape 2" (Metre) 1
For catheter treatments only (PNT or PICC). Not for use in wound care.
CSR Sterile Field Towel
Fenestrated Waterproof Drape
Absorbent Towels
Tissue Forceps
Needle Holder
Description
Description
Description
Plastic Tray
Gauze Sponges
Waterproof Sterile Field
SWC-0123:Minor Laceration Tray Kit - Sterile
Maximum Quantity: 1 Kit/Week
Disposable single useFor sharp/surgical debridement and should only be performed by clinicians with this expertise.
SMK-0042:Initial Wound Care Kit
Maximum Quantity: 1 Kit/Patient Admission
Nurse to identify and order regular wound care supplies after initial visit
Scissors
SDR-0005Dressing Tray Kit - Disposable Single Use
3 Compartment 1200 CC Outer Tray
Rayon Cotton Balls Large Absorbent
Gauze 4" x 4" - 8 Ply
Absorbent Towel - 3 Ply
Waste Bag with Tie
4" Plastic Transfer Forcep
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 39 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
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 Cardinal HealthMDS192474 Each Pair 7 Non-latex, powder free, vinyl examination gloves
SOT-0008 Non-Sterile Vinyl Gloves Medium (Pair) Disposamed Cardinal HealthMDS192475 Each Pair 7 Non-latex, powder free, vinyl examination gloves
SOT-0011 Non-Sterile Vinyl Gloves Medium (Box) Disposamed Cardinal HealthMDS192475 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 Cardinal HealthMDS192476 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 Cardinal HealthN8830 Each Pair 3 Non-latex, powder free, nitrile examination gloves
SOT-0021 Sterile Nitrile Gloves Medium (Pair) Flexam Cardinal HealthN8831 Each Pair 3 Non-latex, powder free, nitrile examination gloves
SOT-0022 Sterile Nitrile Gloves Large (Pair) Flexam Cardinal HealthN8832 Each Pair 3 Non-latex, powder free, nitrile examination gloves
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.
NE CCAC Regional Approved Medical Supplies List
Protective Wear
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 40 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SOT-0023 Sterile Nitrile Gloves Extra Large (Pair) Flexam Cardinal HealthN8833 Each Pair 3 Non-latex, powder free, nitrile examination gloves
SOT-0012 Sterile Nitrile Gloves Medium (Box) Flexam Cardinal HealthN8831 Box of 40 Pairs 1 Non-latex, powder free, nitrile examination gloves
Bulk orders available for ETs, NPs, Clinic, Hospice only
SOT-0013 Non-skid shoe covers (one size fits all) Each Pair 1 per Visit
SOT-0085 N95 Respirator Surgical Small 3M 3M Healthcare1860s Small 1 PPE for CCAC employees only (Not provided to patients or SPOs)
SOT-0086 N95 Respirator Surgical Medium 3M 3M Healthcare1860 Medium 1 PPE for CCAC employees only (Not provided to patients or SPOs)
SOT-0087 N95 Respirator Surgical Large Aura 3M Healthcare1870+ Large 1 PPE for CCAC employees only (Not provided to patients or SPOs)
SOT-0088 Surface Disinfectant Wipes (Flat Pack) Caviwipe Metrex11-1224 45 Wipes 1 PPE for CCAC employees only (Not provided to patients or SPOs)
SOT-0089 Alcohol-Based Hand Sanitizer Rub Purell Advanced
Gojo9651-24-CAN00 118 mL Bottle 1 PPE for CCAC employees only (Not provided to patients or SPOs)
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 41 of 42
CCAC Code Description Brand Name ManufacturerCode Size
Weekly Maximum
QtyNotes
SOT-0038 9 Volt Batteries for Ambulatory Infusion Pump As needed As required for pumps
SOT-0042 Forceps Locking 1/patient admission
SOT-0043 TENS Electrolodes Reusable 1.5 (pckg of 2) 1/patient admission
SOT-0044 TENS Electrolodes Reusable 3.5 (pckg of 2) 1/patient admission
SOT-0045 TENS Electrolodes Reusable 2x4 (pckg of 2) 1/patient admission
SOT-0083 Oral Swab sticks Latex-free Plain Untreated (Box 250) Dynarex 1217 Box of 250 Hospice only Palliative patients only
SOT-0084 Oral Swab sticks Latex-free Plain Untreated (Each) Each 21 Palliative patients only
Miscellaneous
NE CCAC Regional Approved Medical Supplies List
Miscellaneous
NE CCAC Regional Approved Medical Supplies List - Effective April 01 2016 Page 42 of 42