North East CCAC Regional Approved Medical Supplies List

Transcription

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
______________________________________________________________________________
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Please report any errors or feedback to NE.Contracts@ccac-ont.ca
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