1.0 General Supplies Benefit Code
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1 1.0 General Supplies Benefit Code Quantity Ordered Product Descripiton Status NHIB Allowable Qty Gloves Examination, PVC, non-sterile Small 100/ BX BX 1 BOX / 30 DAYS Medium 100 / BX BX 1 BOX / 30 DAYS Large 100/ BX BX 1 BOX / 30 DAYS Needles 18GM 1" 100/ BX BX 1 BX / month 25G, 5/8" 100/ BX BX 1 BX / month Safety Syringe 3ml Luer Lock Each EA 12 ea/ 90 days Large Syringe 20 ml Luer Lock Each EA 4/ month 30 ml Luer Lock Each EA 4 /month 60 ml Luer Lock Catheter Tip Each BX 4 /month Sharps Container 1.4 L EA 2 / 30 days EasiCleanse 5pk EA 1.1 Topical Preparations Barrier Dimethylpolysiloxane 20% 50g CR TU Wipes Skin Protective 50/BX (Allkare) PA BX 4 boxes / year Alcohol 200/BX BX Adehsive Remover Wipes 50/ BX PA BX 6 boxes / year Tolnaftate 1% powder 100g ( Tinactin) BT No Sting Skin Prep Wipes, 50/ BX PA/RA BX 4 boxes/ Year 1.2 Tape Steri-Strips 6mm (1/4") x 7.5 cm, 3 EN PA EN
2 12mm (1/2") x 10 cm, 6 EN PA EN Tape Hypafix 10cm, 10m /BX BX Micropore 2.5cm, 9m/ EA EA Transpore 2.cm, 9m/ EA EA Mepitac Silicone Tape 2 cm x 3m RA BX 1 box/ month 2.0 Wound Care 2.1 Specialized Dressings Disposable Wound Measurment Ruler 25/Pad EA 1 pad/ month Calcium Alginate dressing Kaltostat 7.5 x 12 cm, 10/ BX PA BX 2 boxes / month Kaltostat 2g Strip 5/BX PA BX 2 boxes / month Mesalt 10x10cm. 30/BX PA BX 2 boxes / month Mesalt Ribbon, 10/ PK PA PK 2 boxes / month Charcoal Dressing Actisorb Silver 1.5 x 10.5 cm, 10/BX PA BX 2 boxes / month Foam Dressing Mepilex foam, 10x20cm, 5/ BX PA BX 4 boxes/ Month Mepilex XT 10X10cm, 5/ BX PA BX 4 boxes/ Month Mepilex XT 10X20cm, 5/BX PA BX 4 boxes/ Month Aquacel Foam Adhesive 10x10cm, 10/BX PA BX 4 boxes/ Month Aquacel Foam Adhesive 17.5x17.5cm, 10/BX PA BX 4 boxes/ Month Biatin Silicone Adhesive 7.5x7.5cm, 10/ BX PA BX 2 boxes / month Biatin Silicone Adhasive 10x10cm, 10/bx PA BX 2 boxes / month Biatin Silicone Adhesive 15x15cm, 5/bx PA BX 4 boxes/ Month Biatin Foam Super- Adhesive 15x15cm, 10/bx PA BX 4 boxes/ Month Biatin Foam Super -Adhesive 20x20cm, 10/BX PA BX 4 boxes/ Month Hydrocolloid Dressing DuoDerm Signal 10x10cm, 5/ BX PA BX 4 Boxes / Month DuoDerm Signal 14x14cmm 5/ BX PA BX 4 Boxes / Month DuoDerm Extra Thin CGF 10X10CM, 10/BX PA BX 2 Boxes / Month HydroPhilic Dressing Triad Woud Drsg 71gm PA TU 2 tubes/ month Hydrofibre Dressing Aquacel Extra 10x10cm, 10/ BX PA BX 2 Boxes / month Aquacel 2x45cm, 5/BX PA BX 4 Boxes / Month Exufibre Dressing 10x10cm, 10/ BX PA BX 2 Boxes / Month Exufibre 2X50cm, 5/ BX PA BX 2 Boxes / Month Hydrogel Intrasite Gel, 10/BX PA BX 1 Box / month Multi-Layer Dressing Primapore 8x10cm, 20/ BX PA BX 2 Boxes / Month Primapore 35x10cm, 20/BX PA BX 2 Boxes / Month Non- Adherent dressing impregnated Mepitel One 5x7.5cm, 10/ BX PA BX 2 Boxes / Month
3 Mepitel One 7.5x10cm, 10/ BX PA BX 2 Boxes / Month Restore Contact Layer 10cm x12 cm, 10/ BX PA BX 2 Boxes / Month Anitmicrobial (AMD) Dressing AMD Super Sponges 15cm x 17cm, 20x2" s/ BX PA BX AMD Packing Strips 0.6cm (1/4") x 91cm EA AMD Packing Strips 1.2cm (1/2") x 91cm EA AMD Gauze 11.4cm x 3.7cm EA Transparent Film Dressing OpSite 10x12cm, 50/ BX PA BX 1 box / month OpSite Post-Op Dressing 9.5x8.5cm, 20/ BX PA BX 1 box / month 2.2 Dressings Bandage, Gauze, Elastic ("Kling") 5cm, 12/ BG BG 7.5cm, 12/BG BG 10cm, 12/BG BG 15cm, 6/ BG BG Bandage, Tubular elastic latex free ("BurnNet") Size 1, 25m/ BX (Ex. Fingers, Toes) BX Size 2, 25m/ BX (Ex. Fingers, Wrist) BX Size 3, 25m/ BX (Ex. Knee, Foot, Elbow, Hand) BX Size 4, 25m/ BX (Ex. Kneem Foot, Elbow, Hand) BX Size 5, 25m/ BX (Ex. Calf, Thigh) BX Size 7, 25m/ BX (Ex. Chest, Abdomen, Axilla) BX Gauze non-sterile, 4 ply 10x10cm, 200/ PG PG Gauze, sterile, 4-ply 5x5cm, 25pkg of 2/TR TR 7.5x7.5cm, 25pkg of 2/TR TR 10x10cm, 25pkg of 2/TR TR Gauze packing strip, sterile: 0.6cmx4.5m (Nu-Gauze) EA 1.3cmx 4.5m (Nu-Gauze) EA Pad, Abdominal, Sterile 12x22cm, 36/PG PG Pad, Eye, Sterile 50/ BX BX Hydrofiber Dressing Promogran 28cm², 10/ BX PA/RA BX 2 boxes/ month Antimicrobial Dressing Acticoat Flex 3 Silver, 4x4cm, 12/ BX PA/RA BX 2 boxes/ Month Acticoat Flex 7 Ribbon, 2.5x60cm, 5/ BX PA/RA BX 4 boxes/ Month Aquacel AG Plus Extra Ribbon 1 x 45cm, 5/ BX PA/RA BX 4 boxes/ Month Aquacel AG Plus Extra 10 x 10cm, 10/ BX PA/RA BX 4 boxes/ Month Biatin AG Alginate 3x44cm, 10/ BX PA/RA BX 4 boxes/ Month Biatin AG Alginate 10x10cm, 10/ BX PA/RA BX 2 boxes/ Month
4 Biatin IBU Foam 15x15cm, 5/ BX PA/RA BX 4 boxes/ Month Biatin IBU Foam 20x20cm, 5/ BX PA/RA BX 4 boxes/ Month Exsalt SD7 Wound Dressing 5x5cm, 5/ BX PA/RA BX 4 boxes/ Month Exsalt SD7 Wound Dressing 10x12.5cm, 5/BX PA/RA BX 4 boxes/ Month Hydrofera Blue Dressing 10x10cm, 10/ BX PA/RA BX 2 boxes/ Month Hydrofera Blue (Heavy Exudate) 10x10cm, 5/ BX PA/RA BX 2 boxes/ Month Inadine 9.5x9.5cm, 25/ BX PA/RA BX 2 boxes/ Month Iodosorb, 1x 10g PA/RA TU 2 Tubes/ Month Prisma 28cm², 10/BX PA/RA BX 2 boxes/ Month Restore Siver Contact Layer 10x12cm, 10/BX PA/RA BX 2 boxes/ Month Silvsorb Gel, 7.4ml PA/RA TU 2 Tubes/ Month 2.3 Miscellaneous Dressing Tray, sterile disposable BASIC PA EA 1 per dressing change MINOR PA EA 1 per dressing change Sodium Chloride 0.9% (NS) irrigation 100ml squeeze BT 500ml screw cap bottle BT Liner, Classic Ultra 17x40cm 20/ pkg EA Liner, Classic Super 10x28cm, 50/ pkg EA Betadine Solution 500 ml EA Medi Honey Gel 50 gm tube PA EA 1 Tube / Month 3.0 Continence Supplies Bedpan fracture, non-autoclavable plastic EA 1 / 3 years Catheter, Foley 5ml, indwelling latex 12 FR PA EA 4ea / 3 months 14 FR PA EA 4ea / 3 months 16 FR PA EA 4ea / 3 months 18 FR PA EA 4ea / 3 months 22 FR PA EA 4ea / 3 months Catheter Self- Cath Female 6 inches 14 FR PA EA 36 ea/ 3 months Self- Cath Male 16 inches 14 FR PA EA 36 ea/ 3 months Catheterization Tray PA EA Lubricant (Muko) 3.5 g pouch, 100/ BX PA BX 4/ 3 months Urine Bag Leg Bag w/tubing, medium 562ml PA EA 52/ year Leg Bag w/tubing, large 946ml PA EA 52/ Year Beside Bag PA EA 52/ Year
5 Urinary Irrigation Set PA EA Urinal Male Spillproof, autoclavable EA 1/ 3 years Underpads (heavy use), disposable Blue 43x60 cm(17x24") 300/ BX PA BX 1 box/ 2 months Underpads (Light use), disposable Blue 43x60 cm(17x24") 5/BG PA BG 10 bags / month Underpads, reusable 24x36" / ea PA EA 1/ Year Adult Mesh Pants Mesh Pants, Small-Medium, 5/ BG PA BG 2 bags /month Mesh Pants, Large-Extra Large, 5/ BG PA BG 2 bags /month Mesh Pants, XX-Large, 5/ BG PA BG 2 bags /month Pads for Mesh Pants Attends Bladder Control Pads Ultimate, 30/ BG PA BG 150/ Month Day Regular, 24/ BG PA BG 150/ Month Day Plus, 24/BG PA BG 150/ Month Super, 18/BG PA BG 150/ Month Overnight, 18/BG PA BG 150/ Month Diapers Attends Briefs, Extra Absorbent; medium, (32-44") 24/ BG PA BG 150/ Month Briefs, Extra Absorbent; regular, (44-56"), 24/ BG PA BG 150/ Month Briefs, Extra Absorbent; large, (44-58"), 24/ BG PA BG 150/ Month Briefs, Extra Absorbent; X-Large (58-63") 20/ BG PA BG 150/ Month Briefs, Extra Absorbent; XX-Large (58-68"), 12/ BG PA BG 150/ Month Pull Up Attends Protective Underwear- SuperPlus Absorbency; Youth, Small, (22-34", lbs) 20/BG PA BG 150/ Month Protective Underwear- SuperPlus Absorbency; Medium ( 34-44" lbs) 20/BG PA BG 150/ Month Protective Underwear- SuperPlus Absorbency; Large (44-58", lbs) 18/BG PA BG 150/ Month Protective Underwear-SuperPlus Absorbency; X-Large (58-68", lbs) 14/BG PA BG 150/ Month Protective Underwear-SuperPlus Absorbency; XX-Large (58-68", lbs) 14/BG PA BG 150/ Month 3.1 Ostomy Supplies Paste Adapt Paste 1 x 2 oz PA TU 1/ Month Powder Adapt Stoma Powder 1 x 1 oz PA TU 1/ Month Flanges Flat Cut-to-Fit 44mm Hollister #14202, 5/ BX PA BX 50/ 3 months 57mm Hollister #14203, 5/BX PA BX 50/ 3 months Convex Cut-To-Fit
6 44mm Hollister #14402, 5/ BX PA BX 50/ 3 months 57mm Hollister #14403, 5/ BX PA BX 50/ 3 months Pouches Drainable Ileostomy/Colostomy 44mm Hollister #18172, 10/ BX PA BX 30/ 3 months 57mm Hollister #18173, 10/ BX PA BX 30/ 3 months 3.1 Ostomy Supplies Continued Drainable Urostomy 44mm Hollister #18922, 10/ BX PA BX 30/ 3 months 57mm Hollister #18923, 10/ BX PA BX 30/ 3 months 4.0 Diabetic Supplies Bayer Contour Next EZ Blood Glucose Meter Bayer Next EZ Test Strips, 100/ BX BX Bayer Microlet lancets 200/BX BX One Touch Ultra Supplies One Touch Ultra Test Strips 100/ BX BX One Touch Ultra Soft Lancets 100/ BX BX One Touch Delica Lancets 100/ BX BX 5.0 Compression Therapy Products Coban 2 Layer System /40 PA/RA BX Indicate Right or Left Coban 2 Lite Layer System /40 PA/RA BX Indicate Right or Left Tubigrip Size D (Limb Size 20-24cm) RA BX 8/ year total Tubigrip Size E (Limb Size 24-28cm) RA BX 8/ year total Tubigrip Size F (Limb Size 28-36cm) RA BX 8/ year total Tubigrip Size G (Limb Size 36-46cm) RA BX 8/ year total IF YOU CAN'T FIND WHAT YOU ARE LOOKING FOR ON THIS LIST, PLEASE CONTACT OUR CUSTOMER SERVICE TEAM AT (587) OR US AT INFO@FCMSE.CA
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