13.0 Medical surgical equipment and supplies benefits list

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13.1 General information

13.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

13.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB will lead to denials or reversals of claims.

NIHB recognized prescribers/recommenders include:

  • MD — Physician
  • NP — Nurse Practitioner
  • NSWOC — Nurse Specialized in Wound, Ostomy and Continence
  • (RN renewals only) — Registered Nurse (initial prescription required from MD, NP, NSWOC, WOCC(C))
  • WOCC(C) — Wound, Ostomy and Continence Certified (C)anada
  • OT — Occupational Therapist
  • PT — Physiotherapist
  • RM — Registered Midwife
  • RN — Registered Nurse

NIHB recognized providers include:

  • GEN — Enrolled general MS&E or pharmacy provider

13.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

To initiate the prior approval process, the Medical Surgical Prior Approval Form, found on the Express Scripts Canada website, must be completed in full and submitted to the NIHB regional office along with the following supporting documentation:

  • the prescription or recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
  • detailed assessment as required
  • additional relevant information the provider, physician, nurse practitioner, occupational therapist, or physiotherapist may have to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)

13.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the medical surgical and equipment benefit and are not considered for coverage or appeal under the NIHB program:

  • environmental protection devices and supplies (for example: air cleaners, filters, UV protection garments and lotions, etc.)

13.1.5 Warranties

Providers must honour the manufacturer's warranty.

13.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • prior approval is required for repairs exceeding the maximum cost or frequency
  • request must include detailed cost breakdown of parts, labour time and rates
  • repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

13.1.7 Replacement requirements

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • not working, outside of warranty and the cost of repair exceeds the cost of a new item
  • the item no longer meets the client's needs due to a change in medical condition

All requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

13.1.8 Services included in the price

The following services are to be included in the price of the item:

  • product and parts ordering, and delivery from manufacturer to provider (including delivery costs, exchange rate)
  • dispensing of the benefit, which includes any required adjustments or fittings

13.1.9 Terminology

Item code:

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval:

A program coverage confirmation is issued by a FNIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring authorization before being billed to the program.

Recommended replacement guidelines:

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Maximum price:

The NIHB program has established a maximum price for specific items. Maximum price information may be found on the price files located on the Express Script Canada website.

13.2 Incontinence

13.2.1 Diapers and liners

NIHB provides coverage for incontinence items, which can be either one type of product or a combination of different products, for three months at a time.

The first time a client applies for prior approval for incontinence supplies, the prior approval form must indicate whether the client has a permanent or temporary need for incontinence supplies. Clients who have a permanent condition may be approved for up to two years of incontinence supplies rather than the standard one year.

When a client has been approved for a two-year period, the provider will receive an SA that allows the provider to bill Express Scripts Canada directly without contacting the NIHB regional office to get approval for dispenses during the approved period.

Please note: Clients with a temporary condition will continue to require an annual prescription/written recommendation. Providers will need to apply for prior approval if the request exceeds the recommended replacement guideline.

The following information is required when requesting coverage:

  • medical diagnosis that is the cause(s) of the incontinence
  • type of incontinence (bladder, bowel, or both)
  • when the incontinence occurs (day and/or night)
  • type of incontinence supplies needed
  • size of the incontinence supplies requested (does not apply to children's sizes or liners)
  • quantity of incontinence supplies needed
  • other supporting information (for example, temporary or permanent condition)

Note:

  • a medical justification is required for quantities in excess of 450 incontinence items per three-month period
  • NIHB does not provide coverage for diapers for children under 2 years of age
Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401088 Diaper, pull-up, adult LG or XL MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99401087 Diaper, pull-up, adult SM/MED MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99401089 Diaper, pull-up, adult XXL+ MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99400753 Diaper, pull-up, junior 4 & up MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months Child over 2 years of age
99400940 Diaper, pull-up, youth/adult XS MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months Child over 2 years of age
99401091 Diaper, tab, adult LG or XL MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99401090 Diaper, tab, adult SM or MED MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99401092 Diaper, tab, adult XXL+ MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99400752 Diaper, tab, junior 4 & up MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months Child over 2 years of age
99400939 Diaper, tab, youth/adult XS MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months Child over 2 years of age
99400438 Liners, disposable MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 450 every 3 months
99400755 Pant, incontinence, brief mesh, reusable MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 9 every 3 months

13.2.2 Underpads

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400442 Underpads, disposable MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 150 every 3 months NIHB provides coverage for disposable underpads for regular bowel care routine
99400443 Underpads, washable MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 6 per year Size up to 36" x 54"

13.2.3 Catheters

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400747 Catheter, adhesive strip, external MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400418 Catheter, external male, disposable MD, NP, NSWOC, WOCC(C), RN GEN Yes 90 every 3 months
99400419 Catheter, external male, reusable MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400420 Catheter, indwelling MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 4 every 3 months
99400421 Catheter, intermittent, disposable MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN No 360 every 3 months over 360 items combined requires prior approval
99401154 Catheter, intermittent, special MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes
99400423 Catheter, irrigation MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes
99400424 Catheter, plug MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400425 Catheter, tray catheterization MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes
99400426 Catheter, tray irrigation MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes
99400417 Catheter, adaptor connector closure MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400429 Drainage, leg bag, reusable MD, NP, NSWOC, WOCC(C), RN GEN Yes 4 per year
99400428 Drainage, night bag, disposable MD, NP, NSWOC, WOCC(C), RN GEN Yes 52 per year
99400434 Extension tubing MD, NP, NSWOC, WOCC(C), RN GEN Yes 52 per year
99400430 Leg bag without tubing disposable MD, NP, NSWOC, WOCC(C), RN GEN Yes 52 per year
99400431 Leg bag with tubing disposable MD, NP, NSWOC, WOCC(C), RN GEN Yes 52 per year
99400427 Leg strap for drainable bags MD, NP, NSWOC, WOCC(C), RN GEN Yes 52 per year
99400435 Lubricating jelly tube MD, NP, NSWOC, WOCC(C), RN GEN No 12 every 3 months 114g tube
99400919 Lubricating jelly/packet, single use MD, NP, NSWOC, WOCC(C), RN GEN No 400 every 3 months 3g packet
99400433 Night bottle, reusable MD, NP, NSWOC, WOCC(C), RN GEN Yes 4 per year

13.2.4 Devices

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400941 Pessary MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN No 1 every 6 months

13.3 Ostomy

13.3.1 One piece pouch

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400730 1pc drainable colostomy/ileostomy convex pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400906 1pc, closed-end, colostomy convex pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 120 every 3 months
99400905 1pc, closed-end, flat, colostomy pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 120 every 3 months
99400406 1pc, drainable, flat, colostomy/ ileostomy convex pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400732 1pc, urostomy convex pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400731 1pc, urostomy pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months

13.3.2 Two piece pouch

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400414 2pc, closed-end, colostomy/ileostomy pouch system MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 120 every 3 months
99400415 2pc, drainable, colostomy/ileostomy pouch system MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 30 every 3 months
99400742 2pc, flange for ostomy system MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400743 2pc, system flange/convex pouch system MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400745 2pc, system urostomy pouch MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 30 every 3 months

13.3.3 Ostomy supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400409 Absorbent flake/capsule MD, NP, NSWOC, WOCC(C), RN GEN Yes 2 per year Package of 90
99400763
  • Adaptor
  • Connector
  • Clamp ostomy/catheter
MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 12 per year
99400476 Adhesive remover MD, NP, NSWOC, WOCC(C), RN GEN Yes 6 boxes per year
99400400 Belt, ostomy MD, NP, NSWOC, WOCC(C), RN GEN Yes 3 per year
99400401 Convex insert MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 30 every 3 months
99400402 Filters MD, NP, NSWOC, WOCC(C), RN GEN Yes 2 boxes of 50 per year
99400403 Gel lubricant MD, NP, NSWOC, WOCC(C), RN GEN Yes 12 per year
99400884 Mouldable ring seal MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes
99400782 Mucus dispersant MD, NP, NSWOC, WOCC(C), RN GEN No
99400404 Odor control product, concentrated MD, NP, NSWOC, WOCC(C), RN GEN Yes 12 per year For inside pouch only
99400398 Ostomy, barrier powder MD, NP, NSWOC, WOCC(C), RN GEN Yes 3 every 3 months
99400737 Ostomy, irrigation kit MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 1 every 3 months
99400738 Ostomy, irrigation sleeve MD, NP, NSWOC, WOCC(C), RN GEN Yes 30 every 3 months
99400739 Plastic faceplate MD, NP, NSWOC, WOCC(C), RN GEN Yes 3 every 3 months
99400783 Pouch cover MD, NP, NSWOC, WOCC(C), RN GEN Yes 4 per year
99400411 Protective skin wipes/spray MD, NP, NSWOC, WOCC(C), RN GEN Yes 4 per year
99400408 Skin barrier, paste MD, NP, NSWOC, WOCC(C), RN GEN Yes 3 every 3 months
99400410 Skin barriers/wafer MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 50 every 3 months
99400412 Stoma cone for irrigation MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes 6 per year

13.4 Wound care

Dressings requiring a prior approval must include the following wound assessment information from an MD/RN/LPN/RPN/NP:

13.4.1 Adhesive

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400446 Adhesive suture strips MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400444 Adhesive tape, hypoallergenic MD, NP, NSWOC, WOCC(C), RN GEN No
99400445 Adhesive tape, non-hypoallergenic MD, NP, NSWOC, WOCC(C), RN GEN No
99400447 Montgomery ties MD, NP, NSWOC, WOCC(C), RN GEN No

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

Adhesive tape and suture
  • Blenderm (3M Health Care)
  • Cloth adhesive tape (3M Health Care)
  • Cover strip (3M Health Care)
  • Durapore (3M Health Care)
  • Gentac (Medline)
  • Hypafix (Smith & Nephew)
  • Kind removal silicone tape (3M Health Care)
  • Leukosan strip (BSN Medical)
  • Leukoplast sleek (BSN Medical)
  • Leukostrip (Smith & Nephew)
  • Medfix (Medline)
  • Medipore (3M Health Care)
  • Medipore H (3M Health Care)
  • Mefix (Mölnlycke)
  • Mepitac (Mölnlycke)
  • Micropore (3M Health Care)
  • Pink zinc oxide tape (Medline)
  • Shur strip wound closure strips (Derma Science)
  • Steri strips (3M Medical)
  • Suture strip slus (Derma Science)
  • Transpore (3M Health Care)
  • Ultrafix (Derma Science)
Montgomery ties
  • Montgomery straps (Medline)
  • Montgomery straps (Bioseal)
  • Montgomery straps (Deroyal)

13.4.2 Alginates/hydrofibres/ poly-absorbent fibres dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401155 Alginates/hydrofibres/ poly-absorbent fibres dressing, 5 cm × 5 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year Over 30 items combined requires prior approval
99401156 Alginates/hydrofibres/ poly-absorbent fibres dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400454 Alginates/hydrofibres/ poly-absorbent fibres dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Algicell calcium alginate (Derma Sciences)
  • Algisite M (Smith & Nephew)
  • Aquacel (ConvaTec)
  • Biatain alginate (Coloplast)
  • Curasorb (Covidien Kendall)
  • Cutinova hydro (Smith & Nephew)
  • Debrisan (Pharmacia & Upjohn)
  • Derma calcium alginate (Derma Science)
  • Exufiber (Mölnlycke)
  • Kaltostat (ConvaTec)
  • Maxorb II (Medline)
  • Melgisorb plus (Mölnlycke)
  • Mesalt (Mölnlycke)
  • Nu-derm alginate (Acelity)
  • Opticell (Medline)
  • Qwick (Medline)
  • Restore calcium alginate (Hollister)
  • Sorbsan (Pharma-Plast)
  • Sorbsan plus (Pharma-Plast)
  • Sorbsan SA (Pharma-Plast)
  • Tegaderm high gelling alginate (3M Health Care)
  • Tegaderm high integrity alginate (3M Health Care)
  • UrgoClean (Urgo Medical)

13.4.3 Bandage

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400448 Conforming gauze bandages MD, NP, NSWOC, WOCC(C), RN GEN No
99400449 Elastic bandages MD, NP, NSWOC, WOCC(C), RN GEN No 8 per year
99400450 Impregnated venous ulcer bandage MD, NP, NSWOC, WOCC(C), RN GEN No
99400451 Tubular net dressing MD, NP, NSWOC, WOCC(C), RN GEN No

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

Gauze bandages
  • Duform (Derma Sciences)
  • Dutex conforming bandages (Derma Sciences)
  • Easifix (BSN Medical)
  • Kerlix (Kendall Health care)
  • Kling (Johnson & Johnson)
Elastic bandages
  • Co-plus (BSN Medical)
  • Coban (3M Health Care)
  • Duban cohesive bandages (Derma Sciences)
  • Dusor elastic bandage (Derma Sciences)
  • Econo-san (BSN Medical)
  • Elastocrepe (Smith & Nephew)
  • Elastogrip (BSN Medical)
  • Surgigrip (Smith & Nephew)
  • Tensogrip (BSN Medical)
  • Tensor
  • Tubigrip (Mölnlycke)
Impregnated venous ulcer bandage
  • Calaband (Seton Healthcare Group plc)
  • Gelocast (BSN Medical)
  • Icthopaste (Smith & Nephew)
  • Primer unna boot (Derma Sciences)
  • Unna-Z (Medline)
  • Viscopaste PB7 (Smith & Nephew)
  • Zipzoc (Smith & Nephew)
Tubular net dressing
  • Flexinet (Derma Science)
  • Medi-grip (Medline)
  • Surgifix (Smith & Nephew)
  • Tubifast (Mölnlycke)

13.4.4 Charcoal dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401157 Charcoal dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year over 30 items combined requires prior approval
99400455 Charcoal dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Carbonet (Smith & Nephew)
  • Cliniflex (Clinimed)

13.4.5 Composite dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400811 Composite dressing MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Alldress (Mölnlycke)
  • Comfeel plus hydrocolloid combined with alginate (Coloplast)
  • Compdress (Derma Sciences)
  • Combiderm (ConvaTec)
  • Dudress (Derma Sciences)
  • Exu-dry (Smith & Nephew)
  • Leukomed (BSN Medical)
  • Mesorb (Mölnlycke)
  • Mextra superabsorbent (Mölnlycke)
  • Opsite post-op (Smith & Nephew)
  • Stratasorb (Medline)
  • Tegaderm + pad (3M Health Care)
  • Xtrasorb (Derma Science)

13.4.6 Eye

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400466 Eye pad MD, NP, RN GEN No
99400467 Eye shield MD, NP, RN GEN No

13.4.7 Foam adhesive dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401158 Foam non-adhesive dressing, 5 cm × 5 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year over 30 items combined requires prior approval
99401159 Foam non-adhesive dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99401160 Foam adhesive dressing, 7.5 cm × 7.5 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99401161 Foam adhesive dressing, 12.5 cm × 12.5 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400456 Foam dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Allevyn (Smith & Nephew)
  • Allevyn gentle border (Smith & Nephew)
  • Aquacel foam (ConvaTec)
  • Biatain (Coloplast)
  • Biatain IBU (Coloplast)
  • Biatain silicone (adhesive) (Coloplast)
  • Cutimed cavity (BSN Medical)
  • Cutimed siltec (BSN Medical)
  • Hydrofera blue foam dressing (Hollister)
  • Hydrocell (Derma Sciences)
  • Kendall AMD antimicrobial foam border (Covidien Kendall)
  • Kendall foam (Covidien Kendall
  • Tielle (Acelity)
  • Lyofoam (Seton Health Care Group)
  • Mepilex (Mölnlycke)
  • Mepilex transfer (Mölnlycke)
  • Mepilex border post-op (Mölnlycke)
  • Microfoam (3M Health Care)
  • Optifoam (Medline)
  • Polymem (Ferris Mfg Corp)
  • Restore foam dressing (Hollister)
  • Tegaderm foam high performance (3M Health Care)
  • Tegaderm high performance non-adhesive (3M Health Care)
  • Tegaderm silicone foam boarder (3M Health Care)

13.4.8 Gauze

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400457 Gauze, abdominal pad dressing MD, NP, NSWOC, WOCC(C), RN GEN No
99400196 Gauze, non-sterile dressing, 5 cm × 5 cm, (2 × 2) MD, NP, NSWOC, WOCC(C), RN GEN No
99400756 Gauze non-sterile dressing, 7.5 cm × 7.5 cm, (3 × 3) MD, NP, NSWOC, WOCC(C), RN GEN No
99400458 Gauze non-sterile dressing, 10 cm × 10 cm, (4 × 4) MD, NP, NSWOC, WOCC(C), RN GEN No
99400757 Gauze non-sterile dressing, 6 cm × 8 cm (2.36 × 3.14) MD, NP, NSWOC, WOCC(C), RN GEN No
99400459 Gauze sterile dressing, 5 cm × 5 cm, (2 × 2) MD, NP, NSWOC, WOCC(C), RN GEN No
99400759 Gauze sterile dressing, 7.5 cm × 7.5 cm, (3 × 3) MD, NP, NSWOC, WOCC(C), RN GEN No
99400760 Gauze sterile dressing, 10 cm × 10 cm, (4 × 4) MD, NP, NSWOC, WOCC(C), RN GEN No
99400468 Packing strip MD, NP, RN GEN No

13.4.9 Gel dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401162 Gels/hydrogels dressing, 8 g MD, NP, NSWOC, WOCC(C), RN GEN No 20 items per year over 20 items combined requires prior approval
99401163 Gels/hydrogels dressing, 15 g MD, NP, NSWOC, WOCC(C), RN GEN No
99401164 Gels/hydrogels dressing, 25 g MD, NP, NSWOC, WOCC(C), RN GEN No
99400460 Gels/hydrogels, dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Curafil (including curagel hydrogel impregnated gauze) (Covidien Kendall)
  • Cutimed gel (BSN Medical)
  • Duoderm Hydroactive Gel (ConvaTec)
  • Granugel (ConvaTec)
  • Hypergel (Mölnlycke)
  • Intrasite gel (Smith & Nephew
  • Intrasite conformable (Smith & Nephew)
  • Normlgel (Mölnlycke)
  • Nu-gel hydrogel (Acelity)
  • Purilon (Coloplast
  • Restore hydrogel dressing (Hollister)
  • Skintegrity gel (Medline)
  • Spenco 2nd skin (Spenco Medical)
  • Tegaderm hydrogel wound filler (3M Health Care)
  • Tegagel (3M Health Care)
  • Tenderwet (Medline)

13.4.10 Honey dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400901 Honey dressing MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Medi-honey (Derma Sciences)
  • Thera-honey (Medline)

13.4.11 Hydrocolloid dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401165 Hydrocolloid dressing, std, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year over 30 items combined requires prior approval
99401166 Hydrocolloid dressing, extra thin dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400461 Hydrocolloid dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Comfeel plus hydrocolloid combined with alginate (Coloplast)
  • Comfeel plus transparent hydrocolloid (Coloplast)
  • Duoderm (includes duoderm extra thin, duoderm signal) (ConvaTec)
  • Exuderm satin hydrocolloid (Medline)
  • Granuflex (ConvaTec)
  • Nu-derm hydrocolloid (Acelity)
  • Primacol (Derma Sciences)
  • Restore hydrocolloid dressing (Hollister)
  • Tegaderm hydrocolloid (3M Health Care)
  • Ultec (including ultec pro) (Covidien)

13.4.12 Iodine dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401180 Iodine gel (ointment), 10g tube MD, NP, NSWOC, WOCC(C), RN GEN No 10 items per year over 10 items combined requires prior approval
99401181 Iodine dressing (5g) dressing, 4 cm × 6 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400810 Iodine dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Inadine (Acelity)
  • Iodoflex (Smith & Nephew)
  • Iodosorb paste & ointment (Smith & Nephew)

13.4.13 Non-adherent dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401167 Non-adherent impregnated petroleum dressing, 7.5 cm × 7.5 cm MD, NP, NSWOC, WOCC(C), RN GEN No 50 items per year over 50 items combined requires prior approval
99401168 Non-adherent impregnated petroleum dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99401169 Non-adherent impregnated petroleum dressing, 7.5 cm × 20 cm — 3 strips MD, NP, NSWOC, WOCC(C), RN GEN No
99401170 Non-adherent impregnated chlorhexidine dressing, 5 cm × 5 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year over 30 items combined requires prior approval
99401171 Non-adherent impregnated chlorhexidine dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400462 Non-adherent impregnated dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes
99401172 Non-adherent non-impregnated dressing, 6 cm × 7 cm MD, NP, NSWOC, WOCC(C), RN GEN No 60 items per year over 60 items combined requires prior approval
99401173 Non-adherent non-impregnated dressing, 9 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400463 Non-adherent non-impregnated dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

Non-adherent impregnated dressing
  • Adaptic (Acelity)
  • Bactigras (Smith & Nephew)
  • Chlorhexitulle (Hoechst Morio Roussell)
  • Curad sterile oil emulsion gauze (Medline)
  • Cuticell (including cuticell classic) (BSN Medical)
  • Jelonet (Smith & Nephew)
  • Petrolatum gauze
  • Serotulle (Leo Laboratories)
  • Shur-conform (Derma Sciences)
  • Unitulle (Hoechst Marion Roussel)
  • Versatel (Medline)
Non-adherent non-impregnated dressing
  • Adaptic digit (Acelity)
  • Adaptic touch (Acelity)
  • Cuticell contact (BSN Medical)
  • Medipore + pad soft cloth adhesive (3M Health Care)
  • Melolin (Smith & Nephew)
  • Mepitel (Mölnlycke)
  • Mepore (Mölnlycke)
  • Primapad (Derma Sciences)
  • Primapore (Smith & Nephew)
  • Restore contact layer (Hollister)
  • Tegaderm wound contact layer (3M Health Care)
  • Tegapore (3M Health Care)
  • Telfa (Covidien-Kendall)

13.4.14 Silver dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401182 Silver alginate dressing, 10 cm × 10 cm MD, NP, NSWOC, WOCC(C), RN GEN No 20 items per year over 20 items combined requires prior approval
99401178 Silver alginate ribbon, 1.9 cm × 45.7 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99401177 Silver alginate ribbon, 1 cm × 45.7 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99401179 Silver alginate ribbon, 2.5 cm × 30.5 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400809 Silver dressing — other MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Acticoat 7 (Smith & Nephew)
  • Actisorb (Acelity)
  • Algicell ag (Derma Sciences)
  • Allevyn ag (Smith & Nephew)
  • Aquacel ag (ConvaTec)
  • Arglaes powder (Medline)
  • Biatain ag (Coloplast)
  • Interdry ag (Coloplast)
  • Maxorb extra ag (Medline)
  • Melgisorb ag (Mölnlycke)
  • Mepilex ag (Mölnlycke)
  • Opticell ag (Medline)
  • Optifoam ag (Medline)
  • Polymem silver (Ferris Mfg Corp)
  • Restore calcium alginate with silver (Hollister)
  • Restore contact layer with silver (Hollister)
  • Restore foam dressing with silver (Hollister)
  • Silvercel (including silvercel non adherent) (Acelity)
  • Sorbsan silver (Pharma-Plast)
  • Tegaderm ag mesh (3M Health Care)
  • Tegaderm alginate ag (3M Health Care)

13.4.15 Transparent dressing

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401174 Transparent dressing, 6 cm × 7 cm MD, NP, NSWOC, WOCC(C), RN GEN No 30 items per year over 30 items combined requires prior approval
99401175 Transparent dressing, 10 cm × 12 cm MD, NP, NSWOC, WOCC(C), RN GEN No
99400464 Transparent film adhesive dressing — other MD, NP, NSWOC, WOCC(C), RN GEN Yes
99400465 Transparent film dressing, spray MD, NP, NSWOC, WOCC(C), RN GEN Yes

NIHB is not endorsing any brand and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

  • Bioclusive plus (Acelity)
  • Hypafix transparent (BSN Medical)
  • IV3000 (Smith & Nephew)
  • Leukomed T (BSN Medical)
  • Mepitel film (Mölnlycke)
  • Opsite — all sizes (Smith & Nephew)
  • Opsite spray (Smith & Nephew)
  • Polyskin (Covidien)
  • Suresite (Medline)
  • Tegaderm absorbent acrylic clear dressing (3M Health Care)
  • Tegaderm transparent film (3M Health Care)

13.5 Supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400764 Dressing tray MD, NP, RN GEN Yes
99400318 Gloves latex or vinyl, 100bx MD, NP, RM, RN GEN No 12 per year
99400319 Irrigation solution (pour bottle) MD, NP, NSWOC, WOCC(C), RN, RM GEN No
99400320 Irrigation syringe (60cc fun tip) MD, NP, NSWOC, WOCC(C), RN, RM GEN No 52 per year
99400469 Sterile saline, pour bottle MD, NP, RN GEN No
99400818 Other recycled MS&E items MD, NP, OT, PT GEN Yes

13.6 Servicing

13.6.1 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400820 Delivery, incontinence item Yes
99401269 Delivery, medical surgical Yes
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