Medical Supplies and Equipment Benefit Lists

1.0 General medical supplies and equipment benefits list

See the General medical supplies and equipment benefits list for a full list of eligible products, prior approval requirements, recommended replacement guidelines, price, and prescriber and provider requirements.

For information on policies regarding the provision of general medical supplies and equipment, please consult the Guide for Medical Supplies and Equipment.

General medical supplies and equipment benefits list

List terminology

Item description:
Items are listed within general and specific categories (for example: Audiology), in alphabetical order by category and item.
Item code:
The 8-digit code that must be submitted to ESI Canada for billing purposes.
Prior approval:
Identifies by general category, or by item within the category, whether prior approval must be obtained by the provider before dispensing the item.
Recommended replacement guidelines:
Describe the maximum number of each item a client may receive over a given period of time (frequency). NIHB may consider coverage for exceptional requests for quantity and frequency limits on a case by case basis.
Prescriber type:
MD – Physician
NP – Nurse Practitioner
NSWOC – Nurse specialized in wound, ostomy and continence
O.D. – Doctor of Optometry (Optometrist)
OMT – Certified Opthalmic Technician/Medical Technologist working under Stanton Territorial Health Authority in NWT and Nunavut
OT – Occupational Therapist
PSY – Psychologist
PT - Physiotherapist
RM – Registered Midwife
RN – Registered Nurse
(RN renewals only) – Registered Nurse (initial prescription required from MD, NP, NSWOC, WOCC(C))
WOCC(C) – Wound, Ostomy and Continence Certified (C)anada
Provider type:
GEN – Enrolled General MS&E or Pharmacy Provider
Maximum price:
The NIHB Program has established a maximum price coverage for certain items. The maximum national prices are shown in the tables below (please note that in some cases a price grid has been established for the provinces and one for the territories). The maximum prices for each province and territory are listed on the Express Script Canada website and can be viewed by clicking on the appropriate link in the benefit listings.

When a maximum price is established by the Program, the provider cannot claim a markup on the reimbursement request since it is included in the price.

1.1 Bathing and toileting aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Bath chair 99400295 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Bath lift, battery 99400937 Yes 1 per year $250.00   GEN
Bath lift, battery powered purchase 99400474 Yes 1 every 4 years $1,175.00 MD, NP, OT, PT GEN
Bath lift, battery powered bariatric purchase 99400935 Yes 1 every 4 years $2,000.00 MD, NP, OT, PT GEN
Bath lift, battery powered rental 99400936 Yes   $250.00 MD, NP, OT, PT GEN
Bath lift, repairs 99400938 Yes       GEN
Bathing & toileting aid benefit, repairs 99400307 Yes       GEN
Bedpan 99400294 No 1 every 3 years   MD, NP, OT, RN GEN
Commode-standard, purchase 99400296 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Commode-wheeled, purchase 99400890 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Commode, rental 99400297 Yes     MD, NP, OT, PT, RN GEN
Elevated (raised) toilet seat (standard) 99400298 No 1 every 3 years Price File MD, NP, OT, PT, RN GEN
Elevated (raised) toilet seat (with arms) 99400299 No 1 every 3 years Price File MD, NP, OT, PT, RN GEN
Grab bar for tub (non-permanent) 99400649 No 1 every 3 years Price File MD, NP, OT, PT, RN GEN
Inspection mirror 99400877 Yes Lifetime   MD, NP, OT, PT, RN GEN
Mat, tub, non-slip 99400301 No 1 every 2 years Price File MD, NP, OT, PT, RN GEN
Safety frame for toilet 99400302 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Shower-commode chair 99400303 Yes 1 every 5 years   MD, NP, OT, PT, RN GEN
Toilet tissue aid 99400878 Yes 1 every 5 years   MD, NP, OT, PT, RN GEN
Tub transfer, bench 99400304 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Tub transfer, board 99400305 Yes 1 every 5 years   MD, NP, OT, PT, RN GEN
Urinal 99400306 No 1 every 3 years   MD, NP, OT, PT, RN GEN

1.2 Cushions and protectors

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Elbow protector 99400308 No 1 every 5 years   MD, NP, OT, PT RN GEN
Heel protector, 1 pair 99400310 No 1 per year   MD, NP, OT, PT, RN GEN
Invalid ring 99400311 No 1 every 3 years   MD, NP, OT, PT, RM, RN GEN
Leg lifter 99400309 No 1 every 5 years   MD, NP, OT, PT, RN GEN
Positioning wedge 99400315 Yes 1 every 3 years $87.00 MD, NP, OT, PT, RN GEN
Quad knee separator 99400316 No 1 every 3 years   MD, NP, OT, PT GEN

1.3 Environmental Aids

1.3.1 Dressing aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Button hook 99400277 No 1 every 5 years MD, NP, OT, PT, RN GEN
Dressing hook 99400278 No 1 every 5 years MD, NP, OT, PT, RN GEN
Long handle shoe horn 99400279 No 1 every 5 years MD, NP, OT, PT, RN GEN
Reacher 99400280 No 1 every 5 years MD, NP, OT, PT, RN GEN
Sock/stocking aid 99400281 No 1 every 5 years MD, NP, OT, PT, RN GEN

1.3.2 Feeding aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Backpack for feeding pump 99401124 Yes 1 per year $100.00 MD, NP, OT, RN GEN
Built-up handle OR universal cuff 99400287 No 1 every 5 years   MD, NP, OT, RN GEN
Enteral feeding buttons 99400767 Yes 3 per year   MD, NP GEN
Enteral feeding supplies, adaptors/plugs 99400657 No 12 per year   MD, NP GEN
Feeding aid, Benefit Repairs 99400293 Yes       GEN
Feeding pump bags 99400285 No 250 per year   MD, NP, RN GEN
Feeding pump rental 99400282 Yes     MD, NP, RN GEN
Feeding pump purchase 99400283 Yes 1 every 5 years   MD, NP, RN GEN
Feeding pump pole (IV pole) 99400284 Yes Lifetime   MD, NP, OT, RN GEN
Food guard 99400288 No 1 every 5 years   MD, NP, OT, RN GEN
Gravity feeding supplies, delivery sets with bags 99400651 No 250 per year   MD, NP, RN GEN
Gravity feeding supplies, delivery sets without bags 99400652 No 250 per year   MD, NP, RN GEN
Gravity feeding supplies, bags 99400653 No 250 per year   MD, NP, RN GEN
Gravity feeding supplies, rigid containers 99400654 No 24 per year   MD, NP, RN GEN
Mat, feeding aids, non-slip 99400289 No 1 every 5 years   MD, NP, OT, RN GEN
Other enteral feeding supplies, gastrostomy catheters/tubes 99400655 No 12 per year   MD, NP, RN GEN
Other enteral feeding supplies, nasogastric tube 99400286 No 24 per year   MD, NP, RN GEN
Other enteral feeding supplies, extension sets 99400656 No 12 per year   MD, NP, RN GEN
Overbed table, purchase 99401133 Yes   $140.00 MD, NP, OT, PT, RN GEN
Overbed table, rental 99401145 Yes     MD, NP, OT, PT, RN GEN
Specialized utensils, fork or spork 99400290 No Every 5 years   MD, NP, OT, PT, RN GEN
Specialized utensils, knife 99400291 No Every 5 years   MD, NP, OT, PT, RN GEN
Specialized utensil, spoon 99400292 No Every 5 years   MD, NP, OT, PT, RN GEN
Syringe Luer Lock, disposable, 3cc 99400530 No 52 per year   MD, NP, RN GEN
Syringe Luer Lock, disposable, 5cc 99400535 No 52 per year   MD, NP, RN GEN
Syringe Luer Lock, disposable, 10cc 99400539 No 52 per year   MD, NP, RN GEN
Syringe Luer Lock, disposable, 20cc 99400548 No 52 per year   MD, NP, RN GEN

1.3.3 Miscellaneous supplies and equipment

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Blood pressure monitor with arm cuff, electronic 99400765 No 1 every 5 years $100.00 MD, NP, RM GEN
Breast pump, manual 99400317 No One per birth event $66.00 MD, NP, RM, RN GEN
Breast pump, electric, rental 99400658 Yes     MD, NP, RM, RN GEN
Gloves, latex/vinyl, 100/box 99400318 No 12 boxes per year   MD, NP, RM, RN GEN
Irrigation solution (large volume, pour bottle) 99400319 No     MD, NP, RM, RN GEN
Irrigation syringe (60cc funnel tip) 99400320 No 52 per year   MD, NP, RN GEN
Maternity belt 99400933 No 1 per pregnancy $70.00 MD, NP, PT, RM, RN GEN
Medic Alert Bracelet (standard) 99400471 Yes Lifetime   MD, NP, RN GEN
Nipple Shields 99400932 No 6 shields every 3 months. Maximum coverage of 6 months $15.00 per unit MD, NP, RM, RN GEN
Other recycled MS&E items 99400818 Yes     MD, NP, OT, PT GEN

1.3.4 Lifting and transfer aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Floor to ceiling pole 99400321 No Lifetime Price File MD, NP, OT, PT GEN
Grab bar, bed, purchase 99400322 No 1 every 10 years Price File MD, NP, OT, PT, RN GEN
Grab bar, bed, rental 99400323 Yes     MD, NP, OT, PT, RN GEN
Lift, hydraulic powered 99400324 Yes 1 every 10 years   MD, NP, OT, PT GEN
Lift, hydraulic, standard 99400325 Yes 1 every 10 years   MD, NP, OT, PT GEN
Recycled lift hydraulic, powered 99400817 Yes 1 every 10 years   MD, NP, OT, PT GEN
Recycled lift hydraulic, standard 99400816 Yes 1 every 10 years   MD, NP, OT, PT GEN
Sling/hammock 99400326 Yes 2 every 2 years   MD, NP, OT, PT, RN GEN
Transfer Belt 99400327 No 1 per year   MD, NP, OT, PT, RN GEN
Transfer Board 99400328 No 1 every 10 years   MD, NP, OT, PT, RN GEN
Trapeze, purchase 99400329 Yes Lifetime $658.00 MD, NP, OT, PT GEN
Trapeze, bariatric purchase 99401134 Yes Lifetime $1188.00 MD, NP, OT, PT GEN
Trapeze, rental 99400330 Yes     MD, NP, OT, PT GEN
Lifting/transfer Aid, Repairs 99400331 Yes       GEN

1.4 Gender affirming products

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Brassiere (For Bra Inserts) 99400922 No 2 every 2 years $60.00 MD, NP, PSY GEN
Bra Inserts (Pair) 99400921 No 1 every 2 years $200.00 MD, NP, PSY GEN
Lower Body Garment (e.g. gaff) 99400923 No 2 per year $70.00 MD, NP, PSY GEN
Packer (Phallus) 99400924 No 1 per year $95.00 MD, NP, PSY GEN
Packer Securement 99400926 No 1 per year $110.00 MD, NP, PSY GEN
Packer With STP 99400925 No 1 per year $135.00 MD, NP, PSY GEN
Delivery, gender identity 99400930 No       GEN
Stand to Pee (STP) Device 99400927 No 1 per year $40.00 MD, NP, PSY GEN
Upper Body Garment (e.g. binder) 99400920 No 2 per year $90.00 MD, NP, PSY GEN
Vaginal Dilator Kit 99400928 No 1 every 5 years $120.00 MD, NP, PSY GEN
Vaginal Dilator – Single 99400929 No 1 every 5 years $50.00 MD, NP, PSY GEN

1.5 Mobility aids

1.5.1 Walking aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Cane, aluminum adjustable, quad 99400333 No Lifetime   MD, NP, OT, PT, RN GEN
Cane, single 99400332 No Lifetime   MD, NP, OT, PT, RN GEN
Crutches, axillary - purchase, pair 99400335 No Every 2 years   MD, NP, OT, PT, RN GEN
Crutches, axillary - rental, pair 99400336 Yes     MD, NP, OT, PT, RN GEN
Crutches, specialized, purchase, pair (forearm) 99400337 Yes Every 5 years   MD, NP, OT, PT GEN
Walker, standard, purchase 99400338 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Walker, standard, rental 99400339 Yes     MD, NP, OT, PT, RN GEN
Walker, standard, recycled 99400812 Yes 1 every 5 years   MD, NP, OT, PT, RN GEN
Walker, 2 wheel, purchase 99400931 No 1 every 5 years Price File MD, NP, OT, PT, RN GEN
Walker, 4 wheel, purchase 99400340 No 1 every 5 years Price File MD, NP, OT, PT GEN
Walker, 4 wheel bariatric, purchase 99400934 No 1 every 5 years Price File MD, NP, OT, PT GEN
Walker, wheeled, recycled 99400813 Yes 1 every 5 years   MD, NP, OT, PT, RN GEN
Walker, wheeled, rental 99400341 Yes     MD, NP, RN GEN
Walker, repairs 99400342 Yes       GEN

1.5.2 Walking aids - accessories

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Crutch, hand grips 99400343 No 2 per year MD, NP, OT, PT, RN GEN
Crutch, pads 99400344 No 2 per year MD, NP, OT, PT, RN GEN
Crutch, Tips (ice picks) 99400345 No 1 every 2 years MD, NP, OT, PT, RN GEN
Crutch, Tips (rubber) 99400346 No 1 per year MD, NP, OT, PT, RN GEN
Walker, glide brakes 99400347 No Every 2 years
MD, NP, RN GEN
Walker, skis, set of 2 99400879 No Every 2 years MD, NP, OT, PT, RN GEN
Walker, Tray/pouch 99400880 No 1 every 5 years MD, NP, OT, PT, RN GEN
Walker, wheels 99400348 No Every 2 years MD, NP, OT, PT, RN GEN

1.5.3 Wheelchairs and medical stroller

Item Description Item Code Prior Approval Recommended Replacement guidelines Maximum Price Prescriber Provider
Back-up, manual, wheelchair purchase 99400942 Yes 1 every 5 years   MD, NP, OT, PT GEN
Medical stroller 99400891 Yes 1 every 5 years   MD, NP, OT, PT GEN
Wheelchair, labour 99401144 Yes       GEN
Wheelchair, manual, purchase 99400349 NoFootnote * 1 every 5 years Price File MD, NP, OT, PT GEN
Wheelchair, manual, recycled purchase 99400814 Yes 1 every 5 years   MD, NP, OT, PT GEN
Wheelchair, manual, rental 99400350 Yes     MD, NP, OT, PT GEN
Wheelchair, manual repair 99401223 Yes 1 repair per year after warranty expires $200.00   GEN
Wheelchair, power, purchase 99400785 Yes 1 every 5 years   MD, NP, OT, PT GEN
Wheelchair, power, recycled purchase 99400815 Yes 1 every 5 years   MD, NP, OT, PT GEN
Wheelchair, power, rental 99400918 Yes     MD, NP, OT, PT GEN
Wheelchair, Power repair 99401201 Yes 1 repair per year after warranty expires $500.00 GEN
Wheelchair cushions and parts (back support)
Item Description Item Code Prior Approval Recommended Replacement Guidelines PrescriberFootnote ** Provider
Back, support, child 99400660 Yes 1 every 2 years MD, NP, OT, PT GEN
Back, support, adult 99400357 Yes 1 every 3 years MD, NP, OT, PT GEN
Back support cover, child 99400661 Yes 1 every 2 years MD, NP, OT, PT GEN
Back support cover, adult 99400662 Yes 1 every 2 years MD, NP, OT, PT GEN
Wheelchair cushions and parts (seats)
Item Description Item Code Prior Approval Recommended Replacement Guidelines PrescriberFootnote ** Provider
Cover for seat, child 99400668 Yes 1 every 2 years MD, NP, OT, PT GEN
Cover for seat, adult 99400361 Yes 1 every 2 years MD, NP, OT, PT GEN
Pelvic stabilizer, one, child 99400666 Yes 1 every 3 years MD, NP, OT, PT GEN
Pelvic stabilizer, one, adult 99400367 Yes 1 every 5 years MD, NP, OT, PT GEN
Pelvic stabilizer, pair, child 99400667 Yes 1 every 3 years MD, NP, OT, PT GEN
Pelvic stabilizer, pair, adult 99400368 Yes 1 every 5 years MD, NP, OT, PT GEN
Seat, adult 99400363 Yes 1 every 3 years MD, NP, OT, PT GEN
Seat, child 99400669 Yes 1 every 2 years MD, NP, OT, PT GEN
Wheelchair cushions (back & seat) repairs 99400673 Yes     GEN
Wheelchair cushions and parts
Item Description Item Code Prior Approval Recommended Replacement Guidelines PrescriberFootnote ** Provider
Amputation board 99400881 Yes 1 every 5 years MD, NP, OT, PT GEN
Arm rest, fixed support, one piece 99400372 Yes   MD, NP, OT, PT GEN
Arm rest, fixed support, one piece, pads 99400674 Yes   MD, NP, OT, PT GEN
Arm rest, fixed support, one piece, hardware 99400675 Yes   MD, NP, OT, PT GEN
Arm rest, fixed support, multi component 99400676 Yes   MD, NP, OT, PT GEN
Arm rest, fixed support, multi components, pad 99400677 Yes   MD, NP, OT, PT GEN
Arm rest, fixed support, multi components, hardware 99400678 Yes   MD, NP, OT, PT GEN
Arm rest, movable 99400679 Yes   MD, NP, OT, PT GEN
Axle plate 99400373 Yes   MD, NP, OT, PT GEN
Batteries power wheelchair, pair 99400882 Yes 1 per year   GEN
Brakes 99400883 Yes   MD, NP, OT, PT GEN
Calf board, child 99400681 Yes   MD, NP, OT, PT GEN
Calf board, adult 99400682 Yes   MD, NP, OT, PT GEN
Castor 99400376 Yes   MD, NP, OT, PT GEN
Castor fork 99400377 Yes   MD, NP, OT, PT GEN
Castor housing 99400378 Yes   MD, NP, OT, PT GEN
Castor housing dust cover 99400379 Yes   MD, NP, OT, PT GEN
Castor plate 99400380 Yes   MD, NP, OT, PT GEN
Crossbrace 99400381 Yes   MD, NP, OT, PT GEN
Elevating leg rest/foot rest 99400382 Yes   MD, NP, OT, PT GEN
Footplate 99400383 Yes   MD, NP, OT, PT GEN
Footplate extension 99400683 Yes   MD, NP, OT, PT GEN
Foot rest 99400684 Yes   MD, NP, OT, PT GEN
Foot box, child 99400690 Yes   MD, NP, OT, PT GEN
Foot box, adult 99400691 Yes   MD, NP, OT, PT GEN
Foot pocket, child 99400692 Yes   MD, NP, OT, PT GEN
Foot pocket, adult 99400693 Yes   MD, NP, OT, PT GEN
Front rigging 99400384 Yes   MD, NP, OT, PT GEN
Growable frame 99400385 Yes   MD, NP, OT, PT GEN
Handrim 99400386 Yes   MD, NP, OT, PT GEN
Head rest 99400694 Yes   MD, NP, OT, PT GEN
Heel loop 99400387 Yes   MD, NP, OT, PT GEN
Interfacing/mounting, strap, children only 99400702 Yes   MD, NP, OT, PT GEN
Interfacing/mounting, simple seat 99400703 Yes   MD, NP, OT, PT GEN
Interfacing/mounting, simple back 99400704 Yes   MD, NP, OT, PT GEN
Interfacing/mounting, simple 99400705 Yes   MD, NP, OT, PT GEN
Interfacing mounting, complex 99400706 Yes   MD, NP, OT, PT GEN
Miscellaneous parts, manual wheelchair 99400943 Yes     GEN
Miscellaneous parts, power wheelchair 99400944 Yes     GEN
Neck rest, adjustable, child 99400707 Yes   MD, NP, OT, PT GEN
Neck rest, adjustable, adult 99400708 Yes   MD, NP, OT, PT GEN
Neck rest with headrest, adjustable, child 99400709 Yes   MD, NP, OT, PT GEN
Neck rest with headrest, adjustable, adult 99400710 Yes   MD, NP, OT, PT GEN
Pommel, fixed, child 99400711 Yes   MD, NP, OT, PT GEN
Pommel, fixed, adult 99400712 Yes   MD, NP, OT, PT GEN
Pommel, removable, child 99400713 Yes   MD, NP, OT, PT GEN
Pommel, removable, adult 99400714 Yes   MD, NP, OT, PT GEN
Positioning, ankle 99400715 Yes   MD, NP, OT, PT GEN
Positioning, butterfly 99400716 Yes   MD, NP, OT, PT GEN
Positioning, calf 99400375 Yes   MD, NP, OT, PT GEN
Positioning, chest 99400717 Yes   MD, NP, OT, PT GEN
Positioning, complex 99400718 Yes   MD, NP, OT, PT GEN
Positioning, pads 99400719 Yes   MD, NP, OT, PT GEN
Positioning, pelvic belt, child 99400720 Yes   MD, NP, OT, PT GEN
Positioning, pelvic belt, adult 99400392 Yes   MD, NP, OT, PT GEN
Push handle/backrest tube 99400388 Yes   MD, NP, OT, PT GEN
Push to lock wheel locks 99400389 Yes   MD, NP, OT, PT GEN
Quick-release axle pin 99400390 Yes   MD, NP, OT, PT GEN
Rear Wheel Hub 99400391 Yes   MD, NP, OT, PT GEN
Seat sling/rigid 99400393 Yes   MD, NP, OT, PT GEN
Spokes 99400394 Yes   MD, NP, OT, PT GEN
Tire 99400395 Yes   MD, NP, OT, PT GEN
Tray, elevating, child 99400721 Yes 1 every 2 years MD, NP, OT, PT GEN
Tray, elevating, adult 99400722 Yes 1 every 5 years MD, NP, OT, PT GEN
Tray, standard, child 99400723 Yes 1 every 2 years MD, NP, OT, PT GEN
Tray, standard, adult 99400724 Yes 1 every 5 years MD, NP, OT, PT GEN
Tray, tilting, child 99400725 Yes 1 every 2 years MD, NP, OT, PT GEN
Tray, tilting, adult 99400726 Yes 1 every 5 years MD, NP, OT, PT GEN
Wheel lock 99400396 Yes   MD, NP, OT, PT GEN

1.5.4 Miscellaneous

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Delivery of equipment 99400819 Yes     GEN

1.6 Ostomy supplies and devices

Item Description Item Code Price for Province Price for Territories Prior Approval Replacement Guidelines Prescriber Provider
One-piece urostomy pouch, flat 99400731 $14.03 $16.02 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
One-piece urostomy pouch, convex 99400732 $14.44 $16.51 Yes 50 every 3 months
MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Two-piece urostomy pouch 99400745 $6.73 $7.70 Yes 30 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Flange - Flat 99400742 $9.78 $11.18 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Flange - Convex 99400743 $13.78 $15.75 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
One-piece, Drainable, Flat, Colostomy/Ileostomy pouch 99400406 $8.46 $9.68 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
One-piece, Drainable, Convex, Colostomy/Ileostomy pouch 99400730 $12.54 $14.33 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
One-piece, Closed, Flat, Colostomy/Ileostomy pouch 99400905 $5.06 $5.80 Yes 120 every 3 months MD, NP, NSWOC, WOCC(C) , (RN renewals only) GEN
One-piece, Closed, Convex, Colostomy/Ileostomy pouch 99400906 $7.39 $8.44 Yes 120 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Two-piece, Closed, Colostomy/Ileostomy Pouch 99400414 $3.37 $3.85 Yes 120 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Two-piece, Drainable, Colostomy/Ileostomy Pouch 99400415 $6.53 $7.45 Yes 30 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Ostomy supplies and devices
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Absorbent flakes/capsules 99400409 Yes 2 pkgs of 90 per year MD, NP, NSWOC, WOCC(C), RN GEN
Adaptor/connector/clamp ostomy/cat 99400763 Yes 12 per year MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Adhesive removers 99400476 Yes 6 boxes per year MD, NP, NSWOC, WOCC(C), RN GEN
Belt, ostomy 99400400 Yes 3 per year MD, NP, NSWOC, WOCC(C), RN GEN
Convex inserts 99400401 Yes 30 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Filters 99400402 Yes 2 boxes of 50 per year MD, NP, NSWOC, WOCC(C), RN GEN
Gel lubricant 99400403 Yes 12 per year MD, NP, NSWOC, WOCC(C), RN GEN
Irrigation kit for ostomies 99400737 Yes 1 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Moldable ring seals 99400884 Yes   MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Mucus dispersant 99400782 No   MD, NP, NSWOC, WOCC(C), RN GEN
Odor control product concentrate (for inside pouch only) 99400404 Yes 12 per year MD, NP, NSWOC, WOCC(C), RN GEN
Ostomy barrier powder 99400398 Yes 3 every 3 months MD, NP, NSWOC, WOCC(C), RN GEN
Ostomy irrigation sleeves 99400738 Yes 30 every 3 months MD, NP, NSWOC, WOCC(C), RN GEN
Plastic faceplate 99400739 Yes 3 every 3 months
MD, NP, NSWOC, WOCC(C), RN GEN
Pouch cover 99400783 Yes 4 per year MD, NP, NSWOC, WOCC(C), RN GEN
Protective skin wipes/spray 99400411 Yes 4 boxes per year MD, NP, NSWOC, WOCC(C), RN GEN
Skin barrier/wafer 99400410 Yes 50 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Skin barrier paste 99400408 Yes 3 every 3 months MD, NP, NSWOC, WOCC(C), RN GEN
Stoma cone for irrigation 99400412 Yes 6 cones per year MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN

1.7 Urinary supplies and equipment

1.7.1 Catheter supplies and equipment

Item Description Item Code Prior Approval Recommended Replacement Guidelines Max Price Prescriber Provider
Adaptors/connectors/ closures (catheters) 99400417 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Adhesive strips, generic, for external catheters 99400747 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Catheter plug 99400424 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Catheter tray, catheterization 99400425 Yes     MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Catheter tray, irrigation 99400426 Yes     MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Drainage night bags, disposable 99400428 Yes 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Drainage leg bags, reusable 99400429 Yes 4 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Extension tubing 99400434 Yes 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
External catheters, disposable 99400418 Yes 90 every 3 months   MD, NP, NSWOC, WOCC(C), RN GEN
External catheters, reusable 99400419 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Indwelling catheters 99400420 Yes 4 every 3 months   MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Irrigation catheters 99400423 Yes     MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Irrigation solution 99400319 No     MD, NP, NSWOC, WOCC(C), RN GEN
Irrigation syringe 99400320 No 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Leg bags, w/out tubing, disposable 99400430 Yes 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Leg bags, with tubing, disposable 99400431 Yes 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Leg straps for drainage bags 99400427 Yes 52 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Lubricating jelly/packet, single use (based on a 3 g single use packet) 99400919 No 400 packets every 3 months $0.11 per packet MD, NP, NSWOC, WOCC(C), RN GEN
Lubricating jelly tube (based on a 114 g tube) 99400435 No 12 tubes every 3 months $3.57 per tube MD, NP, NSWOC, WOCC(C), RN GEN
Night bottle, reusable 99400433 Yes 4 per year   MD, NP, NSWOC, WOCC(C), RN GEN
Pessary 99400941 No 1 every 6 months $120.00 MD, NP GEN
Regular intermittent catheter 99400421 No 360 total every 3 months (any combination of these 2 items) $1.70 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Specialized intermittent catheter 99401154 Yes $3.07 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN

1.7.2 Incontinence supplies

Item Code Price for Province Price for Territories Prior Approval Replacement Guidelines Prescriber Provider
Diaper/ Pull-Ups, Jr Size 4 & up (for children over 2 years of age only) 99400753 $1.20 $1.37 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Pull-Ups Youth/XS Adult 99400940 $1.25 $1.42 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diapers/Pull-Ups Adult, Small or Medium 99401087 $1.35 $1.53 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diapers/Pull-Ups Adult, Large or Extra Large 99401088 $1.44 $1.66 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diapers/Pull-Ups, XXX Large 99401089 $1.65 $1.87 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Tabs, Jr Size 4 & up (for children over 2 years of age only) 99400752 $0.95 $1.09 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Tabs Youth/XS Adult 99400939 $1.05 $1.21 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Tabs Adult, Small or Medium 99401090 $1.07 $1.24 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Tabs Adult, Large or Extra Large 99401091 $1.32 $1.50 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Diaper/Tabs Adult, XX or XXX Large 99401092 $1.54 $1.77 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Delivery incontinence items 99400820     Yes     GEN
Liners, Disposable 99400438 $0.60 $0.69 Yes 450 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Pant, (brief) mesh, reusable 99400755 $3.43 $3.43 Yes 9 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Underpads, disposable 99400442 $0.50 $0.61 Yes 150 every 3 months MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Underpads, washable (for size up to 36" x 54")
99400443 $20.28 $20.28 Yes 6 per year MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN

1.8 Wound care products (by product type)

For a list by Product Brand Name, please refer to the Wound Care Products List.

1.8.1 Adhesive tapes and dressing strips

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Adhesive suture strips 99400446 Yes   MD, NP, NSWOC, WOCC(C), RN GEN
Adhesive tape, hypoallergenic 99400444 No   MD, NP, NSWOC, WOCC(C), RN GEN
Adhesive tape, non-hypoallergenic 99400445 No   MD, NP, NSWOC, WOCC(C), RN GEN
Montgomery ties (set) 99400447 No   MD, NP, NSWOC, WOCC(C), RN GEN

1.8.2 Bandages

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Conforming gauze bandages 99400448 No   MD, NP, NSWOC, WOCC(C), RN GEN
Elastic bandages 99400449 No 8 per year MD, NP, NSWOC, WOCC(C), RN GEN
Impregnated venous ulcer bandages 99400450 No   MD, NP, NSWOC, WOCC(C), RN GEN
Tubular net dressing 99400451 No   MD, NP, NSWOC, WOCC(C), RN GEN

1.8.3 Dressings

Please contact your regional office to obtain a prior approval if the maximum amount of items per year or the price per unit is exceeded.

Item Description Item Code Prior Approval Frequency Maximum Price Per Item Prescriber Provider
Alginate/Hydrofibre dressing - other 99400454 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Alginate/Hydrofibre dressing, 5 cm × 5 cm 99401155 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$6.80 MD, NP, NSWOC, WOCC(C), RN GEN
Alginate/Hydrofibre dressing, 10 cm × 10 cm 99401156 $16.47 MD, NP, NSWOC, WOCC(C), RN GEN
Charcoal dressing - other 99400455 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Charcoal dressing, 10 cm × 10 cm 99401157 See Frequency
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$10.69 MD, NP, NSWOC, WOCC(C), RN GEN
Composite dressing 99400811 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Foam dressing medicated/non-medicated - other 99400456 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Foam, non-adhesive dressing, 5 cm × 5 cm 99401158 See Frequency For any combination of these 4 items:
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$4.40 MD, NP, NSWOC, WOCC(C), RN GEN
Foam, non-adhesive dressing, 10 cm × 10 cm 99401159 $10.95 MD, NP, NSWOC, WOCC(C), RN GEN
Foam, adhesive dressing, 7.5 cm × 7.5 cm 99401160 $5.52 MD, NP, NSWOC, WOCC(C), RN GEN
Foam, adhesive dressing, 12.5 cm × 12.5 cm 99401161 $12.02 MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, non-sterile, 5 cm × 5 cm, (2 × 2) 99400196 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, non-sterile, 7.5 cm × 7.5 cm, (3 × 3) 99400756 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, non-sterile, 10 cm × 10 cm, (4 × 4) 99400458 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, non-sterile, 6 cm × 8 cm, (2.36 in × 3.15 in) 99400757 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, sterile, 5 cm × 5 cm, (2 × 2) 99400459 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, sterile, 7.5 cm × 7.5 cm, (3 × 3) 99400759 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, sterile, 10 cm × 10 cm, (4 × 4) 99400760 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gauze, sterile abdominal pad 99400457 No     MD, NP, NSWOC, WOCC(C), RN GEN
Gel/hydrogel dressing – other 99400460 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Gel/hydrogel dressing, 8 g 99401162 See Frequency For any combination of these 3 items:
  • no prior approval required for up to 20 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$5.30 MD, NP, NSWOC, WOCC(C), RN GEN
Gel/hydrogel dressing, 15 g 99401163 $7.47 MD, NP, NSWOC, WOCC(C), RN GEN
Gel/hydrogel dressing, 25 g 99401164 $11.36 MD, NP, NSWOC, WOCC(C), RN GEN
Honey Dressing 99400901 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Hydrocolloid dressing - other 99400461 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Hydrocolloid dressing, standard, 10 cm × 10 cm 99401165 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$12.17 MD, NP, NSWOC, WOCC(C), RN GEN
Hydrocolloid dressing, extra thin, 10 cm × 10 cm 99401166 $7.67 MD, NP, NSWOC, WOCC(C), RN GEN
Iodine dressing – other 99400810 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Iodine gel (ointment), 10 g tube 99401180 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 10 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$25.68 MD, NP, NSWOC, WOCC(C), RN GEN
Iodine dressing, 5 g, 4 cm × 6 cm 99401181 $15.09 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated - other 99400462 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated, petrolatum, 7.5 cm × 7.5 cm 99401167 See Frequency For any combination of these 3 items:
  • no prior approval required for up to 50 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$1.58 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated, petrolatum, 10 cm × 10 cm 99401168 $1.89 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated, petrolatum, 7.5 cm × 20 cm – 3 strips 99401169 $2.81 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated, chlorhex, 5 cm × 5 cm 99401170 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$1.13 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, impregnated, chlorhex, 10 cm × 10 cm 99401171 $2.56 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, non-impregnated 99400463 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, non-impregnated, 6 cm × 7 cm 99401172 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 60 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$0.58 MD, NP, NSWOC, WOCC(C), RN GEN
Non-adherent dressing, non-impregnated, 9 cm × 10 cm 99401173 $0.66 MD, NP, NSWOC, WOCC(C), RN GEN
Silver dressing – other 99400809 Yes     MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Silver alginate dressing, 10 cm × 10 cm 99401182 See Frequency For any combination of these 4 items:
  • no prior approval required for up to 20 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$29.16 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Silver alginate ribbon, 1 cm × 45.7 cm 99401177 $33.71 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Silver alginate ribbon, 1.9 cm × 45.7 cm 99401178 $34.94 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Silver alginate ribbon, 2.5 cm × 30.5 cm 99401179 $31.38 MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN
Transparent dressing, adhesive, 6 cm × 7 cm 99401174 See Frequency For any combination of these 2 items:
  • no prior approval required for up to 30 items per year, while adhering to the maximum price per item
  • prior approval is required above the maximum quantity or price
$0.41 MD, NP, NSWOC, WOCC(C), RN GEN
Transparent dressing, adhesive, 10 cm × 12 cm 99401175 $2.30 MD, NP, NSWOC, WOCC(C), RN GEN
Transparent film dressing, adhesive – other 99400464 Yes     MD, NP, NSWOC, WOCC(C), RN GEN
Transparent film dressing, (spray-on) 99400465 Yes     MD, NP, NSWOC, WOCC(C), RN GEN

1.8.4 Other dressings

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Eye pads 99400466 No   MD, NP, RN GEN
Eye shield 99400467 No   MD, NP, RN GEN
Packing strips 99400468 No   MD, NP, RN GEN
Sterile saline, pour bottle 99400469 No   MD, NP, RN GEN

1.9 Low vision aids

Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Coloured filters 99400873 Yes   O.D., OMT GEN
Face cradle, rental 99400876 Yes   O.D., OMT GEN
Illuminated magnifier - handle 99400870 Yes   O.D., OMT, OT GEN
Illuminated magnifier - head 99400869 Yes   O.D., OMT, OT GEN
Magnifier 99400868 Yes   O.D., OMT, OT GEN
Microscope 99400871 Yes   O.D., OMT GEN
Telescope/monocular 99400872 Yes   O.D., OMT GEN
White cane 99400874 Yes   O.D., OMT GEN
White cane tips 99400875 Yes 3 per year O.D., OMT GEN
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