The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 1

The All Wales Lymphoedema Compression Garment Formulary

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 2

The All Wales Lymphoedema Compression Garment Contract commenced on March 1st 2015. All current stock must be used prior to changing to the

contract. However any new garments to be ordered must comply with the contract. If for clinical reasons, the contract is not to be followed please fill

in an exception form (Appendix 1). Indications for use have been given as a guide only. The formulary has been split into lower limb garments, upper

limb garments, made to measures and miscellaneous items. All product and prescription codes have been complied. If you have any queries

regarding codes please contact the company. All company details are available at the back of the formulary. If you have any comments regarding this

Formulary please contact the National Clinical Lead for Lymphoedema in Wales - Melanie Thomas on Melanie.J.Thomas@wales.nhs.uk It is

intended for use in Wales only but if other areas wish to use it please contact Melanie for agreement.

Contents

Lower Limb Garments Ready to Wear

Product Name Prescription FP10 Page Number

Sheer circular knit fabric lower limb garments class 1-2 (below knee and thigh)

Sigvaris Magic Yes 6-12

Firmer circular knit fabric lower limb garments class 1-3 (below knee and thigh)

Sigvaris Comfort class 1 Sigvaris Cotton class 2 & 3

Yes apart from class 3 cotton in thigh closed toe i.e. only available in open toe

13-28

Lower compression circular knit garments (below knee and thigh)

Medi Duomed Soft class 1 & 2 Yes 29-30

Flat knit compression lower limb garments class 1-3 (below knee and thigh)

Juzo Expert class 1 & 3 Haddenham Pertex 2 class 2

No - alternative made to measure flat knit BSN Elvarex

31-34

Lower compression flat knit garments (below knee and thigh)

Haddenham Pertex Light No - alternative made to measure flat knit in Pertex Light

35-36

Sheer fabric tights class 1-2 Juzo Soft/Attractive Yes 37-39

Firmer fabric tights class 1-3 Juzo Dynamic Yes 40-41

Microfine Toecaps Haddenham Microfine Toecaps Yes – XL not available yet 42

Cotton rich lower limb garments class 1 & 2 (below knee and thigh)

Sigvaris Cotton Yes 43-51

Men’s garments below knee class 1 & 2 Sigvaris Cotton/Comfort Yes 52-61

Upper Limb Garments Ready to Wear

Product Name Prescription Page Number

Upper limb circular knit arm sleeves class 1-2: with/without grip top

Mediven Harmony Yes 63-65

Upper limb circular knit gloves and mitts class 1 Juzo Classic Yes 66

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 3

Upper Limb Garments Ready to Wear... continued

Product Name Prescription Page Number

Upper limb circular knit gloves and mitts class 2 Mediven Harmony Yes 67

Upper limb lower compression circular knit garments

Medi UK Microsoft No alternative available 68

Upper limb flat knit arm sleeves class 1-2 Juzo Expert No - alternative made to measure flat knit Haddenham

69

Upper limb flat knit gloves and mitts class 1-2 Juzo Expert No - alternative made to measure flat knit Haddenham

70

Microfine gloves Haddenham Microfine Size XS, M, L, No XXS available 71

Made To Measure Garments

Product Name Prescription Page Number

Made to measure, lower limb, circular knit, class 1-3 Haddenham Veni No alternative on contract however Sigvaris Magic, Comfort or Cotton is available on Prescription contact the company.

73-74

Made to measure, lower limb, flat knit, class 1-4 BSN Medical Elvarex Yes 75-76

Made to measure, upper limb, circular knit, class 1-3 Sleeves with/without mitt : with/without grip top

Juzo Soft c-g class 1-2 Juzo Dynamic a-g class 1-3

No made to measure circular knits on prescription. Alternative is flat knit or ready to wear

77-78

Made to measure, upper limb, flat knit, class 1-3 Haddenham Goldpunkt Class 2 and 3 available on FP10. Class 1 not available in Goldpunkt fabric

79-81

Made to measure, foot portion (toe caps), flat knit Juzo Expert Yes – please state ‘foot portion’ on prescription

82-83

Wraps

Product Name Prescription Page Number

Upper limb wraps hand and arm BSN Jobst Farrowwrap Lite Armpiece – yes, handpiece - no 85

Lower limb wraps, foot, below knee and thigh BSN Jobst Farrowwrap Strong Yes 86-88

Abdominal wrap Medi UK No – however Comfizz.com may be an option. Please contact the company

89

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 4

Miscellaneous

Product Name Prescription Page Number

Genital shorts women Solidea Silver Wave No - however Comfizz.com may be an option. Please contact the company

91

Genital shorts men Solidea Panty Effect No - however Comfizz.com may be an option. Please contact the company

91

Genital scrotal support Medi UK Whitaker Pouch Yes 92

Head and neck support Medi UK Lipomed Face No 92

Breast oedema support/bra Medi UK Lipomed Bra and Belt No - however Comfizz.com may be an option. Please contact the company

93

Kinesio Tape Haddenham No 93

Glue Haddenham/Juzo No 93

Towelling cotton liner Activa TG Soft No 94

Donning aid Medi UK 2 in 1 Yes 94

Donning aid for arms & legs Sigvaris Ring Sigvaris Rolly

No - alternative Ezy as Yes

95

Donning aid for arms Juzo Slippie No - actiglide/easy slide 95

Contact details for companies 96

Exception Form 97

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 5

Lower Limb Garments - Ready to Wear

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 6

Lower Limb Circular Knit Light Sheer Fabric, Thigh & Below Knee - Sigvaris Magic Class 1-2 Indications- Needing a light fabric garment. Mild to moderate oedema, no more than 20% difference, No skin folds, nil- minor skin

complications, good shape distribution

Size Chart

Advice from Sigvaris when inputting products into EMIS:

Input Sigvaris

Input garment name (e.g. Magic, Comfort, Cotton)

Input class of garment

Input type of garment (e.g. below knee, thigh etc)

Input open/closed toe

Input length

Input size

Input colour

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 7

Below Knee – Sigvaris Magic Class 1 (18-21 mmHg)

OPEN TOE Skin Black

CLOSED TOE Skin Black

Size Length Product

Code Pip Code

Product Code

Pip Code Size Length Product

Code Pip Code

Product Code

Pip Code

XX-small Normal 54166 387-5242 54170 387-5028 XX-small Normal 54168 387-5119 54172 387-4955

XX-small Long 54617 387-5226 54171 387-5010 XX-small Long 54169 387-5093 54173 387-4848

XX-small Plus Normal 66051 387-5309 66059 387-5044 XX-small Plus Normal 66055 387-5150 66063 387-4922

XX-small Plus Long 66052 387-5267 66060 387-5036 XX-small Plus Long 66056 387-5135 66064 387-4880

X-small Normal 34874 343-3539 34898 343-3364 X-small Normal 35018 343-3042 35042 343-3208

X-small Long 34875 343-3588 34899 343-3406 X-small Long 35019 343-3083 35043 343-3240

X-small Plus Normal 34886 343-3620 34910 343-3448 X-small Plus Normal 35030 343-3125 35054 323-3281

X-small Plus Long 34887 343-3661 34911 343-3497 X-small Plus Long 35031 343-3166 35055 343-3323

Small Normal 34877 343-3547 34901 343-3372 Small Normal 35021 343-3059 35045 343-3216

Small Long 34878 343-3596 34902 343-3414 Small Long 35022 343-3091 35046 343-3257

Small Plus Normal 34889 343-3638 34913 343-3455 Small Plus Normal 35033 343-3133 35057 343-3299

Small Plus Long 34890 343-3679 34914 343-3505 Small Plus Long 35034 343-3174 35058 343-3331

Medium Normal 34880 343-3554 34904 343-3380 Medium Normal 35024 343-3067 35048 343-3224

Medium Long 34881 343-3604 34905 343-3422 Medium Long 35025 343-3109 35049 343-3265

Medium Plus Normal 34892 343-3646 34916 343-3471 Medium Plus Normal 35036 343-3141 35060 343-3307

Medium Plus Long 34893 343-3687 34917 343-3513 Medium Plus Long 35037 343-3182 35061 343-3349

Large Normal 34883 343-3562 34907 343-3398 Large Normal 35027 343-3075 35051 343-3232

Large Long 34884 343-3612 34908 343-3430 Large Long 35028 343-3117 35052 343-3273

Large Plus Normal 34895 343-3653 34919 343-3489 Large Plus Normal 35039 343-3158 35063 343-3315

Large Plus Long 34896 343-3695 34920 343-3521 Large Plus Long 35040 343-3190 35064 343-3356

X-Large Normal 55836 387-5259 55840 387-5069 X-Large Normal 55838 387-5127 55842 387-5002

X-Large Long 55837 387-5234 55841 387-5051 X-Large Long 55839 387-5101 55843 387-4997

X-Large Plus Normal 66053 387-5317 66061 387-5085 X-Large Plus Normal 66057 387-5168 66065 387-4989

X-Large Plus Long 66054 387-5275 66062 387-5077 X-Large Plus Long 66058 387-5143 66066 387-4971

Oracle Code - GTB083

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 8

Below Knee – Sigvaris Magic Class 2 (23-32 mmHg)

OPEN TOE Skin Black

CLOSED TOE Skin Black

Size Length Product

Code Pip Code

Product Code

Pip Code Size Length Product

Code Pip Code

Product Code

Pip Code

XX-small Normal 54258 387-5770 54262 387-5606 XX-small Normal 54260 387-5713 54264 387-5507

XX-small Long 54259 387-5754 54263 387-5598 XX-small Long 54261 387-5671 54265 387-5549

XX-small Plus Normal 55148 387-5820 55160 387-5622 XX-small Plus Normal 55154 387-5739 55166 387-5531

XX-small Plus Long 55149 387-5796 55161 387-5614 XX-small Plus Long 55155 387-5697 55167 387-5515

X-small Normal 36314 343-8926 36338 343-7316 X-small Normal 36458 343-7142 36482 343-6888

X-small Long 36315 343-8967 36339 343-7357 X-small Long 36459 343-7183 36483 343-6953

X-small Plus Normal 36326 343-9007 36350 343-7399 X-small Plus Normal 36470 343-7225 36494 343-6995

X-small Plus Long 36327 343-9049 36351 343-7449 X-small Plus Long 36471 343-7266 36495 343-7100

Small Normal 36317 343-8934 36341 343-7324 Small Normal 36461 343-7159 36485 343-6896

Small Long 36318 343-8975 36342 343-7365 Small Long 36362 343-7191 36486 343-6961

Small Plus Normal 36329 343-9015 36353 343-7407 Small Plus Normal 36473 343-7233 36497 343-7001

Small Plus Long 36330 343-9056 36354 343-7456 Small Plus Long 36474 343-7274 36498 343-7118

Medium Normal 36320 343-8942 36344 343-7332 Medium Normal 36464 343-7167 36488 343-6912

Medium Long 36321 343-8983 36345 343-7373 Medium Long 36465 343-7209 36489 343-6979

Medium Plus Normal 36332 343-9023 36356 343-7415 Medium Plus Normal 36476 343-7241 36500 343-7027

Medium Plus Long 36333 343-9064 36357 343-7464 Medium Plus Long 36477 343-7282 36501 343-7126

Large Normal 36323 343-8959 36347 343-7340 Large Normal 36467 343-7175 36491 343-6920

Large Long 36324 343-8991 36348 343-7381 Large Long 36468 343-7217 38492 343-6987

Large Plus Normal 36335 343-9031 36359 343-7423 Large Plus Normal 36479 343-7258 36503 343-7092

Large Plus Long 36336 343-9072 36360 343-7472 Large Plus Long 36480 343-7290 36504 343-7134

X-large Normal 55146 387-5788 55158 387-5655 X-large Normal 55152 387-5721 55164 387-5564

X-large Long 55147 387-5762 55159 387-5630 X-large Long 55153 387-5689 55165 387-5556

X-large Plus Normal 55150 387-5804 55162 387-5663 X-large Plus Normal 55156 387-5747 55168 387-5580

X-large Plus Long 55151 387-5838 55163 387-5648 X-large Plus Long 55157 387-5705 55169 387-5572

Oracle Code - GTB083

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 9

Thigh Length, Open Toe, Grip Top – Sigvaris Magic Class 1 (18-21 mmHg)

Size Length

Skin Black

Size Length

Skin Black

Product Code

Pip Code Product

Code Pip Code

Product code

Pip Code Product

code Pip Code

XX-small Short 58544 387-7878 58616 387-7784 Medium Short 58553 343-4479 58625 343-5492

XX-small Normal 58545 387-7657 58617 387-7644 Medium Normal 58554 343-4438 58626 343-5534

XX-small Long 58546 387-7529 58618 387-7503 Medium Long 58555 343-4511 58627 343-5575

XX-small Plus Short 58562 387-7917 58634 387-7891 Medium Plus Short 58571 343-4560 58643 343-5575

XX-small Plus Normal 58563 387-7776 58635 387-7768 Medium Plus Normal 58572 343-4644 58644 343-5617

XX-small Plus Long 58564 387-7560 58636 387-7545 Medium Plus Long 58573 343-4719 58645 343-5948

X-small Short 58547 343-4453 58619 343-5435 Large Short 58556 343-4487 58628 343-5468

X-small Normal 58548 343-4412 58620 343-5476 Large Normal 58557 343-4446 58629 343-5500

X-small Long 58549 343-4495 58621 343-5518 Large Long 58558 343-4529 58630 343-5542

X-small Plus Short 58565 343-4545 58637 343-5559 Large Plus Short 58574 343-4578 58646 343-5583

X-small Plus Normal 58566 343-4610 58638 343-5591 Large Plus Normal 58575 343-4669 58647 343-5856

X-small Plus Long 58567 343-4693 58639 343-5864 Large Plus Long 58576 343-4727 58648 343-5971

Small Short 58550 343-4461 58622 343-5443 X-large Short 58559 387-7826 58631 387-7800

Small Normal 58551 343-4420 58623 343-5484 X-large Normal 58560 387-7677 58632 387-7669

Small Long 58552 343-4503 58624 343-5526 X-large Long 58561 387-7537 58633 387-7511

Small Plus Short 58568 343-4552 58640 343-5567 X-large Plus Short 58577 387-7925 58649 387-7909

Small Plus Normal 58569 343-4628 58641 343-5609 X-large Plus Normal 58578 387-770 58650 387-7743

Small Plus Long 58570 343-4701 58642 343-5450 X-large Plus Long 58579 387-7578 58651 387-5882

Oracle Code - GTB084

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 10

Thigh Length, Closed Toe, Grip Top – Sigvaris Magic Class 1 (18-21 mmHg)

Size Length

Skin Black

Size Length

Skin Black

Product Code

Pip Code Product

Code Pip Code

Product Code

Pip Code Product

Code Pip Code

XX-small Short 58580 387-7487 58652 387-7467 Medium Short 58589 343-5211 58661 343-4933

XX-small Normal 58581 387-7339 58653 387-7313 Medium Normal 58590 343-5252 58662 343-4974

XX-small Long 58582 387-6232 58654 387-8216 Medium Long 58591 343-5294 58663 343-5013

XX-small Plus Short 58598 387-7453 58670 387-7412 Medium Plus Short 58607 343-5336 35347 343-5054

XX-small Plus Normal 58599 387-7370 58671 387-7354 Medium Plus Normal 58608 343-5377 35378 343-5120

XX-small Plus Long 58600 387-6240 58672 387-6224 Medium Plus Long 58609 343-5419 35349 343-5179

X-small Short 58583 343-5195 58655 343-4909 Large Short 58592 343-5229 35338 343-4941

X-small Normal 58584 343-5237 58656 343-4958 Large Normal 58593 343-5260 35339 343-4982

X-small Long 58585 343-5278 58657 343-4990 Large Long 58594 343-5302 35340 343-5021

X-small Plus Short 58601 343-5310 58673 343-5039 Large Plus Short 58610 343-5344 35350 343-5062

X-small Plus Normal 58602 343-5351 58674 343-5070 Large Plus Normal 58611 343-5385 35351 343-5146

X-small Plus Long 58603 343-5393 58675 343-5153 Large Plus Long 58612 343-5427 35352 343-5187

Small Short 58586 343-5203 58658 343-4925 X-Large Short 58595 387-7495 58667 387-7479

Small Normal 58587 343-5245 58659 343-4966 X-Large Normal 58596 387-7347 58668 387-7327

Small Long 58588 343-5286 58660 343-5005 X-Large Long 58597 387-6245 58669 387-6257

Small Plus Short 58604 343-5328 58676 343-5047 X-Large Plus Short 58613 387-7446 58685 387-7438

Small Plus Normal 58605 343-5369 58677 343-5096 X-Large Plus Normal 58614 387-7388 58686 387-7362

Small Plus Long 58606 343-5401 58678 343-5161 X-Large Plus Long 58615 387-7404 58687 387-7396

Oracle Code - GTB084

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 11

Thigh Length, Open Toe, Grip Top – Sigvaris Magic Class 2 (23-32 mmHg)

Size Length

Skin Black

Size Length

Skin Black

Product Code

Pip Code Product

Code Pip Code

Product Code

Pip Code Product

Code Pip Code

XX-small Short 57332 387-8667 57394 387-8634 Medium Short 57331 343-6664 57403 343-9619

XX-small Normal 57323 387-8576 57395 387-8550 Medium Normal 57332 343-6706 57404 343-9668

XX-small Long 57324 387-8493 57396 387-8477 Medium Long 57333 343-6748 57405 343-9700

XX-small Plus Short 57340 387-8709 57412 387-8683 Medium Plus Short 57349 343-6789 57421 343-9742

XX-small Plus Normal 57341 387-8626 57413 387-8592 Medium Plus Normal 57350 343-6821 57422 343-9783

XX-small Plus Long 57342 387-8535 57414 387-8519 Medium Plus Long 57351 343-6862 57423 343-9825

X-small Short 57325 343-6649 57397 343-9593 Large Short 57334 343-6672 57406 343-9627

X-small Normal 57326 343-6680 57398 343-9643 Large Normal 57335 343-6714 57407 343-9676

X-small Long 57327 343-6722 57399 343-9684 Large Long 57336 343-6755 57408 343-9718

X-small Plus Short 57343 343-6763 57415 343-9726 Large Plus Short 57352 343-6797 57424 343-9759

X-small Plus Normal 57344 343-6805 57416 343-9767 Large Plus Normal 57353 343-6839 57425 343-9791

X-small Plus Long 57345 343-6847 57417 343-9809 Large Plus Long 57354 343-6870 57426 343-9833

Small Short 57328 343-6656 57400 343-9601 X-Large Short 57337 387-8659 57409 387-8675

Small Normal 57329 343-6698 57401 343-9650 X-Large Normal 57338 387-8584 57410 387-8568

Small Long 57330 343-6730 57402 343-9692 X-Large Long 57339 387-8501 57411 387-8485

Small Plus Short 57346 343-6771 57418 343-9734 X-Large Plus Short 57355 387-8697 57427 387-8642

Small Plus Normal 57347 343-6813 57419 343-9775 X-Large Plus Normal 57356 387-8618 57428 387-8600

Small Plus Long 57348 343-6854 57420 343-9817 X-Large Plus Long 57357 387-8543 57429 387-8527

Oracle Code - GTB084

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 12

Thigh, Closed Toe, Grip Top – Sigvaris Magic Class 2 (23-32 mmHg)

Size Length

Skin Black

Size Length

Skin Black

Product Code

Pip Code Product

Code Pip Code

Product Code

Pip Code Product

Code Pip Code

XX-small Short 57358 387-8470 57430 387-8394 Medium Short 57367 343-9379 57439 343-9148

XX-small Normal 57359 387-8337 57431 387-8377 Medium Normal 57368 343-9411 57440 343-9106

XX-small Long 57360 387-8253 57432 387-8238 Medium Long 57369 343-9452 57441 343-9197

XX-small Plus Short 57376 387-8469 57448 387-8436 Medium Plus Short 57385 343-9494 57457 343-9254

XX-small Plus Normal 57377 387-8378 57449 387-8352 Medium plus Normal 57386 343-9536 57458 343-9296

XX-small Plus Long 57378 387-8275 57450 387-8279 Medium Plus Long 57387 343-9577 57459 343-9338

X-small Short 57361 343-9353 57433 343-9122 Large Short 57370 343-9387 57442 343-9155

X-small Normal 57362 343-9395 57434 343-9080 Large Normal 57371 343-9429 57443 343-9114

X-small Long 57363 343-9437 57435 343-9163 Large Long 57372 343-9460 57444 343-0213

X-small Plus Short 57379 343-9478 57451 343-9239 Large Plus Short 57388 343-9502 57460 343-9262

X-small Plus Normal 57380 343-9510 57452 343-9270 Large Plus Normal 57389 343-9544 57461 343-9304

X-small Plus Long 57381 343-9551 57453 343-9312 Large Plus Long 57390 343-9585 57462 343-9346

Small Short 57364 343-9361 57436 343-9130 X-large Short 57373 387-8428 57445 387-8402

Small Normal 57365 343-9403 57437 343-9098 X-large Normal 57374 387-8345 57446 387-8329

Small Long 57366 343-9445 57438 343-9171 X-large Long 57375 387-8267 57447 387-8246

Small plus Short 57382 343-9486 57454 343-9247 X-large Plus Short 57391 387-8451 57463 387-8444

Small plus Normal 57383 343-9528 57455 343-9288 X-large Plus Normal 57392 387-8386 57464 387-8360

Small plus Long 57384 343-9569 57456 343-9320 X-large Plus Long 57393 387-8303 57465 387-8287

Oracle Code - GTB084

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 13

Lower Limb Circular Knit Firmer/Denser Fabric, Thigh & Below Knee - Sigvaris Comfort Class 1

Size Chart: Advice from Sigvaris when

inputting products into EMIS:

Input Sigvaris

Input garment name (e.g. Magic, Comfort, Cotton)

Input class of garment

Input type of garment (e.g. below knee, thigh etc)

Input open/closed toe

Input length

Input size

Input colour

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 14

Below Knee, Open Toe – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 68113-CM 391- 0205 68097-CM 391-0163 68065-CM 391-0189

XX-small Long 68114-CM 391-0007 68098-CM 390-9967 68066-CM 390-9983

XX-small Plus Normal 68125-CM 391-0304 68101-CM 391-0262 68069-CM 391-0288

XX-small Plus Long 68126-CM 391-0106 68102-CM 391-0064 68070-CM 391-0080

X-small Normal 68115-CM 391-0213 47417-CM 361-4252 47385-CM 374-9124

X-small Long 68116-CM 391-0015 47418-CM 361-4294 47386-CM 374-9165

X-small Plus Normal 68127-CM 391-0312 47425-CM 361-4336 47393-CM 374-9215

X-small Plus Long 68128-CM 391-0114 47426-CM 361-4377 47394-CM 374-9272

Small Normal 68117-CM 391-0221 47419-CM 361-4260 47387-CM 374-9132

Small Long 68118-CM 391-0023 47420-CM 361-4302 47388-CM 374-9173

Small Plus Normal 68129-CM 391-0320 47427-CM 361-4344 47395-CM 374-9249

Small Plus Long 68130-CM 391-0122 47428-CM 361-4385 47396-CM 374-9280

Medium Normal 68119-CM 391-0239 47421-CM 361-4278 47389-CM 374-9140

Medium Long 68120-CM 391-0031 47422-CM 361-4310 47390-CM 374-9181

Medium Plus Normal 68131-CM 391-0338 47429-CM 361-4351 47397-CM 374-9256

Medium Plus Long 68132-CM 391-0130 47430-CM 361-4393 47398-CM 374-9298

Large Normal 68121-CM 391-0247 47423-CM 361-4286 47391-CM 374-9157

Large Long 68122-CM 391-0049 47424-CM 361-4328 47392-CM 374-9199

Large Plus Normal 68133-CM 391-0346 47431-CM 361-4369 47399-CM 374-9264

Large Plus Long 68134-CM 391-0148 47432-CM 361-4401 47400-CM 374-9306

X-large Normal 68123-CM 391-0254 68099-CM 391-0171 68067-CM 391-0197

X-large Long 68124-CM 391-0056 68100-CM 390-9975 68068-CM 390-9991

X-large Plus Normal 68135-CM 391-0353 68103-CM 391-0270 68071-CM 391-0296

X-large Plus Long 68136-CM 391-0155 68104-CM 391-0072 68072-CM 391-0098

Oracle Code – GTB292

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 15

Below Knee, Closed Toe – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length

Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 68137-CM 390-9801 68105-CM 390-9769 68073-CM 390-9785

XX-small Long 68138-CM 390-9256 68106-CM 390-9298 68074-CM 390-9314

XX-small Plus Normal 68149-CM 390-9900 68109-CM 390-9868 68077-CM 390-9884

XX-small Plus Long 68150-CM 390-9363 68110-CM 390-9272 68078-CM 390-9371

X-small Normal 68139-CM 390-9819 47513-CM 361-4575 47481-CM 374-9314

X-small Long 68140-CM 390-9249 47514-CM 361-4617 47482-CM 374-9363

X-small Plus Normal 68151-CM 390-9918 47521-CM 361-4658 47489-CM 374-9462

X-small Plus Long 68152-CM 390-9330 47522-CM 361-4690 47490-CM 374-9520

Small Normal 68141-CM 390-9827 47515-CM 361-4583 47483-CM 374-9322

Small Long 68142-CM 390-9231 47516-CM 361-4625 47484-CM 374-9389

Small Plus Normal 68153-CM 390-9926 47523-CM 361-4666 47491-CM 374-9470

Small Plus Long 68154-CM 390-9348 47524-CM 361-4708 47492-CM 374-9538

Medium Normal 68143-CM 390-9835 47517-CM 361-4591 47485-CM 374-9330

Medium Long 68144-CM 390-9215 47518-CM 361-4633 47486-CM 374-9421

Medium Plus Normal 68155-CM 390-9934 47525-CM 361-4674 47493-CM 374-9488

Medium Plus Long 68156-CM 390-9223 47526-CM 361-4716 47494-CM 374-9546

Large Normal 68145-CM 390-9843 47519-CM 361-4609 47487-CM 374-9348

Large Long 68146-CM 390-9199 47520-CM 361-4641 47488-CM 374-9447

Large Plus Normal 68157-CM 390-9942 47527-CM 361-4682 47495-CM 374-9504

Large Plus Long 68158-CM 390-9207 47528-CM 361-4724 47496-CM 374-9561

X-large Normal 68147-CM 390-9850 68107-CM 390-9777 68075-CM 390-9793

X-large Long 68148-CM 390-9264 68108-CM 390-9306 68076-CM 390-9322

X-large Plus Normal 68159-CM 390-9959 68111-CM 390-9876 68079-CM 390-9892

X-large Plus Long 68160-CM 390-9355 68112-CM 390-9280 68080-CM 390-9389

Oracle Code – GTB292

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 16

Thigh Length, NO Grip Top – Sigvaris Comfort Class 1 (18-21 mmHg)

OPEN TOE Savannah Black

CLOSED TOE Savannah Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 68209-CM 391-6475 68185-CM 391-6434 XX-small Short 68245-CM 391-4314 68197-CM 391-4298

XX-small Normal 68210-CM 391-5139 68186-CM 391-5097 XX-small Normal 68246-CM 391-3399 68198-CM 391-3373

XX-small Long 68211-CM 391-4793 68187-CM 391-4751 XX-small Long 68247-CM 391-3084 68199-CM 391-3050

XX-small Plus Short 68227-CM 391-6541 68191-CM 391-6509 XX-small Plus Short 68263-CM 391-4389 68203-CM 391-4363

XX-small Plus Normal 68228-CM 391-5204 68192-CM 391-5162 XX-small Plus Normal 68264-CM 391-3449 68204-CM 391-3423

XX-small Plus Long 68229-CM 391-4868 68193-CM 391-4872 XX-small Plus Long 68265-CM 391-3175 68205-CM 391-3142

X-small Short 68212-CM 391-6483 47649-CM 362-2651 X-small Short 68248-CM 391-4322 47793-CM 362-3139

X-small Normal 68213-CM 391-5147 47650-CM 362-2693 X-small Normal 68249-CM 391-3407 47794-CM 362-3170

X-small Long 68214-CM 391-4801 47651-CM 362-2735 X-small Long 68250-CM 391-3092 47795-CM 362-3212

X-small Plus Short 68230-CM 391-6558 47661-CM 362-2776 X-small Plus Short 68266-CM 391-4397 47805-CM 362-3253

X-small Plus Normal 68231-CM 391-5212 47662-CM 362-2818 X-small Plus Normal 68267-CM 391-3456 47806-CM 362-3295

X-small Plus Long 68232-CM 391-4876 47663-CM 362-2859 X-small Plus Long 68268-CM 391-3183 47807-CM 362-3337

Small Short 68215-CM 391-6459 47652-CM 362-2669 Small Short 68251-CM 391-4272 47796-CM 362-3147

Small Normal 68216-CM 391-5113 47653-CM 362-2701 Small Normal 68252-CM 391-3167 47797-CM 362-3188

Small Long 68217-CM 391-4777 47654-CM 362-2743 Small Long 68253-CM 391-3100 47798-CM 362-3220

Small Plus Short 68233-CM 391-6533 47664-CM 362-2784 Small Plus Short 68269-CM 391-4355 47808-CM 362-3261

Small Plus Normal 68234-CM 391-5196 47665-CM 362-2826 Small Plus Normal 68270-CM 391-3365 47809-CM 362-3303

Small Plus Long 68235-CM 391-4850 47666-CM 362-2867 Small Plus Long 68271-CM 391-3191 47810-CM 362-3345

Medium Short 68218-CM 391-6467 47655-CM 362-2677 Medium Short 68254-CM 391-4280 47799-CM 362-3154

Medium Normal 68219-CM 391-5121 47656-CM 362-2719 Medium Normal 68255--CM 391-3134 47800-CM 362-3196

Medium Long 68220-CM 391-4785 47657-CM 362-2750 Medium Long 68256-CM 391-3118 47801-CM 362-3238

Medium Plus Short 68236-CM 391-6525 47667-CM 362-2792 Medium Plus Short 68272-CM 391-4348 47811-CM 362-3279

Medium Plus Normal 68237-CM 391-5188 47668-CM 362-2834 Medium Plus Normal 68273-CM 391-3076 47812-CM 362-3311

Medium Plus Long 68238-CM 391-4843 47669-CM 362-2875 Medium Plus Long 68274-CM 391-3209 47813-CM 362-3352

Large Short 68221-CM 391-3035 47658-CM 362-2685 Large Short 68257-CM 391-2979 47802-CM 362-3162

Large Normal 68222-CM 391-3019 47659-CM 362-2727 Large Normal 68258-CM 391-2912 47803-CM 362-3204

Large Long 68223-CM 391-2995 47660-CM 362-2768 Large Long 68259-CM 391-2839 47804-CM 362-3246

Large Plus Short 68239-CM 391-3043 47670-CM 362-2800 Large Plus Short 68275-CM 391-2987 47814-CM 362-3287

Large Plus Normal 68240-CM 391-3027 47671-CM 362-2842 Large Plus Normal 68276-CM 391-2946 47815-CM 362-3329

Large Plus Long 68241-CM 391-3001 47672-CM 362-2883 Large Plus Long 68277-CM 391-2904 47816-CM 362-3360

X-large Short 68224-CM 391-6491 68188-CM 391-6442 X-large Short 68260-CM 391-4330 68200-CM 391-4306

X-large Normal 68225-CM 391-5154 68189-CM 391-5105 X-large Normal 68261-CM 391-3415 68201-CM 391-3381

X-large Long 68226-CM 391-4819 68190-CM 391-4769 X-large Long 68262-CM 391-3126 68202-CM 391-3068

X-large Plus Short 68242-CM 391-6566 68194-CM 391-6517 X-large Plus Short 68278-CM 391-4405 68206-CM 391-4371

X-large Plus Normal 68243-CM 391-5220 68195-CM 391-5170 X-large Plus Normal 68279-CM 391-3464 68207-CM 391-3431

X-large Plus Long 68244-CM 391-4884 68196-CM 391-4835 X-large Plus Long 68280-CM 391-3217 68208-CM 391-3159

Oracle Code – GTB294

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 17

Thigh Length, Open Toe, Knobbed Grip Top – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length Savannah Black Caramel

Product Code

PIP code Product

Code PIP code

Product Code

PIP Code

XX-small Short 68497-CM 390-9744 68569-CM 390-9579 68353-CM 390-9629

XX-small Normal 68498-CM 390-9454 68570-CM 390-9520 68354-CM 390-9538

XX-small Long 68499-CM 391-1187 68571-CM 391-1146 68355-CM 391-1161

XX-small Plus Short 68515-CM 390-9751 68587-CM 390-9587 68371-CM 390-9637

XX-small Plus Normal 68516-CM 390-9470 68588-CM 390-9546 68372-CM 390-9553

XX-small Plus Long 68517-CM 391-1286 68589-CM 391-1245 68373-CM 391-1260

X-small Short 68500-CM 390-9736 68572-CM 361-5119 68356-CM 374-9603

X-small Normal 68501-CM 390-9421 68573-CM 361-5150 68357-CM 374-9645

X-small Long 68502-CM 391-1195 68574-CM 361-5192 68358-CM 374-9686

X-small Plus short 68518-CM 390-9678 68590-CM 361-5234 68374-CM 374-9728

X-small Plus Normal 68519-CM 390-9447 68591-CM 361-5275 68375-CM 374-9769

X-small Plus Long 68520-CM 391-1294 68592-CM 361-5317 68376-CM 374-9801

Small Short 68503-CM 390-9694 68575-CM 361-5127 68359-CM 374-9611

Small Normal 68504-CM 390-9397 68576-CM 361-5168 68360-CM 374-9652

Small Long 68505-CM 391-1203 68577-CM 361-5200 68361-CM 374-9694

Small Plus Short 68521-CM 390-9728 68593-CM 361-5242 68377-CM 374-9736

Small Plus Normal 68522-CM 390-9413 68594-CM 361-5283 68378-CM 374-9777

Small Plus Long 68523-CM 391-1302 68595-CM 361-5325 68379-CM 374-9819

Medium Short 68506-CM 390-9702 68578-CM 361-5135 68362-CM 374-9629

Medium Normal 68507-CM 391-1351 68579-CM 361-5176 68363-CM 374-9660

Medium Long 68508-CM 391-1211 68580-CM 361-5218 68364-CM 374-9702

Medium Plus Short 68524-CM 390-9710 68596-CM 361-5259 68380-CM 374-9744

Medium Plus Normal 68525-CM 390-9405 68597-CM 361-5291 68381-CM 374-9785

Medium Plus Long 68526-CM 391-1302 68598-CM 361-5333 68382-CM 374-9827

Large Short 68509-CM 390-9652 68581-CM 361-5143 68365-CM 374-9637

Large Normal 68510-CM 391-1344 68582-CM 361-5184 68366-CM 374-9678

Large Long 68511-CM 391-1229 68583-CM 361-5226 68367-CM 374-9710

Large Plus Short 68527-CM 390-9686 68599-CM 361-5267 68383-CM 374-9751

Large Plus Normal 68528-CM 390-9488 68600-CM 361-5309 68384-CM 374-9793

Large Plus Long 68529-CM 391-1328 68601-CM 361-5341 68385-CM 374-9835

X-large Short 68512-CM 390-9603 68584-CM 390-9595 68368-CM 390-9645

X-large Normal 68513-CM 390-9439 68585-CM 390-9462 68369-CM 390-9496

X-large Long 68514-CM 391-1237 68586-CM 391-1153 68370-CM 391-1179

X-large Plus Short 68530-CM 390-9660 68602-CM 390-9561 68386-CM 390-9611

X-large Plus Normal 68531-CM 391-1369 68603-CM 390-9504 68387-CM 390-9512

X-large Plus Long 68532-CM 391-1336 68604-CM 391-1252 68388-CM 391-1278

Oracle Code – GTB293

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 18

Thigh Length, Closed Toe, Knobbed Grip Top – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Short 68533-CM 391-0973 68605-CM 391-0932 68389-CM 391-0957

XX-small Normal 68534-CM 391-0775 68606-CM 391-0734 68390-CM 391-0759

XX-small Long 68535-CM 391-0403 68607-CM 391-0361 68391-CM 391-0379

XX-small Plus Short 68551-CM 391-1070 68623-CM 391-1039 68407-CM 391-1054

XX-small Plus Normal 68552-CM 391-0874 68624-CM 391-0833 68408-CM 391-0858

XX-small Plus Long 68553-CM 391-0502 68625-CM 391-0460 68409-CM 391-0486

X-small Short 68536-CM 391-0981 68608-CM 361-5598 68392-CM 374-9843

X-small Normal 68537-CM 391-0783 68609-CM 361-5630 68393-CM 374-9934

X-small Long 68538-CM 391-0411 68610-CM 361-5671 68394-CM 374-9967

X-small Plus short 68554-CM 391-1088 68626-CM 361-5713 68410-CM 375-0007

X-small Plus Normal 68555-CM 391-0882 68627-CM 361-5754 68411-CM 375-0064

X-small Plus Long 68556-CM 391-0510 68628-CM 361-5796 68412-CM 375-0130

Small Short 68539-CM 391-0999 68611-CM 361-5606 68395-CM 374-9850

Small Normal 68540-CM 391-0791 68612-CM 361-5648 68396-CM 374-9926

Small Long 68541-CM 391-0429 68613-CM 361-5689 68397-CM 374-9975

Small Plus Short 68557-CM 391-1096 68629-CM 361-5721 68413-CM 375-0015

Small Plus Normal 68558-CM 391-0890 68630-CM 361-5762 68414-CM 375-0080

Small Plus Long 68559-CM 391-0528 68631-CM 361-5804 68415-CM 375-0155

Medium Short 68542-CM 391-1005 68614-CM 361-5614 68398-CM 374-9884

Medium Normal 68543-CM 391-0809 68615-CM 361-5655 68399-CM 374-9942

Medium Long 68544-CM 391-0437 68616-CM 361-5697 68400-CM 374-9983

Medium Plus Short 68560-CM 391-1104 68632-CM 361-5739 68416-CM 375-0023

Medium Plus Normal 68561-CM 391-0908 68633-CM 361-5770 68417-CM 375-0106

Medium Plus Long 68562-CM 391-0536 68634-CM 361-5812 68418-CM 375-0163

Large Short 68545-CM 391-1013 68617-CM 361-5622 68401-CM 374-9900

Large Normal 68546-CM 391-0817 68618-CM 361-5663 68402-CM 374-9942

Large Long 68547-CM 391-0445 68619-CM 361-5705 68403-CM 374-9991

Large Plus Short 68563-CM 391-1112 68635-CM 361-5747 68419-CM 375-0031

Large Plus Normal 68564-CM 391-0916 68636-CM 361-5788 68420-CM 375-0114

Large Plus Long 68565-CM 391-0544 68637-CM 361-5820 68421-CM 375-0171

X-large Short 68548-CM 391-1021 68620-CM 391-0940 68404-CM 391-0965

X-large Normal 68549-CM 391-0825 68621-CM 391-0742 68405-CM 391-0767

X-large Long 68550-CM 391-0452 68622-CM 391-0395 68406-CM 391-0387

X-large Plus Short 68566-CM 391-1120 68638-CM 391-1047 68422-CM 391-1062

X-large Plus Normal 68567-CM 391-0924 68639-CM 391-0841 68423-CM 391-0866

X-large Plus Long 68568-CM 391-0551 68640-CM 391-0478 68424-CM 391-0494

Oracle Code – GTB293

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 19

Lower Limb, Circular Knit, Firmer/Denser Fabric, Thigh & Below Knee - Sigvaris Cotton Class 2 & 3

Size Chart:

Advice from Sigvaris when inputting products into EMIS:

Input Sigvaris

Input garment name (e.g. Magic, Comfort, Cotton)

Input class of garment

Input type of garment (e.g. below knee, thigh etc)

Input open/closed toe

Input length

Input size

Input colour

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 20

Below Knee – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 63394 387-4534 63406 387-4732 XX-small Short 63418 387-4757 63430 387-5358

XX-small Normal 56274 387-4492 56282 387-4500 XX-small Normal 56290 387-5465 56298 387-5473

XX-small Long 56275 387-4518 56283 387-4526 XX-small Long 56291 387-5487 56299 387-5499

XX-small Plus Short 63400 395-8097 63412 395-8089 XX-small Plus Short 63424 399-0439 63436 399-0421

XX-small Plus Normal 56278 397-1629 56286 397-1637 XX-small Plus Normal 56294 397-1645 56302 397-1652

XX-small Plus Long 56279 397-6552 56287 397-6560 XX-small Plus Long 56295 397-6578 56303 397-6586

X-small Short 63395 387-4512 63407 387-4708 X-small Short 63419 387-5176 63431 387-5408

X-small Normal 50302 364-1644 50318 364-1800 X-small Normal 50350 364-3475 50366 364-4457

X-small Long 50303 364-1685 50319 364-1842 X-small Long 50351 364-3517 50367 364-4812

X-small Plus Short 63401 387-4591 63413 387-4641 X-small Plus Short 63425 387-5283 63437 387-5416

X-small Plus Normal 50310 364-1727 50326 364-1883 X-small Plus Normal 50358 364-4374 50374 364-4853

X-small Plus Long 50311 364-1768 50327 364-1925 X-small Plus Long 50359 364-4416 50375 364-4895

Small Short 63396 387-4559 63408 387-4716 Small Short 63420 387-5184 63432 387-5366

Small Normal 50304 364-1651 50320 364-1818 Small Normal 50352 364-3483 50368 364-4465

Small Long 50305 364-1693 50321 364-1859 Small Long 50353 364-3525 50369 364-4820

Small Plus Short 63402 387-4609 63414 387-4658 Small Plus Short 63426 387-5291 63438 387-5424

Small Plus Normal 50312 364-1735 50328 364-1891 Small Plus Normal 50360 364-4382 50376 364-4861

Small Plus Long 50313 364-1776 50329 364-1933 Small Plus Long 50361 364-4424 50377 364-4903

Medium Short 63397 387-4567 63409 387-4724 Medium Short 63421 387-5192 63433 387-5374

Medium Normal 50306 364-1669 50322 364-1826 Medium Normal 50354 364-3491 50370 364-4473

Medium Long 50307 364-1701 50323 364-1867 Medium Long 50355 364-3533 50371 364-4838

Medium Plus Short 63403 387-4617 63415 387-4666 Medium Plus Short 63427 387-5325 63439 387-5432

Medium Plus Normal 50314 364-1743 50330 364-1909 Medium Plus Normal 50362 364-4390 50378 364-4879

Medium Plus Long 50315 364-1784 50331 364-1941 Medium Plus Long 50363 364-4432 50379 364-4911

Large Short 63398 387-4575 63410 387-4690 Large Short 63422 387-5200 63434 387-5382

Large Normal 50308 364-1677 50324 364-1834 Large Normal 50356 364-3509 50372 364-4481

Large Long 50309 364-1719 50325 364-1875 Large Long 50357 364-3541 50373 364-4846

Large Plus Short 63404 387-4625 63416 387-4674 Large Plus Short 63428 387-5333 63440 387-5440

Large Plus Normal 50316 364-1750 50332 364-1917 Large Plus Normal 50364 364-4408 50380 364-4887

Large Plus Long 50317 364-1792 50333 364-1958 Large Plus Long 50365 364-4440 50381 364-4929

X-large Short 63399 387-4583 63411 387-4740 X-large Short 63423 387-5218 63435 387-5390

X-large Normal 56276 372-9795 56284 372-9803 X-large Normal 56292 373-1312 56300 373-1320

X-large Long 56277 372-9837 56285 372-9845 X-large Long 56293 373-1353 56301 373-1361

X-large Plus Short 63405 387-4633 63417 387-4682 X-large Plus Short 63429 387-5341 63441 387-5457

X-large Plus Normal 56280 372-9811 56288 372-9829 X-large Plus Normal 56296 373-1338 56304 373-1346

X-large Plus Long 56281 372-9852 56289 372-9860 X-large Plus Long 56297 373-1379 56305 373-1387

Oracle Code – GTB295

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 21

Below Knee, Knobbed Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 56262 387-5960 64453 397-1728 XX-small Normal 56264 387-5994 64475 397-2064

XX-small Long 56263 387-5978 64454 397-6610 XX-small Long 56265 384-6018 64476 397-6735

XX-small Plus Normal 64660 399-0413 64662 397-1868 XX-small Plus Normal 64664 397-2056 64666 397-2122

XX-small Plus Long 64661 397-6594 64663 397-6677 XX-small Plus Long 64665 397-6602 64667 397-6792

X-small Normal 50382 364-1966 64455 397-1736 X-small Normal 50398 364-3624 64477 397-2072

X-small Long 50383 364-3392 64456 397-6628 X-small Long 50399 364-3681 64478 397-6743

X-small Plus Normal 50390 364-3467 64465 397-1884 X-small Plus Normal 50406 364-3723 64487 397-2130

X-small Plus Long 50391 364-3558 64466 397-6685 X-small Plus Long 50407 364-3731 64488 397-6800

Small Normal 50384 364-3426 64457 397-1744 Small Normal 50400 364-3632 64479 397-2080

Small Long 50385 364-3434 64458 397-6636 Small Long 50401 364-3699 64480 397-6750

Small Plus Normal 50392 364-3582 64467 397-1892 Small Plus Normal 50408 364-3764 64489 397-2148

Small Plus Long 50393 364-3590 64468 397-6693 Small Plus Long 50409 364-3772 64490 397-6818

Medium Normal 50386 364-3400 64459 397-1751 Medium Normal 50402 364-3640 64481 397-2098

Medium Long 50387 364-3442 64460 397-6644 Medium Long 50403 364-3707 64482 397-6768

Medium Plus Normal 50394 364-3566 64469 397-1900 Medium Plus Normal 50410 364-3749 64491 397-2155

Medium Plus Long 50395 364-3608 64470 397-6701 Medium Plus Long 50411 364-3780 64492 397-6826

Large Normal 50388 364-3418 64461 397-1827 Large Normal 50404 364-3657 64483 397-2106

Large Long 50389 364-3459 64462 397-6651 Large Long 50405 364-3715 64484 397-6776

Large Plus Normal 50396 364-3574 64471 397-1918 Large Plus Normal 50412 364-3756 64493 397-2163

Large Plus Long 50397 364-3616 64472 397-6719 Large Plus Long 50413 364-3798 64494 397-6834

X-large Normal 56266 372-9878 64463 397-1835 X-large Normal 56270 373-0983 64485 397-2114

X-large Long 56267 373-0967 64464 397-6669 X-large Long 56271 373-1007 64486 397-6784

X-large Plus Normal 56268 372-9886 64473 397-1876 X-large Plus Normal 56272 373-0991 64495 397-2171

X-large Plus Long 56269 373-0975 64474 397-6727 X-large Plus Long 56273 373-1015 64496 397-6842

Oracle Code – GTB067

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 22

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 2 (23-32 mmHg)

Size Length

Nature Black

Product Code

PIP Code Product

Code PIP Code

X-small Normal 50974 364-4937 50990 364-5090

X-small Long 50975 364-4978 50991 364-5132

X-small Plus Normal 50982 364-5017 50998 364-5173

X-small Plus Long 50983 364-5058 50999 364-5215

Small Normal 50976 364-4945 50992 364-5108

Small Long 50977 364-4986 50993 364-5140

Small Plus Normal 50984 364-5025 51000 364-5181

Small Plus Long 50985 364-5066 51001 364-5223

Medium Normal 50978 364-4952 50994 364-5116

Medium Long 50979 364-4664 50995 364-5157

Medium Plus Normal 50986 364-5033 51002 364-5199

Medium Plus Long 50987 364-5474 51003 364-5231

Large Normal 50980 364-4960 50996 364-5124

Large Long 50981 363-5009 50997 364-5165

Large Plus Normal 50988 364-5041 51004 364-5207

Large Plus Long 50989 364-5082 51005 364-5249

X-large Normal 56318 373-1437 56322 373-1445

X-large Long 56319 373-1478 56323 373-1486

X-large Plus Normal 56320 373-1452 56324 373-1460

X-large Plus Long 56321 373-1494 56325 373-1502

Oracle Code – GTB328

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 23

Thigh Length, Knobbed Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg) OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 56335 387-6024 56347 387-6042 XX-small Short 56359 387-6125 56371 387-6141

XX-small Normal 56336 387-6062 56348 387-6075 XX-small Normal 56360 387-6174 56372 387-6182

XX-small Long 56337 387-6092 56349 387-6117 XX-small Long 56361 387-6190 56373 387-6208

XX-small Plus Short 56341 395-8568 56353 395-8550

XX-small Plus Short 56365 395-8584 56377 395-8576

XX-small Plus Normal 56342 396-7536 56354 396-7528 XX-small Plus Normal 56366 396-7494 56378 396-7486

XX-small Plus Long 56343 395-8600 56355 395-8592 XX-small Plus Long 56367 395-9186 56379 395-9178

X-small Short 50438 364-5256 50462 364-5496

X-small Short 50510 364-5769 50534 364-6676

X-small Normal 50439 364-5298 50463 364-5538 X-small Normal 50511 364-5801 50535 364-6718

X-small Long 50440 364-5330 50464 364-5579 X-small Long 50512 364-5843 50536 364-6759

X-small Plus Short 50450 364-5371 50474 364-5611 X-small Plus Short 50522 364-5884 50546 364-6791

X-small Plus Normal 50451 364-5413 50475 364-5652 X-small Plus Normal 50523 364-6593 50547 364-6833

X-small Plus Long 50452 364-5454 50476 364-5686 X-small Plus Long 50524 364-6635 50548 364-6874

Small Short 50441 364-5264 50465 364-5504 Small Short 50513 364-5777 50537 364-6684

Small Normal 50442 364-5306 50466 364-5546 Small Normal 50514 364-5819 50538 364-6726

Small Long 50443 364-5348 50467 364-5587 Small Long 50515 364-5850 50539 364-6767

Small Plus Short 50453 364-5389 50477 364-5629 Small Plus Short 50525 364-5892 50549 364-6809

Small Plus Normal 50454 364-5421 50478 364-5660 Small Plus Normal 50526 364-6601 50550 364-6841

Small Plus Long 50455 364-5462 50479 364-5694 Small Plus Long 50527 364-6643 50551 364-6882

Medium Short 50444 364-5272 50468 364-5512 Medium Short 50516 364-5785 50540 364-6692

Medium Normal 50445 364-5314 50469 364-5553 Medium Normal 50517 364-5827 50541 364-6734

Medium Long 50446 364-5355 50470 364-5595 Medium Long 50518 364-5868 50542 364-6775

Medium Plus Short 50456 364-5397 50480 364-5637 Medium Plus Short 50528 364-5900 50552 364-6817

Medium Plus Normal 50457 364-5439 50481 364-5678 Medium Plus Normal 50529 364-6619 50553 364-6858

Medium Plus Long 50458 364-5470 50482 364-5702 Medium Plus Long 50530 364-6650 50554 364-6890

Large Short 50447 364-5280 50471 364-5520 Large Short 50519 364-5793 50543 364-6700

Large Normal 50448 364-5322 50472 364-5561 Large Normal 50520 364-5835 50544 364-6742

Large Long 50449 364-5363 50473 364-5603 Large Long 50521 364-5876 50545 364-6783

Large Plus Short 50459 364-5405 50483 364-5645 Large Plus Short 50531 364-5918 50555 364-6825

Large Plus Normal 50460 364-5447 50484 364-5728 Large Plus Normal 50532 364-6627 50556 364-6866

Large Plus Long 50461 364-5488 50485 364-5710 Large Plus Long 50533 364-6668 50557 364-6908

X-large Short 56338 373-1023 56350 373-1031 X-large Short 56362 373-1148 56374 373-1163

X-large Normal 56339 373-1064 56351 373-1072 X-large Normal 56363 373-1197 56375 373-1205

X-large Long 56340 373-1106 56352 373-1114 X-large Long 56364 373-1239 56376 373-1247

X-large Plus Short 56344 373-1049 56356 373-1056 X-large Plus Short 56368 373-1171 56380 373-1189

X-large Plus Normal 56345 373-1080 56357 373-1098 X-large Plus Normal 56369 373-1213 56381 373-1221

X-large Plus Long 56346 373-1122 56358 373-1130 X-large Plus Long 56370 373-1254 56382 373-1262

Oracle Code – GTB296

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 24

Thigh Length, No Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg) OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 64497 395-3890 64533 395-8279 XX-small Short 64569 395-3916 64605 395-8386

XX-small Normal 64498 397-2296 64534 397-2312 XX-small Normal 64570 396-7205 64606 396-7262

XX-small Long 64499 397-3351 64535 397-3369 XX-small Long 64571 395-9533 64607 395-9665

XX-small Plus Short 64515 395-3908 64551 395-8212 XX-small Plus Short 64587 395-3924 64623 395-8493

XX-small Plus Normal 64516 397-2304 64552 397-2536 XX-small Plus Normal 64588 396-7320 64624 396-7387

XX-small Plus Long 64517 397-3476 64553 397-3484 XX-small Plus Long 64589 395-9483 64625 395-9723

X-small Short 64500 395-8113 64536 395-8287 X-small Short 64572 395-8337 64608 395-8394

X-small Normal 64501 397-2379 64537 397-2320 X-small Normal 64573 396-7213 64609 396-7270

X-small Long 64502 397-3427 64538 397-3377 X-small Long 64574 395-9541 64610 395-9673

X-small Plus Short 64518 395-8162 64554 395-8220 X-small Plus Short 64590 395-8444 64626 395-8501

X-small Plus Normal 64519 397-2593 64555 397-2544 X-small Plus Normal 64591 396-7338 64627 396-7395

X-small Plus Long 64520 397-3542 64556 397-3492 X-small Plus Long 64592 395-9475 64628 395-9731

Small Short 64503 395-8121 64539 395-8295 Small Short 64575 395-8345 64611 395-8402

Small Normal 64504 397-2387 64540 397-2338 Small Normal 64576 396-7221 64612 396-7288

Small Long 64505 397-3435 64541 397-3385 Small Long 64577 395-9566 64613 395-9681

Small Plus Short 64521 395-8170 64557 395-8238 Small Plus Short 64593 395-8451 64629 395-8519

Small Plus Normal 64522 397-2601 64558 397-2551 Small Plus Normal 64594 396-7346 64630 396-7403

Small Plus Long 64523 397-3559 64559 397-3500 Small Plus Long 64595 395-9491 64631 395-9749

Medium Short 64506 395-8147 64542 395-8311 Medium Short 64578 395-8360 64614 395-8428

Medium Normal 64507 397-2395 64543 397-2346 Medium Normal 64579 396-7239 64615 396-7296

Medium Long 64508 397-3443 64544 397-3393 Medium Long 64580 395-9558 64616 395-9699

Medium Plus Short 64524 395-8196 64560 395-8253 Medium Plus Short 64596 395-8477 64632 395-8535

Medium Plus Normal 64525 397-2619 64561 397-2569 Medium Plus Normal 64597 396-7353 64633 396-7411

Medium Plus Long 64526 397-3567 64562 397-3518 Medium Plus Long 64598 395-9509 64634 395-9756

Large Short 64509 395-8139 64545 395-8303 Large Short 64581 395-8352 64617 395-8410

Large Normal 64510 397-2403 64546 397-2353 Large Normal 64582 396-7247 64618 396-7304

Large Long 64511 397-3450 64547 397-3401 Large Long 64583 395-9574 64619 395-9707

Large Plus Short 64527 395-8188 64563 395-8246 Large Plus Short 64599 395-8469 64635 395-8527

Large Plus Normal 64528 397-2627 64564 397-2577 Large Plus Normal 64600 396-7361 64636 396-7429

Large Plus Long 64529 397-3575 64565 397-3526 Large Plus Long 64601 395-9517 64637 395-9764

X-large Short 64512 395-8154 64548 395-8329 X-large Short 64584 395-8378 64620 395-8436

X-large Normal 64513 397-2411 64549 397-2361 X-large Normal 64585 396-7254 64621 396-7312

X-large Long 64514 397-3468 64550 397-3419 X-large Long 64586 395-9582 64622 395-9715

X-large Plus Short 64530 395-8204 64566 395-8261 X-large Plus Short 64602 395-8485 64638 395-8543

X-large Plus Normal 64531 397-2635 64567 397-2585 X-large Plus Normal 64603 396-7379 64639 396-7437

X-large Plus Long 64532 397-3583 64568 397-3534 X-large Plus Long 64604 395-9525 64640 395-9772

Oracle Code – GTB296

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 25

Below Knee – Sigvaris Cotton XTRA Class 3 (34-46 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 73875 396-9656 73899 396-9789 XX-small Normal 73923 396-9680 73931 396-9714

XX-small Long 73876 396-3162 73900 396-3436 XX-small Long 73924 396-3022 73932 396-3550

XX-small Plus Normal 73887 396-9649 73911 396-9847 XX-small Plus Normal 73927 396-9722 73935 396-9748

XX-small Plus Long 73888 396-3295 73912 396-3493 XX-small Plus Long 73928 396-3154 73936 396-3584

X-small Normal 73877 364-1974 73901 396-9797 X-small Normal 51038 364-2139 51054 364-2295

X-small Long 73878 364-2014 73902 396-3444 X-small Long 51039 364-2170 51055 364-2337

X-small Plus Normal 73889 364-2055 73913 396-9854 X-small Plus Normal 51046 364-2212 51062 364-2378

X-small Plus Long 73890 364-2097 73914 396-3501 X-small Plus Long 51047 364-2253 51063 364-2410

Small Normal 73879 364-1982 73903 396-9805 Small Normal 51040 364-2147 51056 364-2303

Small Long 73880 364-2022 73904 396-3451 Small Long 51041 364-2188 51057 364-2345

Small Plus Normal 73891 364-2063 73915 396-9862 Small Plus Normal 51048 364-2220 51064 364-2386

Small Plus Long 73892 364-2105 73916 396-3519 Small Plus Long 51049 364-2261 51065 364-2428

Medium Normal 73881 364-1990 73905 396-9813 Medium Normal 51042 364-2154 51058 364-2311

Medium Long 73882 364-2030 73906 396-3469 Medium Long 51043 364-2196 51059 364-2352

Medium Plus Normal 73893 364-2071 73917 396-9870 Medium Plus Normal 51050 364-2238 51066 364-2394

Medium Plus Long 73894 364-2113 73918 396-3527 Medium Plus Long 51051 364-2279 51067 364-2436

Large Normal 73883 364-2006 73907 396-9821 Large Normal 51044 364-2162 51060 364-2329

Large Long 73884 364-2048 73908 396-3477 Large Long 51045 364-2204 51061 364-2360

Large Plus Normal 73895 364-2089 73919 396-9888 Large Plus Normal 51052 364-2246 51068 364-2402

Large Plus Long 73896 364-2121 73920 396-3535 Large Plus Long 51053 364-2287 51069 364-2444

X-large Normal 73885 396-9664 73909 396-9839 X-large Normal 73925 396-9698 73933 396-9706

X-large Long 73886 396-3303 73910 396-3485 X-large Long 73926 396-3147 73934 396-3568

X-large Plus Normal 73897 396-9672 73921 396-9896 X-large Plus Normal 73929 396-9755 73937 396-9730

X-large Plus Long 73898 396-3428 73922 396-3543 X-large Plus Long 73930 396-3287 73938 396-3576

Oracle Codes Open toe - GTB297

Closed toe - GTB298

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 26

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 3 (34-46 mmHg)

Size Length

Black

Product Code

X-small Normal 51118

X-small Long 51119

X-small Plus Normal 51126

X-small Plus Long 51127

Small Normal 51120

Small Long 51121

Small Plus Normal 51128

Small Plus Long 51129

Medium Normal 51122

Medium Long 51123

Medium Plus Normal 51130

Medium Plus Long 51131

Large Normal 51124

Large Long 51125

Large Plus Normal 51132

Large Plus Long 51133

Oracle Code – GTB342

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 27

Thigh, NO Grip Top – Sigvaris Cotton Class 3 (34-46 mmHg)

NOT on prescription

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product Code Product Code Size Length Product Code Product Code

X-small Short 90438-CT 90462-CT X-small Short 90510-CT 90534-CT

X-small Normal 90439-CT 90463-CT X-small Normal 90511-CT 90535-CT

X-small Long 90440-CT 90464-CT X-small Long 90512-CT 90536-CT

X-small Plus Short 90450-CT 90474-CT

X-small Plus Short 90522-CT 90546-CT

X-small Plus Normal 90451-CT 90475-CT X-small Plus Normal 90523-CT 90547-CT

X-small Plus Long 90452-CT 90476-CT X-small Plus Long 90524-CT 90548-CT

Small Short 90441-CT 90465-CT Small Short 90513-CT 90537-CT

Small Normal 90442-CT 90466-CT Small Normal 90514-CT 90538-CT

Small Long 90443-CT 90467-CT Small Long 90515-CT 90539-CT

Small Plus Short 90453-CT 90477-CT Small Plus Short 90525-CT 90549-CT

Small Plus Normal 90454-CT 90478-CT Small Plus Normal 90526-CT 90550-CT

Small Plus Long 90455-CT 90479-CT Small Plus Long 90527-CT 90551-CT

Medium Short 90444-CT 90468-CT Medium Short 90516-CT 90540-CT

Medium Normal 90445-CT 90469-CT Medium Normal 90517-CT 90541-CT

Medium Long 90446-CT 90470-CT Medium Long 90518-CT 90542-CT

Medium Plus Short 90456-CT 90480-CT Medium Plus Short 90528-CT 90552-CT

Medium Plus Normal 90457-CT 90481-CT Medium Plus Normal 90529-CT 90553-CT

Medium Plus Long 90458-CT 90482-CT Medium Plus Long 90530-CT 90554-CT

Large Short 90447-CT 90471-CT Large Short 90519-CT 90543-CT

Large Normal 90448-CT 90472-CT Large Normal 90520-CT 90544-CT

Large Long 90449-CT 90473-CT Large Long 90521-CT 90545-CT

Large Plus Short 90459-CT 90483-CT Large Plus Short 90531-CT 90555-CT

Large Plus Normal 90460-CT 90484-CT Large Plus Normal 90532-CT 90556-CT

Large Plus Long 90461-CT 90485-CT Large Plus Long 90533-CT 90557-CT

X-large Short 96338-CT 96350-CT X-large Short 96362-CT 96374-CT

X-large Normal 96339-CT 96351-CT X-large Normal 96363-CT 96375-CT

X-large Long 96340-CT 96352-CT X-large Long 96364-CT 96376-CT

X-large Plus Short 96344-CT 96356-CT X-large Plus Short 96368-CT 96380-CT

X-large Plus Normal 96345-CT 96357-CT X-large Plus Normal 96369-CT 96381-CT

X-large Plus Long 96346-CT 96358-CT X-large Plus Long 96370-CT 96382-CT

Oracle Code – GTB344

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 28

Thigh, Knobbed Grip Top – Sigvaris Cotton Class 3 (34-46 mmHg) OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product Code PIP Code Product Code PIP Code Size Length Product Code PIP Code Product Code PIP Code

XX-small Short 74016 395-7016 76625 395-7057

X-small Short 74052 395-7032 76661 395-7339

XX-small Normal 74017 396-9904 76626 396-9979 X-small Normal 74053 397-0373 76662 397-0415

XX-small Long 74018 396-4954 76627 396-5159 X-small Long 74054 396-4939 76663 396-5324

XX-small Plus Short 74034 395-7024 76643 395-7222

X-small Plus Short 74070 395-7040 76679 395-7552

XX-small Plus Normal 74035 396-9912 76644 397-0209 X-small Plus Normal 74071 397-0381 76680 397-0985

XX-small Plus Long 74036 396-4962 76645 396-5217 X-small Plus Long 74072 396-4947 76681 396-5381

X-small Short 74019 395-7115 76628 395-7065

X-small Short 74055 395-7396 76664 395-7347

X-small Normal 74020 396-9987 76629 396-9920 X-small Normal 74056 397-0399 76665 397-0423

X-small Long 74021 396-4970 76630 396-5100 X-small Long 74057 396-5225 76666 396-5332

X-small Plus Short 74037 395-7589 76646 395-7230

X-small Plus Short 74073 395-7610 76682 395-7560

X-small Plus Normal 74038 397-0266 76647 397-0217 X-small Plus Normal 74074 397-1041 76683 397-0993

X-small Plus Long 74039 396-5035 76648 396-5167 X-small Plus Long 74075 396-5274 76684 396-5399

Small Short 74022 395-7123 76631 395-7073 Small Short 74058 395-7404 76667 395-7354

Small Normal 74023 397-0001 76632 396-9946 Small Normal 74059 397-0407 76668 397-0431

Small Long 74024 396-4996 76633 396-5126 Small Long 74060 396-5241 76669 396-5340

Small Plus Short 74040 395-7297 76649 395-7248 Small Plus Short 74076 395-7628 76685 395-7578

Small Plus Normal 74041 397-0282 76650 397-0225 Small Plus Normal 74077 397-1058 76686 397-1009

Small Plus Long 74042 396-5043 76651 396-5183 Small Plus Long 74078 396-5290 76687 396-5407

Medium Short 74025 395-7131 76634 395-7081 Medium Short 74061 395-7412 76670 395-7362

Medium Normal 74026 396-9995 76635 396-9938 Medium Normal 74062 397-0472 76671 397-0449

Medium Long 74027 396-4988 76636 396-5118 Medium Long 74063 396-5233 76672 396-5357

Medium Plus Short 74043 395-7305 76652 395-7255 Medium Plus Short 74079 395-7636 76688 395-7586

Medium Plus Normal 74044 397-0274 76653 397-0233 Medium Plus Normal 74080 397-1066 76689 397-1017

Medium Plus Long 74045 396-5050 76654 396-5175 Medium Plus Long 74081 396-5282 76690 396-5415

Large Short 74028 395-7149 76637 395-7099 Large Short 74064 395-7420 76673 395-7370

Large Normal 74029 397-0019 76638 396-9953 Large Normal 74065 397-0480 76674 397-0456

Large Long 74030 396-5001 76639 396-5134 Large Long 74066 396-5258 76675 396-5365

Large Plus Short 74046 395-7313 76655 395-7263 Large Plus Short 74082 395-7644 76691 395-7594

Large Plus Normal 74047 397-0290 76656 397-0241 Large Plus Normal 74083 397-1074 76692 397-1025

Large Plus Long 74048 396-5068 76657 396-5191 Large Plus Long 74084 396-5308 76693 396-5423

X-large Short 74031 395-7156 76640 395-7107 X-large Short 74067 395-7438 76676 395-7388

X-large Normal 74032 397-0027 76641 396-9961 X-large Normal 74068 397-0498 76677 397-0464

X-large Long 74033 396-5019 76642 396-5142 X-large Long 74069 396-5266 76678 396-5373

X-large Plus Short 74049 395-7321 76658 395-7271 X-large Plus Short 74085 395-7651 76694 395-7602

X-large Plus Normal 74050 397-0308 76659 397-0258 X-large Plus Normal 74086 397-1082 76695 397-1033

X-large Plus Long 74051 396-5076 76660 396-5209 X-large Plus Long 74087 396-5316 76696 396-5431

Oracle Code – GTB299

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 29

Circumference (cms) S M L XL XXL

cG Thigh 42-57 48-64 54-71 60-78 66-85

cC Calf 28-34 32-38 36-42 40-46 44-50

cB Ankle 19-21 22-24 25-27 28-30 31-34

Lower Limb Circular Knit LOWER Compression- Mediven Duomed Soft

Duomed Soft below Knee and Thigh Class 1 /2 Indications for use: soft fabric ideal for palliatives and chronic oedema patients who

struggle to apply normal compression stockings only last for 3 months

Size Chart Colour: Sand

Duomed Soft Class 1 Medi Code Size S Size M Size L Size XL Size XXL

Below Knee, Open Toe DT511 367-4850 367-4868 367-4876 367- 4884 367-4892

Below Knee, Closed Toe DT512 367-4926 367-4934 367-4959 367-4967 367-4975

Thigh Length with Silicone Top Band, Open Toe

DT611 367-4983 367-4991 367-5006 367-5014 367-5022

Thigh Length with Silicone Top Band, Closed Toe

DT612 367-5030 367-5048 367-5055 367-5063 367-5071

Duomed Soft Class 2 Medi Code Size S Size M Size L Size XL Size XXL

Below Knee, Open Toe DT521 367-5089 367-5097 367-5105 367- 5113 367-5121

Below Knee, Closed Toe DT522 367-5139 367-5147 367-5154 367-5162 367-5170

Thigh Length with Silicone Top Band, Open Toe

DT621 367-5188 367-5196 367-5204 367-5212 367-5220

Thigh Length with Silicone Top Band, Closed Toe

DT622 367-5238 367-5246 367-5253 367-5261 367-5279

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 30

Circumference (cms) S M L XL XXL

cG Thigh 42-57 48-64 54-71 60-78 66-85

cC Calf 28-34 32-38 36-42 40-46 44-50

cB Ankle 19-21 22-24 25-27 28-30 31-34

Lower Limb Circular Knit LOWER Compression- Mediven Duomed Soft

Duomed Soft below Knee and Thigh Class 1 /2 Indications for use: soft fabric ideal for palliatives and chronic oedema patients who

struggle to apply normal compression stockings only last for 3 months

Size Chart Colour: Black

Duomed Soft Class 1 Medi Code Size S Size M Size L Size XL Size XXL

Below Knee, Open Toe DT511/B/ 388-1802 388-1810 388-1828 388-1836 388-1844

Below Knee, Closed Toe DT512/B/ 388-1851 388-1869 388-1877 388-1885 388-1893

Thigh Length with Silicone Top Band, Open Toe

DT611/B/ 388-1901 388-1919 388-1927 388-1935 388-1943

Thigh Length with Silicone Top Band, Closed Toe

DT612/B/ 388-1950 388-1968 388-1976 388-1984 388-1992

Duomed Soft Class 2 Medi Code Size S Size M Size L Size XL Size XXL

Below Knee, Open Toe DT521/B/ 388-2008 388-2016 388-2024 388-2032 388-2040

Below Knee, Closed Toe DT522/B/ 388-2057 388-2065 388-2073 388-2081 388-2099

Thigh Length with Silicone Top Band, Open Toe

DT621/B/ 388-2107 388-2115 388-2123 388-2131 388-2149

Thigh Length with Silicone Top Band, Closed Toe

DT622/B/ 388-2156 388-2164 388-2172 388-2180 388-2198

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 31

Lower Limb, Flat Knit, Below Knee and Thigh, Class 1 & 3 - Juzo Expert / Class 2 - Haddenham Pertex 2

NOT available on prescription; Open or Closed Toe with or without Grip Tops

Indications for use: Established lymphoedema especially with the presence of skin folds; skin and tissues requiring firm support from

the stiff fabric.

Also available: Extra Wide Below Knee Only Circumferences

4 x-small extra wide

6 small extra wide

8 medium extra wide

10 large extra wide

12 x-large extra wide

14 xx-large extra wide

D 29.5 – 32.5 32.5 – 35.5 35.5 – 39.0 38.5 – 42.0 41.5 – 45.5 44.5 – 48.5

C 31.5 – 34.5 34.5 – 37.5 37.5 – 41.0 40.5 – 44.5 43.0 – 47.0 45.5 – 49.5

cB 18.5 – 20.0 20.0 – 22.0 22.0 – 24.0 24.0 – 26.0 26.0 – 28.5 28.0 – 30.5

cY 28.0 – 30.5 29.0 – 31.5 31.0 – 34.0 33.0 – 36.0 35.0 – 38.5 37.0 – 40.5

cA 18.5 – 20.0 20.0 – 22.0 22.0 – 24.0 24.0 – 26.0 26.0 – 28.5 28.0 – 30.5

NOTE:

Class 1 code = 3021

Class 3 code = 3023

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 32

Colours:

Grip Top options:

When ordering the company has recommended the following:

Juzo Expert AD (below knee), size and compression level 1 or 3

Juzo Expert AG (thigh), size, compression level 1 or 3 and type of grip top (if required)

IF YOU REQUIRE Extra Wide Calf or Short foot/ Long foot PLEASE state size requirement you want on order form as these will be

made per your requirements, i.e. Juzo Expert AD Below Knee class 1, size medium (10) extra wide at point CC increase to 40cm, foot

size closed toe 28cm i.e. long foot. YOU MUST STATE SIZE NEEDED IN cms

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 33

Lower Limb Ready to Wear Flat Knit compression Lower limb Garments Class 2 - Haddenham Pertex 2

NOT available on prescription

Indications for use: Moderate to complex lymphoedema where skin and soft tissue requires stiffness of the material without the

need for high levels of compression. To be considered if donning and doffing RAL class 1 garment too difficult for a patient.

Size Chart:

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 34

Options for Garments

Toe Closed toe or Open toe CT / OT

Extra Wide Extra Wide option EW

Leg Length If not Regular length, choose Short Leg or Long Leg SL / LL

Foot Length If not Regular foot length, choose Short Foot or Long Foot SF / LF

Colour If not Beige, choose Light Beige or Black

Beige = 0

Black = 5

Light Beige = 11

Grip Top Strong Plain is default, or choose Fine Lace or Strong Lace State preference on order

Product Code Product Code

Below Knee, Open or

Closed Toe 921

Thigh, NO grip top,

Open or Closed Toe 922

Below Knee with 3cm

Grip Top, Open or

Closed Toe

920

Thigh with 5cm Grip

Top, Open or Closed

Toe

923

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 35

Lower Limb, Flat Knit, Below and Thigh, LOWER Compression Support Products – Haddenham Pertex Light

NOT available on prescription

Indications for use: Moderate to complex lymphoedema where skin and soft tissue requires stiffness of the material without the

need for high levels of compression. To be considered if donning and doffing RAL class 1 garment too difficult for a patient.

Size Chart:

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 36

Options for Garments

Toe Closed toe or Open toe CT / OT

Extra Wide Extra Wide option EW

Leg Length If not Regular length, choose Short Leg or Long Leg SL / LL

Foot Length If not Regular foot length, choose Short Foot or Long Foot SF / LF

Colour If not Beige, choose Light Beige or Black

Beige = 0

Black = 5

Light Beige = 11

Grip Top Strong Plain is default, or choose Fine Lace or Strong Lace State preference on order

Product Code Product Code

Below Knee, Open or

Closed Toe 901

Thigh, NO grip top,

Open or Closed Toe 902

Below Knee with 3cm

Grip Top, Open or

Closed Toe

900

Thigh with 5cm Grip

Top, Open or Closed

Toe

903

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 37

Lower Limb, Circular Knit, Light Sheer Fabric, Tights, Class 1 & 2 – Juzo Attractive/Soft

Size Chart for articles: Juzo Attractive 2701/2702/2781/2782 & Juzo Soft 2001/2002

Long

Standard

Petite

Large

Normal

Petite

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 38

Note: Batik (tie dye) is available on

prescription in Wales only. Need to request

Black Pepper or Sugar garment with tie dye

colour. No extra charge to Wales.

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 39

When writing prescription the following format has been recommended by the company:

Fabric Compression level Type Garment

OT / CT Garment Size Colour

Juzo Soft Class 2 (23-32 mmHg)

Tights Open Toe Lymphoedema Garment

3 Almond (Beige)

Juzo Attractive

Class 1 (18-23 mmHg)

Tights Closed Toe Lymphoedema Garment

6 Black Pepper (Black)

Indications: Class 1 – mild compression (18-21 mmHg) For mild to moderate lymphoedema, lipoedema, minor obstructive disorders accompanied by feelings of tiredness or heaviness in the legs, as a preventative measure during pregnancy, or for the therapeutic treatment of scars Class 2 – moderate compression (23-32 mmHg) For moderate lymphoedema, lipoedema, varicose veins, leg swelling during pregnancy, for the long-term treatment of healed leg ulcers or where a propensity for oedema formation exists

Note: Batik (tie dye) is available on

prescription in Wales only. Need to request

Black Pepper or Sugar garment with tie dye

colour. No extra charge to Wales.

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 40

Lower Limb, Circular Knit, Firmer/Denser Fabric, Tights, Class 1, 2 & 3 – Juzo Dynamic

Indications: For those people needing a more robust fabric to control their lymphoedema

Size Chart

Long

Standard

Petite

Large

Normal

Petite

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 41

When writing prescription the following format has been recommended by the company:

Fabric Compression level Type Garment

OT / CT Garment Size Colour

Juzo Dynamic

Class 2 (23-32 mmHg)

Tights Open Toe Lymphoedema Garment 3 Almond (Beige)

Juzo Dynamic

Class 3 (34-46 mmHg)

Tights Closed Toe Lymphoedema Garment 4 Black Pepper (Black)

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 42

Toes Caps - Haddenham Microfine Toecaps

Indications: reduce and prevent swelling in the toes. Can be cut without fraying to size

Colours: Sand/ Beige/ Black

Ready-to-wear range of compression toe caps (20–36mmHg).

Circumference at ball of foot

Size Sand Beige Black PIP Code Sand PIP Code Black

21-23cm X- Small 218S-1 218-1 218B-1 347-9649 376-6284

23-25cm Small 218S-2 218-2 218B-2 347-9656 376-6292

25-27cm Medium 218S-3 218-3 218B-3 347-9664 376-6300

27-29cm Large 218S-4 218-4 218B-4 347-9672 376-6318

29-31cm X-Large 218S-5 218-5 218B-5 Not available

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 43

Lower Limb, Circular Knit, COTTON RICH, Thigh & Below Knee - Sigvaris Cotton Class 1 & 2

Indications: for those people with Latex allergy or sensitive, fragile skin

Size Chart:

Advice from Sigvaris when inputting products into EMIS:

Input Sigvaris

Input garment name (e.g. Magic, Comfort, Cotton)

Input class of garment

Input type of garment (e.g. below knee, thigh etc)

Input open/closed toe

Input length

Input size

Input colour

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 44

Below Knee - Sigvaris Cotton Class 1 (18-21 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 56236 387-4401 63899 396-1034 XX-small Normal 63935 387-4450 63971 387-4476

XX-small Long 56237 387-4419 63900 397-3625 XX-small Long 63936 387-4468 63972 387-4484

XX-small Plus Normal 63891 396-1000 63917 396-1190 XX-small Plus Normal 63953 396-1018 63989 396-1026

XX-small Plus Long 63892 397-3591 63918 397-3682 XX-small Plus Long 63954 397-3609 63990 397-3617

X-small Normal 54034 363-6255 63902 396-1059 X-small Normal 63938 363-6412 63974 363-7030

X-small Long 54035 363-6297 63903 397-3633 X-small Long 63939 363-6453 63975 363-7071

X-small Plus Normal 54042 363-6339 63920 396-1208 X-small Plus Normal 63956 363-6495 63992 363-7113

X-small Plus Long 54043 363-6370 63921 397-3690 X-small Plus Long 63957 363-6990 63993 363-7154

Small Normal 54036 363-6263 63905 396-1067 Small Normal 63941 363-6420 63977 363-7048

Small Long 54037 363-6305 63906 397-3641 Small Long 63942 363-6461 63978 363-7089

Small Plus Normal 54044 363-6347 63923 396-1216 Small Plus Normal 63959 363-6503 63995 363-7121

Small Plus Long 54045 363-6388 63924 397-3708 Small Plus Long 63960 363-7006 63996 363-7162

Medium Normal 54038 363-6271 63908 396-1075 Medium Normal 63944 363-6438 63980 363-7055

Medium Long 54039 363-6313 63909 397-3658 Medium Long 63945 363-6479 63981 363-7097

Medium Plus Normal 54046 363-6354 63926 396-1224 Medium Plus Normal 63962 363-6511 63998 363-7139

Medium Plus Long 54047 363-6396 63927 397-3716 Medium Plus Long 63963 363-7014 63999 363-7170

Large Normal 54040 363-6289 63911 396-1091 Large Normal 63947 363-6446 63983 363-7063

Large Long 54041 363-6321 63912 397-3666 Large Long 63948 363-6487 63984 363-7105

Large Plus Normal 54048 363-6362 63929 396-1232 Large Plus Normal 63965 363-6529 64001 363-7147

Large Plus Long 54049 363-6404 63930 397-3724 Large Plus Long 63966 363-7022 64002 363-7188

X-large Normal 56238 372-9530 63914 396-1109 X-large Normal 63950 372-9571 63986 372-9589

X-large Long 56239 372-9555 63915 397-3674 X-large Long 63951 372-9613 63987 372-9621

X-large Plus Normal 56240 372-9548 63932 396-1240 X-large Plus Normal 63968 372-9597 64004 372-9605

X-large Plus Long 56241 372-9563 63933 397-3732 X-large Plus Long 63969 372-9639 64005 372-9647

Oracle Codes Open toe - GTB075

Closed toe - GTB078

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 45

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 1 (18-21 mmHg)

Size Length

Black

Product Code

X-small Normal 50862

X-small Long 50863

X-small Plus Normal 50870

X-small Plus Long 50871

Small Normal 50864

Small Long 50865

Small Plus Normal 50872

Small Plus Long 50873

Medium Normal 50866

Medium Long 50867

Medium Plus Normal 50874

Medium Plus Long 50875

Large Normal 50868

Large Long 50869

Large Plus Normal 50876

Large Plus Long 50877

X-large Normal 56258

X-large Long 56259

X-large Plus Normal 56260

X-large Plus Long 56261

Oracle Code – GTB327

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 46

Thigh Length, Knobbed Grip Top – Sigvaris Cotton Class 1 (18-21 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 56326 387-4427 64153 395-4930 XX-small Short 64189 395-3791 64225 395-5879

XX-small Normal 56327 387-4435 64154 396-2354 XX-small Normal 64190 396-2586 64226 396-2602

XX-small Long 56328 387-4443 64155 397-4292 XX-small Long 64191 397-4359 64227 397-4375

XX-small Plus Short 64150 395-3783 64171 395-5119

XX-small Plus Short 64207 395-3809 64243 395-5937

XX-small Plus Normal 64151 396-2347 64172 396-2529 XX-small Plus Normal 64208 396-2594 64244 396-2719

XX-small Plus Long 64152 397-4227 64173 397-4235 XX-small Plus Long 64209 397-4367 64245 397-4482

X-small Short 50262 363-7584 64156 395-4948

X-small Short 64192 395-5531 64228 395-5887

X-small Normal 50263 363-7626 64157 396-2362 X-small Normal 64193 396-2669 64229 396-2610

X-small Long 50264 363-7667 64158 397-4300 X-small Long 64194 397-4433 64230 397-4383

X-small Plus Short 50274 363-7709 64174 395-5127 X-small Plus Short 64210 395-5705 64246 395-5945

X-small Plus Normal 50275 363-7741 64175 396-2537 X-small Plus Normal 64211 396-2776 64247 396-2727

X-small Plus Long 50276 363-7782 64176 397-4243 X-small Plus Long 64212 397-4540 64248 397-4490

Small Short 50265 363-7592 64159 395-4955 Small Short 64195 395-5549 64231 395-5895

Small Normal 50266 363-7634 64160 396-2370 Small Normal 64196 396-2677 64232 396-2628

Small Long 50267 363-7675 64161 397-4318 Small Long 64197 397-4441 64233 397-4391

Small Plus Short 50277 363-7717 64177 395-5135 Small Plus Short 64213 395-5713 64249 395-5952

Small Plus Normal 50278 363-7758 64178 396-2545 Small Plus Normal 64214 396-2784 64250 396-2735

Small Plus Long 50279 363-7790 64179 397-4250 Small Plus Long 64215 397-4557 64251 397-4508

Medium Short 50268 363-7600 64162 395-4963 Medium Short 64198 395-5556 64234 395-5903

Medium Normal 50269 363-7642 64163 396-2388 Medium Normal 64199 396-2685 64235 396-2636

Medium Long 50270 363-7683 64164 397-4326 Medium Long 64200 397-4458 64236 397-4409

Medium Plus Short 50280 363-7725 64180 395-5143 Medium Plus Short 64216 395-5721 64252 395-5960

Medium Plus Normal 50281 363-7766 64181 396-2552 Medium Plus Normal 64217 396-2792 64253 396-2743

Medium Plus Long 50282 363-7808 64182 397-4268 Medium Plus Long 64218 397-4565 64254 397-4516

Large Short 50271 363-7618 64165 395-4971 Large Short 64201 395-5564 64237 395-5911

Large Normal 50272 363-7659 64166 396-2396 Large Normal 64202 396-2693 64238 396-2644

Large Long 50273 363-7691 64167 397-4334 Large Long 64203 397-4466 64239 397-4417

Large Plus Short 50283 363-7733 64183 395-5150 Large Plus Short 64219 395-5739 64255 395-5978

Large Plus Normal 50284 363-7774 64184 396-2560 Large Plus Normal 64220 396-2800 64256 396-2750

Large Plus Long 50285 363-7816 64185 397-4276 Large Plus Long 64221 397-4573 64257 397-4524

X-large Short 56329 372-9738 64168 395-4989 X-large Short 64204 395-5572 64240 395-5929

X-large Normal 56330 372-9753 64169 396-2404 X-large Normal 64205 396-2701 64241 396-2651

X-large Long 56331 372-9779 64170 397-4342 X-large Long 64206 397-4474 64242 397-4425

X-large Plus Short 56332 372-9746 64186 395-5168 X-large Plus Short 64222 395-5747 64258 395-5986

X-large Plus Normal 56333 372-9761 64187 396-2578 X-large Plus Normal 64223 396-2818 64259 396-2768

X-large Plus Long 56334 372-9787 64188 397-4284 X-large Plus Long 64224 397-4581 64260 397-4532

Oracle Code – GTB071

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 47

Thigh Length, No Grip Top – Sigvaris Cotton Class 1 (18-21 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 64006 395-3742 64042 395-4518 XX-small Short 64078 395-3767 64114 395-4732

XX-small Normal 64007 396-1257 64043 396-1448 XX-small Normal 64079 396-1976 64115 396-1992

XX-small Long 64008 397-3740 64044 397-3781 XX-small Long 64080 397-3765 64116 397-4003

XX-small Plus Short 64024 395-3759 64060 395-4575 XX-small Plus Short 64096 395-3775 64132 395-4831

XX-small Plus Normal 64025 396-1323 64061 396-1331 XX-small Plus Normal 64097 396-1984 64133 396-2172

XX-small Plus Long 64026 397-3757 64062 397-3898 XX-small Plus Long 64098 397-3773 64134 397-4110

X-small Short 64009 395-4179 64045 395-4526 X-small Short 64081 395-4633 64117 395-4740

X-small Normal 64010 396-1505 64046 396-1455 X-small Normal 64082 396-2057 64118 396-2008

X-small Long 64011 397-3849 64047 397-3799 X-small Long 64083 397-4060 64119 397-4011

X-small Plus Short 64027 395-4468 64063 395-4583 X-small Plus Short 64099 395-4682 64135 395-4849

X-small Plus Normal 64028 396-1398 64064 396-1349 X-small Plus Normal 64100 396-2230 64136 396-2180

X-small Plus Long 64029 397-3955 64065 397-3906 X-small Plus Long 64101 397-4177 64137 397-4128

Small Short 64012 395-4294 64048 395-4534 Small Short 64084 395-4641 64120 395-4757

Small Normal 64013 396-1513 64049 396-1463 Small Normal 64085 396-2065 64121 396-2016

Small Long 64014 397-3856 64050 397-3807 Small Long 64086 397-4078 64122 397-4029

Small Plus Short 64030 395-4476 64066 395-4591 Small Plus Short 64102 395-4690 64138 395-4856

Small Plus Normal 64031 396-1406 64067 396-1356 Small Plus Normal 64103 396-2248 64139 396-2198

Small Plus Long 64032 397-3963 64068 397-3914 Small Plus Long 64104 397-4185 64140 397-4136

Medium Short 64015 395-4302 64051 395-4542 Medium Short 64087 395-4658 64123 395-4765

Medium Normal 64016 396-1521 64052 396-1471 Medium Normal 64088 396-2073 64124 396-2024

Medium Long 64017 397-3864 64053 397-3815 Medium Long 64089 397-4086 64125 397-4037

Medium Plus Short 64033 395-4484 64069 395-4609 Medium Plus Short 64105 395-4708 64141 395-4864

Medium Plus Normal 64034 396-1414 64070 396-1364 Medium Plus Normal 64106 396-2255 64142 396-2206

Medium Plus Long 64035 397-3971 64071 397-3922 Medium Plus Long 64107 397-4193 64143 397-4144

Large Short 64018 395-4310 64054 395-4559 Large Short 64090 395-4666 64126 395-4773

Large Normal 64019 396-1539 64055 396-1489 Large Normal 64091 396-2081 64127 396-2032

Large Long 64020 397-3872 64056 397-3823 Large Long 64092 397-4094 64128 397-4045

Large Plus Short 64036 395-4492 64072 395-4617 Large Plus Short 64108 395-4716 64144 395-4872

Large Plus Normal 64037 396-1422 64073 396-1372 Large Plus Normal 64109 396-2263 64145 396-2214

Large Plus Long 64038 397-3989 64074 397-3930 Large Plus Long 64110 397-4201 64146 397-4151

X-large Short 64021 395-4328 64057 395-4567 X-large Short 64093 395-4674 64129 395-4781

X-large Normal 64022 396-1547 64058 396-1497 X-large Normal 64094 396-2099 64130 396-2040

X-large Long 64023 397-3880 64059 397-3831 X-large Long 64095 397-4102 64131 397-4052

X-large Plus Short 64039 395-4500 64075 395-4625 X-large Plus Short 64111 395-4724 64147 395-4880

X-large Plus Normal 64040 396-1430 64076 396-1380 X-large Plus Normal 64112 396-2271 64148 396-2222

X-large Plus Long 64041 397-3997 64077 397-3948 X-large Plus Long 64113 397-4219 64149 397-4169

Oracle Code – GTB071

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 48

Below Knee – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 63394 387-4534 63406 387-4732 XX-small Short 63418 387-4757 63430 387-5358

XX-small Normal 56274 387-4492 56282 387-4500 XX-small Normal 56290 387-5465 56298 387-5473

XX-small Long 56275 387-4518 56283 387-4526 XX-small Long 56291 387-5487 56299 387-5499

XX-small Plus Short 63400 395-8097 63412 395-8089 XX-small Plus Short 63424 399-0439 63436 399-0421

XX-small Plus Normal 56278 397-1629 56286 397-1637 XX-small Plus Normal 56294 397-1645 56302 397-1652

XX-small Plus Long 56279 397-6552 56287 397-6560 XX-small Plus Long 56295 397-6578 56303 397-6586

X-small Short 63395 387-4512 63407 387-4708 X-small Short 63419 387-5176 63431 387-5408

X-small Normal 50302 364-1644 50318 364-1800 X-small Normal 50350 364-3475 50366 364-4457

X-small Long 50303 364-1685 50319 364-1842 X-small Long 50351 364-3517 50367 364-4812

X-small Plus Short 63401 387-4591 63413 387-4641 X-small Plus Short 63425 387-5283 63437 387-5416

X-small Plus Normal 50310 364-1727 50326 364-1883 X-small Plus Normal 50358 364-4374 50374 364-4853

X-small Plus Long 50311 364-1768 50327 364-1925 X-small Plus Long 50359 364-4416 50375 364-4895

Small Short 63396 387-4559 63408 387-4716 Small Short 63420 387-5184 63432 387-5366

Small Normal 50304 364-1651 50320 364-1818 Small Normal 50352 364-3483 50368 364-4465

Small Long 50305 364-1693 50321 364-1859 Small Long 50353 364-3525 50369 364-4820

Small Plus Short 63402 387-4609 63414 387-4658 Small Plus Short 63426 387-5291 63438 387-5424

Small Plus Normal 50312 364-1735 50328 364-1891 Small Plus Normal 50360 364-4382 50376 364-4861

Small Plus Long 50313 364-1776 50329 364-1933 Small Plus Long 50361 364-4424 50377 364-4903

Medium Short 63397 387-4567 63409 387-4724 Medium Short 63421 387-5192 63433 387-5374

Medium Normal 50306 364-1669 50322 364-1826 Medium Normal 50354 364-3491 50370 364-4473

Medium Long 50307 364-1701 50323 364-1867 Medium Long 50355 364-3533 50371 364-4838

Medium Plus Short 63403 387-4617 63415 387-4666 Medium Plus Short 63427 387-5325 63439 387-5432

Medium Plus Normal 50314 364-1743 50330 364-1909 Medium Plus Normal 50362 364-4390 50378 364-4879

Medium Plus Long 50315 364-1784 50331 364-1941 Medium Plus Long 50363 364-4432 50379 364-4911

Large Short 63398 387-4575 63410 387-4690 Large Short 63422 387-5200 63434 387-5382

Large Normal 50308 364-1677 50324 364-1834 Large Normal 50356 364-3509 50372 364-4481

Large Long 50309 364-1719 50325 364-1875 Large Long 50357 364-3541 50373 364-4846

Large Plus Short 63404 387-4625 63416 387-4674 Large Plus Short 63428 387-5333 63440 387-5440

Large Plus Normal 50316 364-1750 50332 364-1917 Large Plus Normal 50364 364-4408 50380 364-4887

Large Plus Long 50317 364-1792 50333 364-1958 Large Plus Long 50365 364-4440 50381 364-4929

X-large Short 63399 387-4583 63411 387-4740 X-large Short 63423 387-5218 63435 387-5390

X-large Normal 56276 372-9795 56284 372-9803 X-large Normal 56292 373-1312 56300 373-1320

X-large Long 56277 372-9837 56285 372-9845 X-large Long 56293 373-1353 56301 373-1361

X-large Plus Short 63405 387-4633 63417 387-4682 X-large Plus Short 63429 387-5341 63441 387-5457

X-large Plus Normal 56280 372-9811 56288 372-9829 X-large Plus Normal 56296 373-1338 56304 373-1346

X-large Plus Long 56281 372-9852 56289 372-9860 X-large Plus Long 56297 373-1379 56305 373-1387

Oracle Code – GTB295

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 49

Below Knee, Knobbed Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 56262 387-5960 64453 397-1728 XX-small Normal 56264 387-5994 64475 397-2064

XX-small Long 56263 387-5978 64454 397-6610 XX-small Long 56265 384-6018 64476 397-6735

XX-small Plus Normal 64660 399-0413 64662 397-1868 XX-small Plus Normal 64664 397-2056 64666 397-2122

XX-small Plus Long 64661 397-6594 64663 397-6677 XX-small Plus Long 64665 397-6602 64667 397-6792

X-small Normal 50382 364-1966 64455 397-1736 X-small Normal 50398 364-3624 64477 397-2072

X-small Long 50383 364-3392 64456 397-6628 X-small Long 50399 364-3681 64478 397-6743

X-small Plus Normal 50390 364-3467 64465 397-1884 X-small Plus Normal 50406 364-3723 64487 397-2130

X-small Plus Long 50391 364-3558 64466 397-6685 X-small Plus Long 50407 364-3731 64488 397-6800

Small Normal 50384 364-3426 64457 397-1744 Small Normal 50400 364-3632 64479 397-2080

Small Long 50385 364-3434 64458 397-6636 Small Long 50401 364-3699 64480 397-6750

Small Plus Normal 50392 364-3582 64467 397-1892 Small Plus Normal 50408 364-3764 64489 397-2148

Small Plus Long 50393 364-3590 64468 397-6693 Small Plus Long 50409 364-3772 64490 397-6818

Medium Normal 50386 364-3400 64459 397-1751 Medium Normal 50402 364-3640 64481 397-2098

Medium Long 50387 364-3442 64460 397-6644 Medium Long 50403 364-3707 64482 397-6768

Medium Plus Normal 50394 364-3566 64469 397-1900 Medium Plus Normal 50410 364-3749 64491 397-2155

Medium Plus Long 50395 364-3608 64470 397-6701 Medium Plus Long 50411 364-3780 64492 397-6826

Large Normal 50388 364-3418 64461 397-1827 Large Normal 50404 364-3657 64483 397-2106

Large Long 50389 364-3459 64462 397-6651 Large Long 50405 364-3715 64484 397-6776

Large Plus Normal 50396 364-3574 64471 397-1918 Large Plus Normal 50412 364-3756 64493 397-2163

Large Plus Long 50397 364-3616 64472 397-6719 Large Plus Long 50413 364-3798 64494 397-6834

X-large Normal 56266 372-9878 64463 397-1835 X-large Normal 56270 373-0983 64485 397-2114

X-large Long 56267 373-0967 64464 397-6669 X-large Long 56271 373-1007 64486 397-6784

X-large Plus Normal 56268 372-9886 64473 397-1876 X-large Plus Normal 56272 373-0991 64495 397-2171

X-large Plus Long 56269 373-0975 64474 397-6727 X-large Plus Long 56273 373-1015 64496 397-6842

Oracle Code – GTB067

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 50

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 2 (23-32 mmHg)

Size Length

Nature Black

Product Code

PIP Code Product

Code PIP Code

X-small Normal 50974 364-4937 50990 364-5090

X-small Long 50975 364-4978 50991 364-5132

X-small Plus Normal 50982 364-5017 50998 364-5173

X-small Plus Long 50983 364-5058 50999 364-5215

Small Normal 50976 364-4945 50992 364-5108

Small Long 50977 364-4986 50993 364-5140

Small Plus Normal 50984 364-5025 51000 364-5181

Small Plus Long 50985 364-5066 51001 364-5223

Medium Normal 50978 364-4952 50994 364-5116

Medium Long 50979 364-4664 50995 364-5157

Medium Plus Normal 50986 364-5033 51002 364-5199

Medium Plus Long 50987 364-5474 51003 364-5231

Large Normal 50980 364-4960 50996 364-5124

Large Long 50981 363-5009 50997 364-5165

Large Plus Normal 50988 364-5041 51004 364-5207

Large Plus Long 50989 364-5082 51005 364-5249

X-large Normal 56318 373-1437 56322 373-1445

X-large Long 56319 373-1478 56323 373-1486

X-large Plus Normal 56320 373-1452 56324 373-1460

X-large Plus Long 56321 373-1494 56325 373-1502

Oracle Code – GTB328

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 51

Thigh Length, Knobbed Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 56335 387-6024 56347 387-6042 XX-small Short 56359 387-6125 56371 387-6141

XX-small Normal 56336 387-6062 56348 387-6075 XX-small Normal 56360 387-6174 56372 387-6182

XX-small Long 56337 387-6092 56349 387-6117 XX-small Long 56361 387-6190 56373 387-6208

XX-small Plus Short 56341 395-8568 56353 395-8550

XX-small Plus Short 56365 395-8584 56377 395-8576

XX-small Plus Normal 56342 396-7536 56354 396-7528 XX-small Plus Normal 56366 396-7494 56378 396-7486

XX-small Plus Long 56343 395-8600 56355 395-8592 XX-small Plus Long 56367 395-9186 56379 395-9178

X-small Short 50438 364-5256 50462 364-5496

X-small Short 50510 364-5769 50534 364-6676

X-small Normal 50439 364-5298 50463 364-5538 X-small Normal 50511 364-5801 50535 364-6718

X-small Long 50440 364-5330 50464 364-5579 X-small Long 50512 364-5843 50536 364-6759

X-small Plus Short 50450 364-5371 50474 364-5611 X-small Plus Short 50522 364-5884 50546 364-6791

X-small Plus Normal 50451 364-5413 50475 364-5652 X-small Plus Normal 50523 364-6593 50547 364-6833

X-small Plus Long 50452 364-5454 50476 364-5686 X-small Plus Long 50524 364-6635 50548 364-6874

Small Short 50441 364-5264 50465 364-5504 Small Short 50513 364-5777 50537 364-6684

Small Normal 50442 364-5306 50466 364-5546 Small Normal 50514 364-5819 50538 364-6726

Small Long 50443 364-5348 50467 364-5587 Small Long 50515 364-5850 50539 364-6767

Small Plus Short 50453 364-5389 50477 364-5629 Small Plus Short 50525 364-5892 50549 364-6809

Small Plus Normal 50454 364-5421 50478 364-5660 Small Plus Normal 50526 364-6601 50550 364-6841

Small Plus Long 50455 364-5462 50479 364-5694 Small Plus Long 50527 364-6643 50551 364-6882

Medium Short 50444 364-5272 50468 364-5512 Medium Short 50516 364-5785 50540 364-6692

Medium Normal 50445 364-5314 50469 364-5553 Medium Normal 50517 364-5827 50541 364-6734

Medium Long 50446 364-5355 50470 364-5595 Medium Long 50518 364-5868 50542 364-6775

Medium Plus Short 50456 364-5397 50480 364-5637 Medium Plus Short 50528 364-5900 50552 364-6817

Medium Plus Normal 50457 364-5439 50481 364-5678 Medium Plus Normal 50529 364-6619 50553 364-6858

Medium Plus Long 50458 364-5470 50482 364-5702 Medium Plus Long 50530 364-6650 50554 364-6890

Large Short 50447 364-5280 50471 364-5520 Large Short 50519 364-5793 50543 364-6700

Large Normal 50448 364-5322 50472 364-5561 Large Normal 50520 364-5835 50544 364-6742

Large Long 50449 364-5363 50473 364-5603 Large Long 50521 364-5876 50545 364-6783

Large Plus Short 50459 364-5405 50483 364-5645 Large Plus Short 50531 364-5918 50555 364-6825

Large Plus Normal 50460 364-5447 50484 364-5728 Large Plus Normal 50532 364-6627 50556 364-6866

Large Plus Long 50461 364-5488 50485 364-5710 Large Plus Long 50533 364-6668 50557 364-6908

X-large Short 56338 373-1023 56350 373-1031 X-large Short 56362 373-1148 56374 373-1163

X-large Normal 56339 373-1064 56351 373-1072 X-large Normal 56363 373-1197 56375 373-1205

X-large Long 56340 373-1106 56352 373-1114 X-large Long 56364 373-1239 56376 373-1247

X-large Plus Short 56344 373-1049 56356 373-1056 X-large Plus Short 56368 373-1171 56380 373-1189

X-large Plus Normal 56345 373-1080 56357 373-1098 X-large Plus Normal 56369 373-1213 56381 373-1221

X-large Plus Long 56346 373-1122 56358 373-1130 X-large Plus Long 56370 373-1254 56382 373-1262

Oracle Code – GTB296

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 52

Men’s Garments, Circular Knit, Below Knee - Sigvaris Cotton Class 1 & 2 Comfort Class 1 & 2

Indications: for normal shaped legs requiring compression

Size Chart:

Advice from Sigvaris when inputting products into EMIS:

Input Sigvaris

Input garment name (e.g. Magic, Comfort, Cotton)

Input class of garment

Input type of garment (e.g. below knee, thigh etc)

Input open/closed toe

Input length

Input size

Input colour

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 53

Below Knee, Sigvaris Cotton Class 1 (18-21 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 56236 387-4401 63899 396-1034 XX-small Normal 63935 387-4450 63971 387-4476

XX-small Long 56237 387-4419 63900 397-3625 XX-small Long 63936 387-4468 63972 387-4484

XX-small Plus Normal 63891 396-1000 63917 396-1190 XX-small Plus Normal 63953 396-1018 63989 396-1026

XX-small Plus Long 63892 397-3591 63918 397-3682 XX-small Plus Long 63954 397-3609 63990 397-3617

X-small Normal 54034 363-6255 63902 396-1059 X-small Normal 63938 363-6412 63974 363-7030

X-small Long 54035 363-6297 63903 397-3633 X-small Long 63939 363-6453 63975 363-7071

X-small Plus Normal 54042 363-6339 63920 396-1208 X-small Plus Normal 63956 363-6495 63992 363-7113

X-small Plus Long 54043 363-6370 63921 397-3690 X-small Plus Long 63957 363-6990 63993 363-7154

Small Normal 54036 363-6263 63905 396-1067 Small Normal 63941 363-6420 63977 363-7048

Small Long 54037 363-6305 63906 397-3641 Small Long 63942 363-6461 63978 363-7089

Small Plus Normal 54044 363-6347 63923 396-1216 Small Plus Normal 63959 363-6503 63995 363-7121

Small Plus Long 54045 363-6388 63924 397-3708 Small Plus Long 63960 363-7006 63996 363-7162

Medium Normal 54038 363-6271 63908 396-1075 Medium Normal 63944 363-6438 63980 363-7055

Medium Long 54039 363-6313 63909 397-3658 Medium Long 63945 363-6479 63981 363-7097

Medium Plus Normal 54046 363-6354 63926 396-1224 Medium Plus Normal 63962 363-6511 63998 363-7139

Medium Plus Long 54047 363-6396 63927 397-3716 Medium Plus Long 63963 363-7014 63999 363-7170

Large Normal 54040 363-6289 63911 396-1091 Large Normal 63947 363-6446 63983 363-7063

Large Long 54041 363-6321 63912 397-3666 Large Long 63948 363-6487 63984 363-7105

Large Plus Normal 54048 363-6362 63929 396-1232 Large Plus Normal 63965 363-6529 64001 363-7147

Large Plus Long 54049 363-6404 63930 397-3724 Large Plus Long 63966 363-7022 64002 363-7188

X-large Normal 56238 372-9530 63914 396-1109 X-large Normal 63950 372-9571 63986 372-9589

X-large Long 56239 372-9555 63915 397-3674 X-large Long 63951 372-9613 63987 372-9621

X-large Plus Normal 56240 372-9548 63932 396-1240 X-large Plus Normal 63968 372-9597 64004 372-9605

X-large Plus Long 56241 372-9563 63933 397-3732 X-large Plus Long 63969 372-9639 64005 372-9647

Oracle Codes Open toe - GTB075

Closed toe - GTB078

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 54

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 1 (18-21 mmHg)

Size Length Black

Product Code

X-small Normal 50862

X-small Long 50863

X-small Plus Normal 50870

X-small Plus Long 50871

Small Normal 50864

Small Long 50865

Small Plus Normal 50872

Small Plus Long 50873

Medium Normal 50866

Medium Long 50867

Medium Plus Normal 50874

Medium Plus Long 50875

Large Normal 50868

Large Long 50869

Large Plus Normal 50876

Large Plus Long 50877

X-large Normal 56258

X-large Long 56259

X-large Plus Normal 56260

X-large Plus Long 56261

Oracle Code – GTB327

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 55

Below Knee – Sigvaris Cotton Class 2 (23-32 mmHg) OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Short 63394 387-4534 63406 387-4732 XX-small Short 63418 387-4757 63430 387-5358

XX-small Normal 56274 387-4492 56282 387-4500 XX-small Normal 56290 387-5465 56298 387-5473

XX-small Long 56275 387-4518 56283 387-4526 XX-small Long 56291 387-5487 56299 387-5499

XX-small Plus Short 63400 395-8097 63412 395-8089 XX-small Plus Short 63424 399-0439 63436 399-0421

XX-small Plus Normal 56278 397-1629 56286 397-1637 XX-small Plus Normal 56294 397-1645 56302 397-1652

XX-small Plus Long 56279 397-6552 56287 397-6560 XX-small Plus Long 56295 397-6578 56303 397-6586

X-small Short 63395 387-4512 63407 387-4708 X-small Short 63419 387-5176 63431 387-5408

X-small Normal 50302 364-1644 50318 364-1800 X-small Normal 50350 364-3475 50366 364-4457

X-small Long 50303 364-1685 50319 364-1842 X-small Long 50351 364-3517 50367 364-4812

X-small Plus Short 63401 387-4591 63413 387-4641 X-small Plus Short 63425 387-5283 63437 387-5416

X-small Plus Normal 50310 364-1727 50326 364-1883 X-small Plus Normal 50358 364-4374 50374 364-4853

X-small Plus Long 50311 364-1768 50327 364-1925 X-small Plus Long 50359 364-4416 50375 364-4895

Small Short 63396 387-4559 63408 387-4716 Small Short 63420 387-5184 63432 387-5366

Small Normal 50304 364-1651 50320 364-1818 Small Normal 50352 364-3483 50368 364-4465

Small Long 50305 364-1693 50321 364-1859 Small Long 50353 364-3525 50369 364-4820

Small Plus Short 63402 387-4609 63414 387-4658 Small Plus Short 63426 387-5291 63438 387-5424

Small Plus Normal 50312 364-1735 50328 364-1891 Small Plus Normal 50360 364-4382 50376 364-4861

Small Plus Long 50313 364-1776 50329 364-1933 Small Plus Long 50361 364-4424 50377 364-4903

Medium Short 63397 387-4567 63409 387-4724 Medium Short 63421 387-5192 63433 387-5374

Medium Normal 50306 364-1669 50322 364-1826 Medium Normal 50354 364-3491 50370 364-4473

Medium Long 50307 364-1701 50323 364-1867 Medium Long 50355 364-3533 50371 364-4838

Medium Plus Short 63403 387-4617 63415 387-4666 Medium Plus Short 63427 387-5325 63439 387-5432

Medium Plus Normal 50314 364-1743 50330 364-1909 Medium Plus Normal 50362 364-4390 50378 364-4879

Medium Plus Long 50315 364-1784 50331 364-1941 Medium Plus Long 50363 364-4432 50379 364-4911

Large Short 63398 387-4575 63410 387-4690 Large Short 63422 387-5200 63434 387-5382

Large Normal 50308 364-1677 50324 364-1834 Large Normal 50356 364-3509 50372 364-4481

Large Long 50309 364-1719 50325 364-1875 Large Long 50357 364-3541 50373 364-4846

Large Plus Short 63404 387-4625 63416 387-4674 Large Plus Short 63428 387-5333 63440 387-5440

Large Plus Normal 50316 364-1750 50332 364-1917 Large Plus Normal 50364 364-4408 50380 364-4887

Large Plus Long 50317 364-1792 50333 364-1958 Large Plus Long 50365 364-4440 50381 364-4929

X-large Short 63399 387-4583 63411 387-4740 X-large Short 63423 387-5218 63435 387-5390

X-large Normal 56276 372-9795 56284 372-9803 X-large Normal 56292 373-1312 56300 373-1320

X-large Long 56277 372-9837 56285 372-9845 X-large Long 56293 373-1353 56301 373-1361

X-large Plus Short 63405 387-4633 63417 387-4682 X-large Plus Short 63429 387-5341 63441 387-5457

X-large Plus Normal 56280 372-9811 56288 372-9829 X-large Plus Normal 56296 373-1338 56304 373-1346

X-large Plus Long 56281 372-9852 56289 372-9860 X-large Plus Long 56297 373-1379 56305 373-1387

Oracle Codes Open toe - GTB295

Closed toe - GTB326

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 56

Below Knee, Knobbed Grip Top – Sigvaris Cotton Class 2 (23-32 mmHg)

OPEN TOE Nature Black

CLOSED TOE Nature Black

Size Length Product

Code PIP Code

Product Code

PIP Code Size Length Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 56262 387-5960 64453 397-1728 XX-small Normal 56264 387-5994 64475 397-2064

XX-small Long 56263 387-5978 64454 397-6610 XX-small Long 56265 384-6018 64476 397-6735

XX-small Plus Normal 64660 399-0413 64662 397-1868 XX-small Plus Normal 64664 397-2056 64666 397-2122

XX-small Plus Long 64661 397-6594 64663 397-6677 XX-small Plus Long 64665 397-6602 64667 397-6792

X-small Normal 50382 364-1966 64455 397-1736 X-small Normal 50398 364-3624 64477 397-2072

X-small Long 50383 364-3392 64456 397-6628 X-small Long 50399 364-3681 64478 397-6743

X-small Plus Normal 50390 364-3467 64465 397-1884 X-small Plus Normal 50406 364-3723 64487 397-2130

X-small Plus Long 50391 364-3558 64466 397-6685 X-small Plus Long 50407 364-3731 64488 397-6800

Small Normal 50384 364-3426 64457 397-1744 Small Normal 50400 364-3632 64479 397-2080

Small Long 50385 364-3434 64458 397-6636 Small Long 50401 364-3699 64480 397-6750

Small Plus Normal 50392 364-3582 64467 397-1892 Small Plus Normal 50408 364-3764 64489 397-2148

Small Plus Long 50393 364-3590 64468 397-6693 Small Plus Long 50409 364-3772 64490 397-6818

Medium Normal 50386 364-3400 64459 397-1751 Medium Normal 50402 364-3640 64481 397-2098

Medium Long 50387 364-3442 64460 397-6644 Medium Long 50403 364-3707 64482 397-6768

Medium Plus Normal 50394 364-3566 64469 397-1900 Medium Plus Normal 50410 364-3749 64491 397-2155

Medium Plus Long 50395 364-3608 64470 397-6701 Medium Plus Long 50411 364-3780 64492 397-6826

Large Normal 50388 364-3418 64461 397-1827 Large Normal 50404 364-3657 64483 397-2106

Large Long 50389 364-3459 64462 397-6651 Large Long 50405 364-3715 64484 397-6776

Large Plus Normal 50396 364-3574 64471 397-1918 Large Plus Normal 50412 364-3756 64493 397-2163

Large Plus Long 50397 364-3616 64472 397-6719 Large Plus Long 50413 364-3798 64494 397-6834

X-large Normal 56266 372-9878 64463 397-1835 X-large Normal 56270 373-0983 64485 397-2114

X-large Long 56267 373-0967 64464 397-6669 X-large Long 56271 373-1007 64486 397-6784

X-large Plus Normal 56268 372-9886 64473 397-1876 X-large Plus Normal 56272 373-0991 64495 397-2171

X-large Plus Long 56269 373-0975 64474 397-6727 X-large Plus Long 56273 373-1015 64496 397-6842

Oracle Code – GTB067

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 57

Below Knee, Closed Toe – Sigvaris Cotton XTRA MAXI Foot 10-13 Class 2 (23-32 mmHg)

Size Length

Nature Black

Product Code

PIP Code Product

Code PIP Code

X-small Normal 50974 364-4937 50990 364-5090

X-small Long 50975 364-4978 50991 364-5132

X-small Plus Normal 50982 364-5017 50998 364-5173

X-small Plus Long 50983 364-5058 50999 364-5215

Small Normal 50976 364-4945 50992 364-5108

Small Long 50977 364-4986 50993 364-5140

Small Plus Normal 50984 364-5025 51000 364-5181

Small Plus Long 50985 364-5066 51001 364-5223

Medium Normal 50978 364-4952 50994 364-5116

Medium Long 50979 364-4664 50995 364-5157

Medium Plus Normal 50986 364-5033 51002 364-5199

Medium Plus Long 50987 364-5474 51003 364-5231

Large Normal 50980 364-4960 50996 364-5124

Large Long 50981 363-5009 50997 364-5165

Large Plus Normal 50988 364-5041 51004 364-5207

Large Plus Long 50989 364-5082 51005 364-5249

X-large Normal 56318 373-1437 56322 373-1445

X-large Long 56319 373-1478 56323 373-1486

X-large Plus Normal 56320 373-1452 56324 373-1460

X-large Plus Long 56321 373-1494 56325 373-1502

Oracle Code – GTB328

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 58

Below Knee, Open Toe – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 68113-CM 391- 0205 68097-CM 391-0163 68065-CM 391-0189

XX-small Long 68114-CM 391-0007 68098-CM 390-9967 68066-CM 390-9983

XX-small Plus Normal 68125-CM 391-0304 68101-CM 391-0262 68069-CM 391-0288

XX-small Plus Long 68126-CM 391-0106 68102-CM 391-0064 68070-CM 391-0080

X-small Normal 68115-CM 391-0213 47417-CM 361-4252 47385-CM 374-9124

X-small Long 68116-CM 391-0015 47418-CM 361-4294 47386-CM 374-9165

X-small Plus Normal 68127-CM 391-0312 47425-CM 361-4336 47393-CM 374-9215

X-small Plus Long 68128-CM 391-0114 47426-CM 361-4377 47394-CM 374-9272

Small Normal 68117-CM 391-0221 47419-CM 361-4260 47387-CM 374-9132

Small Long 68118-CM 391-0023 47420-CM 361-4302 47388-CM 374-9173

Small Plus Normal 68129-CM 391-0320 47427-CM 361-4344 47395-CM 374-9249

Small Plus Long 68130-CM 391-0122 47428-CM 361-4385 47396-CM 374-9280

Medium Normal 68119-CM 391-0239 47421-CM 361-4278 47389-CM 374-9140

Medium Long 68120-CM 391-0031 47422-CM 361-4310 47390-CM 374-9181

Medium Plus Normal 68131-CM 391-0338 47429-CM 361-4351 47397-CM 374-9256

Medium Plus Long 68132-CM 391-0130 47430-CM 361-4393 47398-CM 374-9298

Large Normal 68121-CM 391-0247 47423-CM 361-4286 47391-CM 374-9157

Large Long 68122-CM 391-0049 47424-CM 361-4328 47392-CM 374-9199

Large Plus Normal 68133-CM 391-0346 47431-CM 361-4369 47399-CM 374-9264

Large Plus Long 68134-CM 391-0148 47432-CM 361-4401 47400-CM 374-9306

X-large Normal 68123-CM 391-0254 68099-CM 391-0171 68067-CM 391-0197

X-large Long 68124-CM 391-0056 68100-CM 390-9975 68068-CM 390-9991

X-large Plus Normal 68135-CM 391-0353 68103-CM 391-0270 68071-CM 391-0296

X-large Plus Long 68136-CM 391-0155 68104-CM 391-0072 68072-CM 391-0098

Oracle Code – GTB292

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 59

Below Knee, Closed Toe – Sigvaris Comfort Class 1 (18-21 mmHg)

Size Length

Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 68137-CM 390-9801 68105-CM 390-9769 68073-CM 390-9785

XX-small Long 68138-CM 390-9256 68106-CM 390-9298 68074-CM 390-9314

XX-small Plus Normal 68149-CM 390-9900 68109-CM 390-9868 68077-CM 390-9884

XX-small Plus Long 68150-CM 390-9363 68110-CM 390-9272 68078-CM 390-9371

X-small Normal 68139-CM 390-9819 47513-CM 361-4575 47481-CM 374-9314

X-small Long 68140-CM 390-9249 47514-CM 361-4617 47482-CM 374-9363

X-small Plus Normal 68151-CM 390-9918 47521-CM 361-4658 47489-CM 374-9462

X-small Plus Long 68152-CM 390-9330 47522-CM 361-4690 47490-CM 374-9520

Small Normal 68141-CM 390-9827 47515-CM 361-4583 47483-CM 374-9322

Small Long 68142-CM 390-9231 47516-CM 361-4625 47484-CM 374-9389

Small Plus Normal 68153-CM 390-9926 47523-CM 361-4666 47491-CM 374-9470

Small Plus Long 68154-CM 390-9348 47524-CM 361-4708 47492-CM 374-9538

Medium Normal 68143-CM 390-9835 47517-CM 361-4591 47485-CM 374-9330

Medium Long 68144-CM 390-9215 47518-CM 361-4633 47486-CM 374-9421

Medium Plus Normal 68155-CM 390-9934 47525-CM 361-4674 47493-CM 374-9488

Medium Plus Long 68156-CM 390-9223 47526-CM 361-4716 47494-CM 374-9546

Large Normal 68145-CM 390-9843 47519-CM 361-4609 47487-CM 374-9348

Large Long 68146-CM 390-9199 47520-CM 361-4641 47488-CM 374-9447

Large Plus Normal 68157-CM 390-9942 47527-CM 361-4682 47495-CM 374-9504

Large Plus Long 68158-CM 390-9207 47528-CM 361-4724 47496-CM 374-9561

X-large Normal 68147-CM 390-9850 68107-CM 390-9777 68075-CM 390-9793

X-large Long 68148-CM 390-9264 68108-CM 390-9306 68076-CM 390-9322

X-large Plus Normal 68159-CM 390-9959 68111-CM 390-9876 68079-CM 390-9892

X-large Plus Long 68160-CM 390-9355 68112-CM 390-9280 68080-CM 390-9389

Oracle Code – GTB292

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 60

Below Knee, Open Toe – Sigvaris Comfort Class 2 (23-32 mmHg)

Size Length Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 69529-CM 391-6616 69513-CM 391-6574 69481-CM 391-6590

XX-small Long 69530-CM 391-5576 69514-CM 391-5535 69482-CM 391-5550

XX-small Plus Normal 69541-CM 391-6814 69517-CM 391-6772 69485-CM 391-6798

XX-small Plus Long 69542-CM 391-5675 69518-CM 391-5634 69486-CM 391-5659

X-small Normal 69531-CM 391-6624 39128-CM 363-2817 39064-CM 375-3068

X-small Long 69532-CM 391-5584 39129-CM 363-2858 39065-CM 375-3100

X-small Plus Normal 69543-CM 391-6822 39136-CM 363-2932 39072-CM 375-3142

X-small Plus Long 69544-CM 391-5683 39138-CM 363-2890 39073-CM 375-3183

Small Normal 69533-CM 391-6632 39130-CM 363-2825 39066-CM 375-3076

Small Long 69534-CM 391-5592 39131-CM 363-2866 39067-CM 375-3118

Small Plus Normal 69545-CM 391-6830 39137-CM 363-2940 39074-CM 375-3159

Small Plus Long 69546-CM 391-5651 39139-CM 363-2908 39075-CM 375-3191

Medium Normal 69535-CM 391-6640 39132-CM 363-2833 39068-CM 375-3084

Medium Long 69536-CM 391-5600 39133-CM 363-2874 39069-CM 375-3126

Medium Plus Normal 69547-CM 391-6848 39140-CM 363-2957 39076-CM 375-3167

Medium Plus Long 69548-CM 391-5709 39141-CM 363-2916 39077-CM 375-3209

Large Normal 69537-CM 391-6657 39134-CM 363-2841 39070-CM 375-3092

Large Long 69538-CM 391-5618 39135-CM 363-2882 39071-CM 375-3134

Large Plus Normal 69549-CM 391-6855 39142-CM 363-2965 39078-CM 375-3175

Large Plus Long 69550-CM 391-5717 39143-CM 363-2924 39079-CM 375-3217

X-large Normal 69539-CM 391-6665 69515-CM 391-6582 69483-CM 391-6608

X-large Long 69540-CM 391-5626 69516-CM 391-5543 69484-CM 391-5568

X-large Plus Normal 69551-CM 391-6863 69519-CM 391-6780 69487-CM 391-6806

X-large Plus Long 69552-CM 391-5725 69520-CM 391-5642 69488-CM 391-5667

Oracle Code – GTB074

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 61

Below Knee, Closed Toe – Sigvaris Comfort Class 2 (23-32 mmHg)

Size Length

Savannah Black Caramel

Product Code

PIP Code Product

Code PIP Code

Product Code

PIP Code

XX-small Normal 69553-CM 391-5279 69521-CM 391-5238 69489-CM 391-5253

XX-small Long 69554-CM 391-4983 69522-CM 391-4892 69490-CM 391-4918

XX-small Plus Normal 69565-CM 391-5378 69525-CM 391-5337 69493-CM 391-5352

XX-small Plus Long 69566-CM 391-4991 69526-CM 391-5006 69494-CM 391-5022

X-small Normal 69555-CM 391-5287 39144-CM 363-1298 39080-CM 375-3225

X-small Long 69556-CM 391-4934 39145-CM 363-1330 39081-CM 375-3266

X-small Plus Normal 69567-CM 391-5386 39152-CM 363-1371 39088-CM 375-3308

X-small Plus Long 69568-CM 391-5048 39153-CM 363-1413 39089-CM 375-3357

Small Normal 69557-CM 391-5295 39146-CM 363-1306 39082-CM 357-3233

Small Long 69558-CM 391-4942 39147-CM 363-1348 39083-CM 375-3274

Small Plus Normal 69569-CM 391-5394 39154-CM 363-1389 39090-CM 375-3316

Small Plus Long 69570-CM 391-5055 39155-CM 363-1421 39091-CM 375-3365

Medium Normal 69559-CM 391-5303 39148-CM 363-1314 39084-CM 375-3241

Medium Long 69560-CM 391-4959 39149-CM 363-1355 39085-CM 375-3282

Medium Plus Normal 69571-CM 391-5402 39156-CM 363-1397 39092-CM 375-3327

Medium Plus Long 69572-CM 391-5063 39157-CM 363-1439 39032-CM 375-3373

Large Normal 69561-CM 391-5311 39130-CM 363-1322 39086-CM 375-3258

Large Long 69562-CM 391-4967 39151-CM 363-1363 39087-CM 375-3290

Large Plus Normal 69573-CM 391-5410 39158-CM 361-1405 39094-CM 375-3332

Large Plus Long 69574-CM 391-5071 39159-CM 363-1447 39095-CM 375-3381

X-large Normal 69563-CM 391-5329 69523-CM 391-5246 69491-CM 391-5261

X-large Long 69564-CM 391-4975 69524-CM 391-4900 69492-CM 391-4926

X-large Plus Normal 69575-CM 391-5428 69527-CM 391-5345 69495-CM 391-5360

X-large Plus Long 69576-CM 391-5089 69528-CM 391-5014 69496-CM 391-5030

Oracle Code – GTB074

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 62

Upper Limb Garments - Ready to Wear

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 63

Upper Limb, Circular Knit, Arm Sleeves Class 1 and 2 - Mediven Harmony

Indications: mild moderate swelling of the upper limb, limited folds

Size Chart: Colour: Sand

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 64

Mediven Harmony Class 1 Product Codes and PIP Codes

Armsleeve (C-G) Medi Code

Size I (1) Size II (2) Size III (3) Size IV (4) Size V (5) Size VI (6) Size VII (7) Size VIII (8)

Arm sleeve C-G DT714H 381-7277 381-7285 381-7301 381-7319 381-7327 381-7335 381-7343 381-7368

Arm sleeve extra wide (XW) C-G

DT715H 381-7384 381-7392 381-7400 381-7418 381-7426 381-7434 381-7442 381-7459

Arm sleeve with Grip top C-G

DT746H 381-7525 381-7533 381-7541 381-7558 381-7566 381-7574 381-7582 381-7590

Arm sleeve with Grip top XW C-G

DT747H 381-7665 381-7673 381-7681 381-7699 381-7707 381-7715 381-7723 381-7731

Combined Armsleeve (A-G)

Medi Code

I (1) II (2) III (3) IV (4) V (5) VI (6) VII (7) VIII (8)

Arm sleeve A-G DT734H 381-8002 381-8010 381-8028 381-8036 381-8044 381-8051 381-8069 381-8077

Arm Sleeve XW A-G DT735H 381-8085 381-8093 381-8101 381-8119 381-8127 381-8135 381-8143 381-8150

Arm Sleeve A-G With Grip Top

DT754H 381-8168 381-8176 381-8184 381-8192 381-8200 381-8218 381-8226 381-8234

Arm Sleeve A-G XW With Grip top

DT755H 381-8242 381-8259 381-8267 381-8275 381-8283 381-8291 381-8309 831-8317

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 65

Mediven Harmony Class 2 Product Codes and PIP Codes

Armsleeve (C-G) Medi Code

Size I (1) Size II (2) Size III (3) Size IV (4) Size V (5) Size VI (6) Size VII (7) Size VIII (8)

Arm sleeve C-G DT716H 381-8606 381-8614 381-8622 381-8630 381-8648 381-8655 381-8663 381-8671

Arm sleeve extra wide (XW) C-G

DT717H 381-8689 381-8697 381-8705 381-8713 381-8721 381-8739 381-8747 381-8754

Arm sleeve with Grip top C-G

DT750H 381-8762 381-8770 381-8788 381-8796 381-8804 381-8812 381-8820 381-8838

Arm sleeve with Grip top XW C-G

DT751H 381-8846 381-8853 381-8861 381-8879 381-8887 381-8895 381-8903 381-8911

Combined Armsleeve (A-G)

Medi Code

Size I (1) Size II (2) Size III (3) Size IV (4) Size V (5) Size VI (6) Size VII (7) Size VIII (8)

Arm sleeve A-G DT736H 381-9083 381-9091 381-9109 381-9117 381-9125 381-9133 381-9141 381-9158

Arm Sleeve XW A-G DT737H 381-9166 381-9174 381-9182 381-9190 381-9208 381-9216 381-9224 381-9232

Arm Sleeve A-G With Grip Top

DT758H 381-9240 381-9257 381-9265 381-9273 381-9281 381-9299 381-9307 381-9351

Arm Sleeve A-G XW With Grip top

DT759H 381-9323 381-9331 381-9349 381-9356 381-9364 381-9372 381-9380 831-9398

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 66

Upper Limb, Circular Knit Gloves and Mitts Class 1 – Juzo Classic

Colour : Beige

Juzo Classic Gloves Class 1

Juzo Classic Mitts Class 1

Description Juzo Code

Size II (2) Size III

(3) Size IV

(4) Size V

(5)

Juzo Classic Glove

2301 383-3407 383-3431 383-3423 383-3415

Description Juzo Code

Size II (2)

Size III (3)

Size IV (4)

Size V (5)

Juzo Classic Mitt 2301 356-0208 356-0216 356-0224 356-0232

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Upper Limb, Circular Knit, Gloves and Mitts Class 2 - Mediven Harmony Gloves

Size Chart:

Colour: Sand

Description

Medi code

Size II (2)

Size III (3)

Size IV (4)

Size V (5)

Size VI (6)

Size VII (7)

Medi Harmony Glove DT761H 381-9620 381-9638 381-9646 381-9653 381-9661 381-9679

Medi Hand Piece (mitt) DT722H 381-9562 381-9570 381-9588 381-9596 381-9604 381-9612

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 68

Upper Limb, Circular Knit, LOWER Compression Support Products - Medi Maxis Microsoft Arm Sleeve

NOT on prescription

Indications: mild oedema / palliative / support

Size Chart:

Armsleeve (C-G) Colour Size I (1) Size II (2) Size III (3) Size IV (4) Size V (5) Size VI (6) Size VII (7)

Arm sleeve C-G Short Length with Grip Top

Sand XR99101 XR99102 XR99103 XR99104 XR99105 XR99106 XR99107

Arm sleeve C-G Long Length with Grip Top

Sand XR99111 XR99112 XR99113 XR99114 XR99115 XR99116 XR99117

Combined Armsleeve (A-G)

Colour Size I (1) Size II (2) Size III (3) Size IV (4) Size V (5) Size VI (6) Size VII (7)

Arm sleeve A-G Short Length with Grip Top

Sand XR69101 XR69102 XR69103 XR69104 XR69105 XR69106 XR69107

Arm Sleeve A-G Long Length with Grip Top

Sand XR69111 XR69112 XR69113 XR69114 XR69115 XR69116 XR69117

Maxis Micro Soft – Round Knit Arm Sleeve Size Chart

Size (cms)

cA cC cD cE cG

1 14-17 11-13 17-23 17-23 19-26

2 16-19 13-15 20-26 20-26 22-29

3 18-21 15-17 23-29 23-29 25-32

4 20-23 17-19 26-32 26-32 29-36

5 22-25 19-21 29-35 29-35 33-40

6 24-27 21-23 32-38 32-38 37-44

7 26-29 23-25 35-41 35-41 41-48

Length C-G (cms)

Short Long

44-48 49-52

Hand piece circumferences (cms)

Size 1 2 3 4 5 6 7

cA 14-17 16-19 18-21 20-23 22-25 24-27 26-29

cB 14.5-18 16.5-20 18.5-22 20.5-24 22.5-26 24.5-28 26.5-30

cC 11-13 13-15 15-17 17-19 19-21 21-23 23-25

cC1 12-14.5 14-16.5 16-18.5 18-20.5 20-22.5 22-24.5 24-26.5

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 69

Upper Limb Off the Shelf Flat Knit Arm Sleeves Class 1 and 2 - Juzo Expert

NOT on prescription

Colours: Black or Beige Available: Arm Sleeve CG with or without Grip Top

Size Chart: Combined Arm Sleeve with or without Grip Top

If you need CG circumference bigger, please state measurement on order

X-Small Small Medium Large

cG 27.0 – 31.0 31.0 – 34.0 33.0 – 37.0 36.0 – 41.0

cF 24.5 – 28.0 27.0 – 31.0 30.0 – 33.0 32.0 – 36.0

cE 24.0 – 27.0 26.0 – 29.0 28.0 – 31.0 30.0 – 34.0

cD 22.5 – 25.5 24.5 – 27.5 26.5 – 30.0 29.0 – 33.0

cC1 17.5 – 18.5 18.5 – 21.0 21.0 – 23.0 22.0 – 25.0

cC 15.0 – 17.0 17.0 – 19.0 19.0 – 21.0 20.0 – 23.0

cA 17.5 – 19.0 19.0 – 21.0 20.0 – 23.0 22.0 – 25.0

LENGTH Standard Extra (Long)

CA-CC 5.5

CC-CE 22-24 24-26

CC-CG 42-46 44-48

When ordering, consider the following:

Product code

Class

Colour

Grip top

Compression sleeve CG armsleeve

Compression sleeve AGA combined arm sleeve

Length

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 70

Upper Limb Off the Shelf Flat Knit Gloves and Mitts Class 1 and 2 - Juzo Expert

Colour: Beige

Description Class 1 Code Class 2 Code

Juzo Flat Knit Gloves & Mitt 3021 3022

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 71

Microfine Gloves - Haddenham Microfine

Indications: hand oedema requiring ultra thin/ smooth/soft fabric. Good for palliatives. Can be worn under an AG garment. Length of

fingers can be cut as required and does not cause fraying.

Size Circumference Palm at Base of

Fingers

Circumference Palm at Fold of

Thumb Sand Beige Black

PIP Code Sand

PIP Code Black

XXSmall Not available on prescription 208S-0 208-0 208B-0 - -

XSmall Below 18cm Below 19cm 208S-1 208-1 208B-1 347-9631 376-6219

Small 18-20cm 19-21cm 208S-2 208-2 208B-2 347-9607 376-6227

Medium 20-22cm 21-23cm 208S-3 208-3 208B-3 347-9615 376-6243

Large Over 22cm Over 24cm 208S-4 208-4 208B-4 347-9623 376-6268

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 72

Made To Measure Garments Upper / Lower Limb

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 73

Made to Measure Lower Limb Circular Knit - Haddenham VENI Class 1, 2

and 3

NOT on Prescription

Colours:

Options available:

Open / Closed Toe / Slant Cut Foot for open toe

Below Knee, Thigh Length, Tights

Grip Tops: 3cm Plain / 5cm String Plain / 5cm Fine Lace / 5cm Strong Lace

Fly Opening

Open Crotch

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 75

Made to Measure Lower Limb Flat Knit BSN Jobst Elvarex Class 1, 2, 3 and 4; Below Knee, Thigh, Tights

Colours: Beige, Black, Dark Blue, Dark Brown and Grey

Note: PIP code for all colours if not beige is L-A008

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 77

Made To Measure Upper Limb Circular Knit Class 1-3 – Juzo

Juzo Soft CG Class 1-2 Juzo Dynamic AG Class 1-3

NOT on Prescription

Colours:

Juzo Dynamic available in Almond (Beige) and Black Pepper

Note: Juzo Soft is not available as combined arm sleeve with mitt – only sleeve (CG)

Silicone border available

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 79

Made to Measure Upper Limb FLAT KNIT - Haddenham GOLDPUNKT Class 1, 2 & 3

Indications: abnormal shape, creases / folds, stubborn oedema / off shelf garments do not fit.

Colours:

PIP Codes:

Product PIP

Code

Product PIP

Code

Product PIP

Code

GLOVE (gauntlet) NO Fingers

GLOVE with Fingers

ARMSLEEVE Wrist to Axilla (CG)

Class 2 (23-32 mmHg) GP-62 Class 2 (23-32 mmHg) GP-65 Class 2 (23-32 mmHg) GP-72

Class 3 (34-46 mmHg) GP-63 Class 3 (34-46 mmHg) GP-66 Class 3 (34-46 mmHg) GP73

ARMSLEEVE Glove NO Fingers

ARMSLEEVE Glove with Fingers

OPTIONS

Class 2 (23-32 mmHg) GP-75 Class 2 (23-32 mmHg) GP-78 Silicone Grip Top CM-80

Class 3 (34-46 mmHg) GP-76 Class 3 (34-46 mmHg) GP-79 Zip CM-81

Shoulder Cap CM-83

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 82

Made to Measure Foot Portion - JUZO Expert Flat Knit Class 1, 2 and 3

Colours:

Note:

Remember to

indicate ‘foot

portion’ when

prescribing or

requesting a

prescription

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 84

Wraps

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 85

Upper Limb Wrap Hand and Arm – BSN Jobst Farrowwrap Lite

Available on Prescription - Mild to moderate Lymphoedema and chronic oedema

LEFT RIGHT

Beige Black Beige Black

Size Length BSN Code PIP Code BSN Code PIP Code BSN Code PIP Code BSN Code PIP Code

Small Short 76650-11 392-6953 76650-29 392-6987 76650-12 392-6771 76650-30 392-6805

Small Regular 76650-05 392-7019 76650-23 392-7043 76650-06 392-6839 76650-24 392-6862

Small Long 76650-35 392-7076 76650-17 392-7100 76650-00 392-6896 76650-18 392-6920

Medium Short 76650-13 392-6961 76650-31 392-6995 76650-14 392-6789 76650-32 392-6813

Medium Regular 76650-07 392-7027 76650-25 392-7050 76650-08 392-6847 76650-26 392-6870

Medium Long 76650-01 392-7084 76650-19 392-7118 76650-02 392-6904 76650-20 392-6938

Large Short 76650-15 392-6979 76650-33 392-7001 76650-16 392-6797 76650-34 392-6821

Large Regular 76650-09 392-7035 76650-27 392-7068 76650-10 392-6854 76650-28 392-6888

Large Long 76650-03 392-7092 76650-21 392-7126 76650-04 392-6912 76650-22 392-6946

Wrist Elbow Axilla

Length

Small 14cm-18cm 20cm-27cm 22cm-31cm Short 40cm-43cm

Medium 16cm-21cm 25cm-34cm 29cm-39cm Regular 44cm-47cm

Large 19cm-25cm 30cm-40cm 32cm-45cm Long 48cm-51cm

BSN Code

Extra small 76653-00

Small 76653-01

Medium 76653-02

Large 76653-03

Handpiece – Not on prescription

Colour: Beige only

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 86

Lower Limb Wraps BSN Jobst Farrowwrap Strong: Footpiece, Legpiece and Thighpiece

Footpiece Legpiece Thighpiece

Size Length BSN Code PIP Code Size Length BSN Code PIP Code BSN Code PIP Code

- - - - Extra small Short - - 76649-05 382-0222

Extra small Regular 76646-04 381-9976 Extra small Regular 76648-00 382-0073 76649-00 382-0172

Extra small Long 76646-09 381-9927 Extra small Tall 76648-05 382-0024 76649-10 382-0123

- - - - Small Short - - 76649-06 382-0255

Small Regular 76646-05 382-0008 Small Regular 76648-01 382-0107 76649-01 382-0206

Small Long 76646-00 381-9950 Small Tall 76648-06 382-0057 76649-11 382-0156

- - - - Medium Short - - 76649-07 382-0248

Medium Regular 76646-06 381-9992 Medium Regular 76648-02 382-0099 76649-02 382-0198

Medium Long 76646-01 381-9943 Medium Tall 76648-07 382-0040 76649-12 382-0149

- - - - Large Short - - 76649-08 382-0230

Large Regular 76646-07 381-9984 Large Regular 76648-03 382-0081 76649-03 382-0180

Large Long 76646-02 381-9935 Large Tall 76648-08 382-0032 76649-13 382-0131

- - - - Extra large Short - - 76649-09 382-0214

Extra large Regular 76646-08 381-9968 Extra large Regular 76648-04 382-0065 76649-04 382-0164

Extra large Long 76646-03 381-9919 Extra large Tall 76648-09 382-0016 76649-14 382-0115

Footpiece Legpiece Thighpiece

Size Mid-foot Regular Tall Mid-calf Ankle Regular Tall Groin Above

knee Short Regular Tall

Extra small 22-24cm 15-17cm 18-20cm 36-43cm 21-25cm 35-39cm 40-44cm 60-70cm 47-52cm 16-20cm 21-26cm 27-31cm

Small 25-27cm 16-19cm 20-22cm 42-50cm 25-30cm 37-41cm 42-46cm 65-75cm 53-59cm 16-20cm 21-26cm 27-31cm

Medium 28-30cm 18-20cm 21-23cm 48-58cm 30-36cm 39-43cm 44-48cm 70-80cm 60-66cm 16-20cm 21-26cm 27-31cm

Large 31-34cm 19-22cm 23-25cm 53-63cm 36-42cm 41-45cm 46-50cm 75-90cm 67-73cm 16-20cm 21-26cm 27-31cm

Extra large 35-40cm 21-24cm 25-27cm 58-68cm 42-50cm 42-46cm 47-51cm 85-100cm 74-80cm 16-20cm 21-26cm 27-31cm

Colour: Beige

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The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 89

Abdominal Supports - Medi UK

NOT on Prescription

Indications: supporting the abdominal area including aprons. Two can be connected together for larger areas.

To order- Write Medi Abdominal Support and what size you require.

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 90

Miscellaneous

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 91

Female Genital Shorts - IMS Europe SOLIDEA

NOT available on Prescription

Indications: Support for swelling in women’s genitalia (Compression shorts for genital swelling for women Silver Wave)

Genital Male Shorts - IMS Europe SOLIDEA

NOT available on Prescription

Indications: support for swelling in Men’s genitals. (Compression shorts for men)

Colour Code

Noisette SM02

Nero SM09

Champagne SM22

Colour Code

Black SM09

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 92

Genital Scrotal Support - Medi UK Whitaker Pouch

Indications: Support for swelling in testicular area

Measurement guide

Circumference of Scrotum

Size Code Pip Code

33 - 40 cm Small DT700/2 363-9713

41 - 48 cm Medium DT700/3 363-9721

49 - 56 cm Large DT700/4 363-9739

Measurement guide - Whitaker Pouch Belt

Waist Circumference Standard Belt 40cm extension req'd 80cm extension req’d

100 - 150 cm *

145 - 190 cm * *

185 - 225 cm *

*

Head & Neck Garment - Medi UK Ltd Lipomed Face

NOT available on prescription

Indications: swelling in head or neck after surgery

Size: small under 38cm around neck

large over 40cm around neck

Velcro straps can be adjusted as required

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 93

Breast and Chest Wall Compression - Medi UK Lipomed Bra and Belt

NOT available on prescription

Indications: breast oedema or seroma

Colour: white or black

Measurement chart:

Lipomed BRA S M L XL

Chest Circumference

70 - 80 cms 80 - 90 cms 90 - 105 cms 105 - 125 cms

Lipomed BELT I II III

Circ. below breast 70 - 85 cms 85 - 105 cms 105 - 125 cms

Kinesiotape - Haddenham Healthcare

NOT on prescription

Colours: light skin tone, dark skin tone and blue. One size.

Glue - Haddenham Healthcare or Juzo Ltd

NOT on prescription

Indications: helps keep garments in place. One size.

Can be purchased from either Haddenham or Juzo Ltd.

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 94

Towelling Cotton Liner - ACTIVA TG Soft

NOT on prescription

Indications: provides support in palliative patients

Comes in 3 sizes: Small width 6cm

Medium width 8.5cm

Large width 14cm

Comes in 10m Rolls

Donning Aid for Open and Closed Toe Lower Limb Garments- Medi UK Mediven 2-in-One

Product Code: Pip Code

Mediven 2in1 DT904 329-8932

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 95

Donning Aid - Arms or Legs

Sigvaris Ring (Sigvaris Extensor) NOT on Prescription

Sigvaris Rolly (Rolly Compression Hosiery Applicator) Product code 64655 Available on prescription – please use ‘Rolly Compression Hosiery Applicator’

Donning Aid for Upper Limb fabric - Juzo UK – The Upper Limb Slippie

NOT on prescription

Product Code:

Upper Limb Slippie 1902

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 96

Contact Details of the Awarded Companies Activa Healthcare 1 Lancaster Park Newborough Road Needwood Burton on Trent Staffordshire DE13 9PD Tel.: 01283 576 800

Juzo UK Ltd South Court Sharston Manchester Greater Manchester M22 4SN Tel.: 01382 826620 Fax : 01382 826641 E-mail: adam.withey@juzo.com

BSN Medical Willerby Hill Business Part Willerby Hull HU10 6FE Tel.: 0845 122 3600 Fax : 0845 122 3666 E-mail: orders.uk@bsnmedical.com

Medi (UK) Limited Plough Lane Hereford HR4 0EL Tel.: 01432 373 500 Fax : 01432 342 383 Web Site: www.mediuk.co.uk E-mail: enquiries@mediuk.co.uk

Haddenham Healthcare Ltd Crendon House Crendon Industrial Park Long Crendon Bucks HP18 9BB Tel.: 01844 208842 Fax : 01844 208843 E-mail: sales@hadhealth.com

Sigvaris Britain Ltd 4 Sopwith Park Royce Close Andover Hampshire SP10 3TS Tel.: 01264 326666 E-mail: peter.vacher@sigvaris.com

IMS Euro 46-47 Europa Business Park Bird Hall Lane Cheadle Heath Stockport Cheshire SK3 0XA Tel.: 07522314105 E-mail: david@imseuro.co.uk

The All Wales Lymphoedema Compression Garment Formulary FINAL v4.0 23/02/16 Page 97

All Wales Compression Garment Contract

Exceptions to Ordering Compression Garments

This form must be completed if you are ordering, prescribing or recommending a compression

garment/ product that is against the option from the National Lymphoedema Compression

Formulary. We understand that clinical implications might require a product that is not on the

formulary; however it is imperative that we capture this information on every occasion. Many

thanks for your support. Patient recognisable data to you as a therapist must be given to audit

individual need.

Therapist Name (in Full)

Health Board

Patient Initials

DOB

Recommended Product from contract (including company and product name)

Actual Product Ordered (including company and product name)

Quantity

Class

Upper limb/Lower limb/Genital

Clinical Reason for not complying with contract

Date

Please email this form back to: Lymphoedema.Network.Wales@wales.nhs.uk