A = Prix (TVAc) - Prijs (incl. BTW) B = Remboursement Bén. ordin./Prestataire conventionné - Remboursement V.I.P.O. / Prestataire avec ou sans convention Terugbetaling Gew. recht. / Verstr. met overeenkomst - Terugbetaling W.I.G.W. / Verstr. met of zonder overeenkomst C = Supplément patient Bén. ordin. / Prestataire conventionné - Supplément patient V.I.P.O. / Prestataire avec ou sans convention Supplement patiënt Gew. recht. / Verstr. met overeenkomst - Supplement patiënt W.I.G.W. / Verstr. met of zonder overeenkomst D = Remboursement Bén. ordin. / Prestataire non conventionné Terugbetaling Gew. recht. / Verstr. zonder overeenkomst E = Supplément patient Bén. ordin. / Prestataire non conventionné Supplement patiënt / Verstr. zonder overeenkomst F = Marge de délivrance Afleveringsmarge 704815-704826 Tranche d’enveloppe pour défibrillateur cardiaque implantable Enveloppeschijf voor implanteerbare hartdefibrillator 704830-704841 Tranche d’enveloppe pour défibrillateur cardiaque de remplacement implantable Enveloppeschijf voor implanteerbare vervangingshartdefibrillator 704852-704863 Défibrillateur cardiaque implantable après liquidation totale de l’enveloppe Implanteerbare hartdefibrillator na volledige vereffening van de enveloppe 704874-704885 Défibrillateur cardiaque de remplacement implantable après liquidation totale de l’enveloppe Implanteerbare vervangingshartdefibrillator na volledige vereffening van de enveloppe Catégorie 1 - Défibrillateur cardiaque classique SINGLE chamber Categorie 1 - Klassieke SINGLE chamber hartdefibrillator Plafond (€) : 13.401,26 € Code d'identification Identificatiecode 195001000013 Fournisseur Leverancier Biotronik Mise à jour 01-12-2014- Bijwerking 01-12-2014 Nom du produit Productnaam Ilesto 7 VR-T DX ProMRI (DF-1) Numéro de référence Referentienummer 390094 A partir de Vanaf Jusqu'au Tot 01-01-2014 Page 1 195001000022 Biotronik Ilesto 7 VR-T ProMRI (DF-1) 390082 01-01-2014 195001000031 Biotronik Ilesto 7 VR-T ProMRI (DF-4) 390088 01-01-2014 195001000047 Biotronik Lumax 740 VR-T 365609 01-01-2014 195001000056 Biotronik Lumax 740 VR-T DX 372419 01-01-2014 195001000065 Biotronik Lumax 740 VR-T DX ProMRI 381463 01-01-2014 195001000074 Biotronik Lumax 740 VR-T ProMRI 381459 01-01-2014 195001000083 Boston Scientific Benelux Energen ICD F140 01-01-2014 195001000092 Boston Scientific Benelux Energen ICD F141 01-01-2014 195001000101 Boston Scientific Benelux INCEPTA ICD F160 01-01-2014 195001000117 Boston Scientific Benelux INCEPTA ICD F161 01-01-2014 195001000126 Boston Scientific Benelux Punctua ICD F050 01-01-2014 195001000135 Boston Scientific Benelux Punctua NE ICD F051 01-01-2014 195001000144 Boston Scientific Benelux Teligen 100 HE ICD F102 01-01-2014 195001000153 Boston Scientific Benelux Teligen 100 HE ICD F103 01-01-2014 195001000162 Medtronic EVERA S VR DVBC3D1 01-01-2014 195001000171 Medtronic EVERA S VR DVBC3D4 01-01-2014 195001000187 Medtronic EVERA XT VR DVBB2D1 01-01-2014 195001000196 Medtronic EVERA XT VR DVBB2D4 01-01-2014 195001000205 Medtronic Protecta VR D364VRG 01-01-2014 195001000214 Medtronic Protecta VR (DF4) D364VRM 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 2 195001000223 Medtronic Protecta XT VR D354VRG 01-01-2014 195001000232 Medtronic Protecta XT VR D354VRM 01-01-2014 195001000241 Medtronic Secura VR D 234 VRC 01-01-2014 195001000257 Medtronic Secura VR D214VRM 01-01-2014 195001000266 St. Jude Medical Current + VR CD1211-36 01-01-2014 195001000275 St. Jude Medical Current + VR CD1211-36Q 01-01-2014 195001000284 St. Jude Medical Ellipse VR CD1277-36 01-01-2014 195001000293 St. Jude Medical Ellipse VR CD1277-36Q 01-01-2014 195001000302 St. Jude Medical Ellipse VR IS-1/DF-1 DF-4 CD1377-36 01-01-2014 195001000311 St. Jude Medical Ellipse VR IS-1/DF-1 DF-4 CD1377-36C 01-01-2014 195001000327 St. Jude Medical Ellipse VR IS-1/DF-1 DF-4 CD1377-36Q 01-01-2014 195001000336 St. Jude Medical Ellipse VR IS-1/DF-1 DF-4 CD1377-36QC 01-01-2014 195001000345 St. Jude Medical Fortify Assura VR CD1259-40 01-01-2014 195001000354 St. Jude Medical Fortify Assura VR CD1259-40Q 01-01-2014 195001000363 St. Jude Medical Fortify Assura VR IS-1/DF-1 DF-4 CD1359-40 01-01-2014 195001000372 St. Jude Medical Fortify Assura VR IS-1/DF-1 DF-4 CD1359-40C 01-01-2014 195001000381 St. Jude Medical Fortify Assura VR IS-1/DF-1 DF-4 CD1359-40Q 01-01-2014 195001000397 St. Jude Medical Fortify Assura VR IS-1/DF-1 DF-4 CD1359-40QC 01-01-2014 195001000406 St. Jude Medical Fortify ST VR CD1235-40 01-01-2014 195001000415 St. Jude Medical Fortify ST VR CD1235-40Q 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 3 195001000424 St. Jude Medical Fortify VR CD1233-40 01-01-2014 195001000433 St. Jude Medical Fortify VR CD1233-40Q 01-01-2014 195001000442 Sorin Paradym RF VR 9250 01-01-2014 195001000451 Sorin Paradym VR 8250 01-01-2014 195001000467 Boston Scientific Benelux Autogen D174 01-03-2014 195001000476 Boston Scientific Benelux Autogen D175 01-03-2014 195001000485 Boston Scientific Benelux Inogen D140 01-03-2014 195001000494 Boston Scientific Benelux Inogen D141 01-03-2014 195001000503 Boston Scientific Benelux Origen D050 01-03-2014 195001000512 Boston Scientific Benelux Origen D051 01-03-2014 195001000521 Sorin Intensia VR 124 TDF022C 01-05-2014 195001000537 Biotronik Idova 7 VR-T ProMRI DF-1 383592 01-06-2014 195001000546 Biotronik Idova 7 VR-T ProMRI DF-4 383593 01-06-2014 195001000555 Biotronik Idova 7 VR-T DX ProMRI DF-1 383601 01-06-2014 195001000564 Sorin Paradym 2 VR 8252 01-08-2014 195001000573 Medtronic EVERA MRI XT VR SureScan DVMB2D4 01-10-2014 195001000582 Medtronic EVERA MRi S VR SureScan DVMC3D4 01-10-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 4 Catégorie 2 - Défibrillateur cardiaque classique DUAL chamber Categorie 2 - Klassieke DUAL chamber hartdefibrillator Plafond (€) : 13.401,26 € Code d'identification Identificatiecode Fournisseur Leverancier Nom du produit Productnaam Numéro de référence Referentienummer A partir de Vanaf 195002000015 Biotronik Ilesto 7 DR-T ProMRI (DF-1) 390068 01-01-2014 195002000024 Biotronik Ilesto 7 DR-T ProMRI (DF-4) 390074 01-01-2014 195002000033 Biotronik Lumax 740 DR-T 365606 01-01-2014 195002000042 Biotronik Lumax 740 DR-T ProMRI 381461 01-01-2014 195002000051 Boston Scientific Benelux Energen ICD F142 01-01-2014 195002000067 Boston Scientific Benelux Energen ICD F143 01-01-2014 195002000076 Boston Scientific Benelux INCEPTA ICD F162 01-01-2014 195002000085 Boston Scientific Benelux INCEPTA ICD F163 01-01-2014 195002000094 Boston Scientific Benelux Punctua ICD F052 01-01-2014 195002000103 Boston Scientific Benelux Punctua NE ICD F053 01-01-2014 195002000112 Boston Scientific Benelux Teligen 100 HE ICD F110 01-01-2014 195002000121 Boston Scientific Benelux Teligen 100 HE ICD F111 01-01-2014 195002000137 Medtronic EVERA S DR DDBC3D1 01-01-2014 195002000146 Medtronic EVERA S DR DDBC3D4 01-01-2014 195002000155 Medtronic EVERA XT DR DDBB2D1 01-01-2014 195002000164 Medtronic EVERA XT DR DDBB2D4 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Jusqu'au Tot Page 5 195002000173 Medtronic Protecta DR D364DRG 01-01-2014 195002000182 Medtronic Protecta DR (DF4) D364DRM 01-01-2014 195002000191 Medtronic Protecta XT DR D354DRG 01-01-2014 195002000207 Medtronic Protecta XT DR D354DRM 01-01-2014 195002000216 Medtronic Secura DR D 234 DRG 01-01-2014 195002000225 Medtronic Secura DR D214DRM 01-01-2014 195002000234 St. Jude Medical Current + DR CD2211-36 01-01-2014 195002000243 St. Jude Medical Current + DR CD2211-36Q 01-01-2014 195002000252 St. Jude Medical Ellipse DR CD2277-36 01-01-2014 195002000261 St. Jude Medical Ellipse DR CD2277-36Q 01-01-2014 195002000277 St. Jude Medical Ellipse DR IS-1/DF-1 DF-4 CD2377-36 01-01-2014 195002000286 St. Jude Medical Ellipse DR IS-1/DF-1 DF-4 CD2377-36C 01-01-2014 195002000295 St. Jude Medical Ellipse DR IS-1/DF-1 DF-4 CD2377-36Q 01-01-2014 195002000304 St. Jude Medical Ellipse DR IS-1/DF-1 DF-4 CD2377-36QC 01-01-2014 195002000313 St. Jude Medical Fortify Assura DR CD2259-40 01-01-2014 195002000322 St. Jude Medical Fortify Assura DR CD2259-40Q 01-01-2014 195002000331 St. Jude Medical Fortify Assura DR IS-1/DF-1 DF-4 CD2359-40 01-01-2014 195002000347 St. Jude Medical Fortify Assura DR IS-1/DF-1 DF-4 CD2359-40C 01-01-2014 195002000356 St. Jude Medical Fortify Assura DR IS-1/DF-1 DF-4 CD2359-40Q 01-01-2014 195002000365 St. Jude Medical Fortify Assura DR IS-1/DF-1 DF-4 CD2359-40QC 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 6 195002000374 St. Jude Medical Fortify DR CD2233-40 01-01-2014 195002000383 St. Jude Medical Fortify DR CD2233-40Q 01-01-2014 195002000392 St. Jude Medical Fortify ST DR CD2235-40 01-01-2014 195002000401 St. Jude Medical Fortify ST DR CD2235-40Q 01-01-2014 195002000417 Sorin Paradym DR 8550 01-01-2014 195002000426 Sorin Paradym RF DR 9550 01-01-2014 195002000435 Boston Scientific Benelux Autogen D176 01-03-2014 195002000444 Boston Scientific Benelux Autogen D177 01-03-2014 195002000453 Boston Scientific Benelux Inogen D142 01-03-2014 195002000462 Boston Scientific Benelux Inogen D143 01-03-2014 195002000471 Boston Scientific Benelux Origen D052 01-03-2014 195002000487 Boston Scientific Benelux Origen D053 01-03-2014 195002000496 Sorin Intensia DR 154 TDF021C 01-05-2014 195002000505 Biotronik Idova 7 DR-T ProMRI DF-1 383576 01-06-2014 195002000514 Biotronik Idova 7 DR-T ProMRI DF-4 383577 01-06-2014 195002000523 Sorin Paradym 2 DR 8552 01-08-2014 195002000532 Medtronic EVERA MRI XT DR SureScan DDMB2D4 01-10-2014 195002000541 Medtronic EVERA MRI S DR SureScan DDMC3D4 01-10-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 7 Catégorie 3 - Défibrillateur cardiaque de resynchronisation Categorie 3 - Resynchronisatiehartdefibrillator Plafond (€) : 13.401,26 € Code d'identification Identificatiecode Fournisseur Leverancier Nom du produit Productnaam Numéro de référence Referentienummer A partir de Vanaf 195003000017 Biotronik Ilesto 7 HF-T ProMRI (DF-1) 390055 01-01-2014 195003000026 Biotronik Ilesto 7 HF-T ProMRI (DF-4) 390061 01-01-2014 195003000035 Biotronik Lumax 740 HF-T 365608 01-01-2014 195003000044 Biotronik Lumax 740 HF-T ProMRI 381462 01-01-2014 195003000053 Boston Scientific Benelux Cognis 100 HE CRT-D P106 01-01-2014 195003000062 Boston Scientific Benelux Cognis 100 HE CRT-D P107 01-01-2014 195003000071 Boston Scientific Benelux Cognis 100 HE CRT-D P108 01-01-2014 195003000087 Boston Scientific Benelux Energen CRT-D P142 01-01-2014 195003000096 Boston Scientific Benelux Energen CRT-D P143 01-01-2014 195003000105 Boston Scientific Benelux INCEPTA CRT-D P162 01-01-2014 195003000114 Boston Scientific Benelux INCEPTA CRT-D P163 01-01-2014 195003000123 Boston Scientific Benelux INCEPTA CRT-D P165 01-01-2014 195003000132 Boston Scientific Benelux Punctua CRT-D P052 01-01-2014 195003000141 Boston Scientific Benelux Punctua NE CRT-D P053 01-01-2014 195003000157 Medtronic Brava DTBC2D1 01-01-2014 195003000166 Medtronic Brava DF4 DTBC2D4 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Jusqu'au Tot Page 8 195003000175 Medtronic BRAVA QUAD DTBC2QQ 01-01-2014 195003000184 Medtronic Consulta CRT-D D 234 TRK 01-01-2014 195003000193 Medtronic Consulta CRT-D D214TRM 01-01-2014 195003000202 Medtronic Protecta CRT-D D364TRG 01-01-2014 195003000211 Medtronic Protecta CRT-D (DF4) D364TRM 01-01-2014 195003000227 Medtronic Protecta XT CRT-D D354TRG 01-01-2014 195003000236 Medtronic Protecta XT CRT-D D354TRM 01-01-2014 195003000245 Medtronic VIVA QUAD S DTBB2QQ 01-01-2014 195003000254 Medtronic VIVA QUAD XT DTBA2QQ 01-01-2014 195003000263 Medtronic Viva S DTBB2D1 01-01-2014 195003000272 Medtronic Viva S DF4 DTBB2D4 01-01-2014 195003000281 Medtronic Viva XT DTBA2D1 01-01-2014 195003000297 Medtronic Viva XT DF4 DTBA2D4 01-01-2014 195003000306 St. Jude Medical Promote + CD3211-36 01-01-2014 195003000315 St. Jude Medical Promote + CD3211-36Q 01-01-2014 195003000324 St. Jude Medical Promote Quadra CRT CD3239-40 (DF-1) 01-01-2014 195003000333 St. Jude Medical Promote Quadra CRT CD3239-40Q (SJ4-LLHH) 01-01-2014 195003000342 St. Jude Medical Quadra Assura CD3267-40 01-01-2014 195003000351 St. Jude Medical Quadra Assura CD3267-40Q 01-01-2014 195003000367 St. Jude Medical Quadra Assura IS-1/DF-1 DF-4 CD3367-40 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 9 195003000376 St. Jude Medical Quadra Assura IS-1/DF-1 DF-4 CD3367-40C 01-01-2014 195003000385 St. Jude Medical Quadra Assura IS-1/DF-1 DF-4 CD3367-40Q 01-01-2014 195003000394 St. Jude Medical Quadra Assura IS-1/DF-1 DF-4 CD3367-40QC 01-01-2014 195003000403 St. Jude Medical Quadra Assura MP IS-1/DF-1 DF-4 CD3371-40 01-01-2014 195003000412 St. Jude Medical Quadra Assura MP IS-1/DF-1 DF-4 CD3371-40C 01-01-2014 195003000421 St. Jude Medical Quadra Assura MP IS-1/DF-1 DF-4 CD3371-40Q 01-01-2014 195003000437 St. Jude Medical Quadra Assura MP IS-1/DF-1 DF-4 CD3371-40QC 01-01-2014 195003000446 St. Jude Medical Unify Assura CD3261-40 01-01-2014 195003000455 St. Jude Medical Unify Assura CD3261-40Q 01-01-2014 195003000464 St. Jude Medical Unify Assura IS-1/DF-1 DF-4 CD3361-40 01-01-2014 195003000473 St. Jude Medical Unify Assura IS-1/DF-1 DF-4 CD3361-40C 01-01-2014 195003000482 St. Jude Medical Unify Assura IS-1/DF-1 DF-4 CD3361-40Q 01-01-2014 195003000491 St. Jude Medical Unify Assura IS-1/DF-1 DF-4 CD3361-40QC 01-01-2014 195003000507 St. Jude Medical Unify CRT CD3235-40 01-01-2014 195003000516 St. Jude Medical Unify CRT CD3235-40-Q 01-01-2014 195003000525 St. Jude Medical Unify Quadra CRT CD3251-40 (DF-1) 01-01-2014 195003000534 St. Jude Medical Unify Quadra CRT CD3251-40Q (SJ4-LLHH) 01-01-2014 195003000543 Sorin Paradym CRT 8750 01-01-2014 195003000552 Sorin Paradym RF CRT 9750 01-01-2014 195003000561 Sorin Paradym RF CRT-D 9770 01-01-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 10 195003000577 Boston Scientific Benelux Autogen G172 01-03-2014 195003000586 Boston Scientific Benelux Autogen G173 01-03-2014 195003000595 Boston Scientific Benelux Autogen G175 01-03-2014 195003000604 Boston Scientific Benelux Autogen G177 01-03-2014 195003000613 Boston Scientific Benelux Autogen G179 01-03-2014 195003000622 Boston Scientific Benelux Inogen G140 01-03-2014 195003000631 Boston Scientific Benelux Inogen G141 01-03-2014 195003000647 Boston Scientific Benelux Inogen G146 01-03-2014 195003000656 Boston Scientific Benelux Inogen G148 01-03-2014 195003000665 Boston Scientific Benelux Origen G050 01-03-2014 195003000674 Boston Scientific Benelux Origen G051 01-03-2014 195003000683 Sorin Intensia SONR 184 TDF019C 01-05-2014 195003000692 Biotronik Idova 7 HF-T ProMRI DF-1 383560 01-06-2014 195003000701 Biotronik Idova 7 HF-T ProMRI DF-4 383561 01-06-2014 195003000717 Medtronic VIVA QUAD XT DTBA2Q1 01-06-2014 195003000726 Medtronic VIVA QUAD S DTBB2Q1 01-06-2014 195003000735 Medtronic BRAVA QUAD DTBC2Q1 01-06-2014 195003000744 Sorin Paradym 2 SONR CRT-D 8772 01-08-2014 195003000753 Sorin Paradym SonR Tri-V 8970 ICV1231 01-12-2014 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 11 Catégorie 4 - Défibrilateur cardiaque souscutané Categorie 4 - Subcutane hartdefibrillator Plafond (€) : 13.401,26 € Code d'identification Identificatiecode 195004000012 Fournisseur Leverancier Boston Scientific Benelux Mise à jour 01-12-2014- Bijwerking 01-12-2014 Nom du produit Productnaam SQ-RX Pulse Generator (S-ICD) Numéro de référence Referentienummer 1010 A partir de Vanaf Jusqu'au Tot 01-01-2014 Page 12 Mise à jour 01-12-2014- Bijwerking 01-12-2014 Page 13
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