1. No category

Alberta Health
AADL Approved Product List - Prosthetic Benefits
Pricing effective April 1, 2014
© 2013 Government of
Alberta April 1, 2014
#Name?
Alberta Health - Professional Services and Health Benefits
Manual P - Prosthetics Approved Product List
General Information
Functional Levels
Lower Limb
Level 0
Does not have the ability or potential to ambulate or transfer safely with or without
assistance and a prosthesis does not enhance their quality of life or mobility.
Level 1
The ability or potential to use a prosthesis for transfers or ambulation on level
surfaces at fixed pace. This prosthesis is typical for the household ambulator.
Level 2
The ability or potential for ambulation with the ability to traverse low-level
environmental barriers such as curbs, stairs, or uneven surfaces. This prosthesis is
typical for the limited community ambulator.
Level 3
The ability or potential for ambulation with variable pace. This prosthesis is typical of
a community ambulator with the ability to traverse most environmental barriers while
participating in activities of daily living that require prosthetic use beyond simple
locomotion.
Level 4
The ability or potential for prosthetic ambulation that exceeds basic ambulation skills,
exhibiting high impact, stress, or energy levels. This prosthesis is typical of the
prosthetic demands of the child or active adult functioning in the community.
Upper Limb
Level 5
The ability to enhance a patient's body awareness to improve quality of life and or
prepare for the patient's future functional ability.
Level 6
The ability to use the prostheses for basic hand skill activities. Generally, these
activities are required for lifting, stabilizing or holding objects between two extremities.
Level 7
The ability to demonstrate a high level of function with the prosthesis that enables a
client to perform sophisticated, hand skill patterns. Some typical activities would
include grasping and releasing, positioning (pre-position) of the terminal device, or
changing to alternate terminal devices.
Level 9
The ability to demonstrate a high level of function with a myoelectric prosthesis that
enables a client to perform sophisticated, hand skill patterns.
Generic Pricing Procedure
Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number.
Procedure
1. Enter the catalogue number and verify the product description is correct.
2. Enter the manufacturer invoice cost for the component into the calculator. Do not include shipping costs,
exchange or any other cost. The cost used for generic catalogue number must be the manufacturer's invoice cost
only. The calculator will automatically add mark-up, shipping and labour costs.
3. Enter manufacturer name and part number as indicated.
4. Copy and paste the calculation into the Benefit Note on E-Business.
5. Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-1
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1 - 7, or 9
P926
AADL Price
#
Stump Protectors
Physician Prescription Required
Stump Protector
1 Protector Per Limb
Per 2 Years
$838.35 Each
For immediate post-operative use. A socket adaptor may be added in order
to determine the client's eligibilty/suitabilty for a definitive prosthesis.
##
Shrinker Socks - Lower Limb
Shrinker Socks - Custom Made
TF Shrinker Sock - After 12 Months
6 Socks Per 12 Months
3 Socks Per 12 Months
TT Shrinker Sock - Non-Ambulatory
2 Socks Per 12 Months
TT Shrinker Sock - New Amp
P541
Prior Approval
1-4
P579
$63.87 Each
1-4
P520
$63.87 Each
0
P581
$52.39 Each
1-4
P582
$52.39 Each
1-4
P490
$52.39 Each
2 Socks Per 12 Months
TF Shrinker Sock - New Amp
2HPM9613
TT Shrinker Sock - After 12 months
1-4
3 Socks Per 12 Months
6 Socks
Socks Per 12 Months
2HPHDW
##
Lower Limb Socket Procedures
Physician Prescription Required
Check Socket
2 Check Socket Per 2
Years
Ankle Disarticulation/Chopart P-SK-301
1-4
P113
$807.21 Each
Hemipelvectomy
1-4
P120
$939.96 Each
Hip Disarticulation P-SK-306
1-4
P119
$939.96 Each
Knee Disarticulation P-SK-303
1-4
P116
$807.21 Each
Proximal Femoral Focal Deficiency PFFD
1-4
P498
$797.88 Each
Transfemoral P-SK-304
1-4
P117
$807.21 Each
Transtibial P-SK-302
1-4
P114
$753.63 Each
1-4
P012
$3,348.30 Each
Boyde/Chopart
1-4
P929
$3,569.55 Each
Hip Disarticulation/Hemipelvectomy (HD/HP) HD-70
1-4
P033
$4,928.39 Each
Definitive Socket
Ankle disarticulation (AD) P-AD-20
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Procedure Per 2 Years
APL P-2
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-4
P020
$4,174.88 Each
1-4
P003
Prior Approval
AADL Price
##
Lower Limb Socket Procedures
Physician Prescription Required
Definitive Socket
Knee Disarticulation (KD)
1 Procedure Per 2 Years
Partial Foot
Prior Approval - Fax the name of the client, PHN, description of the
procedure, cost of materials and hours to fabricate the partial foot prosthesis.
When approved by the AADL Manager, create the authorization on
ebusiness.
Proximal Femoral Focal Deficiency (PFFD) PD-60
1-4
P031
$5,288.53 Each
Rotation Plasty
1-4
P928
$3,932.73 Each
Transfemoral (TF) P-TF-50
1-4
P027
$4,359.28 Each
Transtibial (TT) P-TT-30
1-4
P017
$3,534.47 Each
1-4
P096
$4,359.28 Each
1-4
P099
$3,534.47 Each
1-4
P095
$4,174.88 Each
1 - 7, or 9
E703
$1,295.63 Each
Socket Replacement - New Amputee
1 Early Replacement
Per 2 Years
Above Knee P-TF-51
Replacement within 6 months
Below Knee Socket P-TT-31
Replacement within 6 months
Knee Disarticulation Socket
Replacement within 6 months
Temporary Socket
3 Temporary Sockets
Per 2 Years
For new amputee or client with complex issues with volume and/or shape.
Criteria: Where multiple sockets will be required due to anticipated swelling
and/or shape and/or volume change of the stump. If a check socket is
required, only 2 temporary sockets will be funded. Ambulation with socket.
##
Additions to Lower/Upper Limb Procedures
Air Cushion - Transfemoral
Bariatric Option
1 Per 2 Years
1-4
P141
$544.97 Each
1-4
P924
$466.00 Each
1 - 7, or 9
P931
$177.00 Each
1-7
P163
$177.01 Each
1 Per 2 Years
Client is 100 lb. over normal weight or over 275 lb.
ISNY Socket Modifications
Suction Socket Procedure
1 Per 2 Years
1 Suction Socket Per 2
Years
To be billed with definitive prosthesis only.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-3
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-7
P156
$133.62 Each
1-4
P128
$509.02 Each
1-4
P127
$44.26 Each
1-7
P934
$360.88 Each
AADL Price
##
Additions to Lower/Upper Limb Procedures
Suprachondylar/Epichondylar
Modification
P-SA-301
1 Per 2 Years
Syme's Posterior or Lateral Opening
P-SK-308
1 Per 2 Years
Syme's PTB Design
P-SK-307
1 Per 2 Years
Thermolyn Insert/ Thermo Plastic Lining
1 Per 2 Years
##
Stubbies
2 Per 3 Years
Stubbies
Laminated or Non-Laminated Sockets with crepe bottom
1-4
P717
Prior Approval
Prior Approval to establish contribution.
Submit hours and material costs to the AADL Manager.
##
Suction- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $914.28 per year or a maximum
quantity of 6 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing
a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 6
suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely
monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different
types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar
maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Contex Gel Sleeve
3 mm Transtibial Gel Sleeve
Easy Sleeve - heavy duty
6 Per 12 Months
P649
$144.55 Each
1-4
P166
$96.39 Each
1-7
N100
$247.59 Max. Each
2- 4
E505
$146.79 Each
6 Suction Sleeves Per
Limb Per 12 Months
SFR-24-6HP
Generic Suction Sleeve
1-4
6 Suction Sleeves Per
12 Months
See Generic Pricing Procedure
Ossur Iceflex Endurance sleeve
F-0107XX
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
6 Suction Sleeves Per
Limb Per 12 Months
APL P-4
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
##
Tension- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $1026.84 per year or a
maximum quantity of 12 per year. The maximum price and quantity maximum for each of the sleeves is noted.
When providing a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with
more than 12 suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will
be closely monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing
different types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or
dollar maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Generic Tension Sleeve
12 Tension Sleeves Per
12 Months
1-7
N110
$74.16 Max. Each
1-4
P158
$86.70 Each
See Generic Pricing Procedure
Neoprene Sleeve
DKS316
12 Per 12 Months
Heavy duty or equivalent (no Rx required)
##
Suspension Belts
Pelvic Belt
Light
1 Per 12 Months
Padded
PTB Cuff
Silesian Belt
1-4
P173
$375.07 Each
1-4
P174
$595.11 Each
1-4
P204
$315.80 Each
1-4
P179
$274.36 Each
1-4
P182
$170.78 Each
1-4
P171
$509.28 Each
1-4
P170
$236.85 Each
1 Per 12 Months
1 Per 12 Months
TES Belt
21B37
2 Per 12 Months
Waist Belt
Padded
1 Per 12 Months
Standard
##
Additions to Suspension
Fork Strap
Ottobock Gator Sleeve Protector
1 Per 12 Months
1-4
P167
$244.60 Each
1-4
P041
$24.65 Each
6 Per 12 Months
Not required for P153, P155 - c/w sleeves.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-5
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Functional
Level
Qty. / Freq.
Cat. No.
AADL Price
###
Gel Cushion Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner
1 Custom Liner Per 12
Months
Duplicate
2 - 4, 6 - 7, or 9
P725
$652.38 Each
Initial
2 - 4, 6 - 7, or 9
P724
$1,020.33 Each
1 - 7, or 9
N121
$1,497.45 Max. Each
Partial Foot/Ankle Disarticulation
1-4
E714
$1,497.45 Each
Transfemoral/Syme's/Above Elbow
1 - 7, or 9
E713
$1,613.95 Each
Each
1-4
E504
$1,497.45 Each
Generic Custom Gel Cushion Liner
1 Custom Liner Per 12
Months
See Generic Pricing Procedure
Ottobock Custom Made TEC
1 Custom Liner Per 12
Months
Transtibial
###
Gel Cushion Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Cushion Liner
2 Liners Per 12 Months
1-4
N120
$746.86 Max. Each
1-4
P056
$856.62 Each
1-4
E715
$443.23 Each
1 - 7, or 9
E522
$649.42 Each
See Generic Pricing Procedure
Iceross TF Seal-in Liner
2 Per 12 Months
No pins, no locking systems or sleeves
Ohio Willow Wood Alpha Cushion Liner
Ottobock Simplicity Liner
With and without cover, no lock.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
2 Liners Per Limb Per
12 Months
2 Liners Per Limb Per
12 Months
APL P-6
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Gel Locking Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner - Locking
1 Custom Liner Per 12
Months
Duplicate
2- 4
P727
$722.38 Each
Initial
2- 4
P726
$1,058.41 Each
1-7
N131
$1,058.41 Max. Each
Generic Custom Gel Locking Liner
1 Custom Liner Per 12
Months
See Generic Pricing Procedure
###
Gel Locking Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Locking Liner
2 Liners Per 12 Months
1-7
N130
$805.10 Max. Each
1-7
E518
$642.70 Each
1 - 4, 6 or 7
P646
$509.42 Each
1-7
E716
$615.82 Each
See Generic Pricing Procedure
Iceross Dermo/Stabilo Liners
Ohio Willow Wood Alpha Cushion Liner
With Lock
Ossur Iceross Comfort Liner
1-5006XX
2 Liners Per 12 Months
2 Liners Per 12 Months
2 Liners Per 12 Months
###
Additions to Liners
Alpha Gel Cup
Iceross Pads
Molded Distal Cushion
Ossur Iceross Silicone Distal Cap
1-3000XX
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
2 Per 12 Months
1 - 4, 6 or 7
P720
$103.23 Each
1 - 7, or 9
E517
$111.13 Each
1-7
P694
$92.96 Each
1-7
P713
$297.74 Each
2 Pads Per Limb Per 12
Months
1 Per 12 Months
2 Per 12 Months
APL P-7
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-7
E704
AADL Price
###
Additions to Liners
Ottobock TEC Spots
2 TEC Spots per limb
Per 12 Months
$78.63 Each
###
Spacer Socks
Filler Cast Sock - 1 Ply
12 Socks Per 12 Months
1 - 7, or 9
P218
$16.27 Each
###
Socket Inserts- Lower and Upper
Kemblow Liner - Transtibial
Leather Socket Knee Disarticulation - KD
1 Per 2 Years
1 Per 2 Years
Pelite Liner
TR, TH
1 Per 2 Years
Transtibial TFSK-316
$589.57 Each
1-4
P356
$501.03 Each
1-4
P147
$421.78 Each
5 - 7, or 9
P474
$270.34 Each
1-4
P145
$366.45 Each
1 - 7, or 9
P149
$841.54 Each
1-4
P151
$890.40 Each
1-7
P935
$558.33 Each
1 Per 2 Years
TF SK-319
Symes/Knee Disarticulation Stovepipe
Liner
P143
1 Per 2 Years
Liner - Transfemoral
P-SK-317
Silicone or Equivalent
TT, TR, TH SK-318
1-4
1 Per 2 Years
###
Additions to Socket Inserts
Expandable Wall Socket
Full Leather Lining
Ischial Containment
Suprachondylar Liner Buildup
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 2 Years
1-7
P125
$677.68 Each
1-7
P933
$215.84 Each
1-4
P932
$177.00 Each
1-4
P930
$132.75 Each
1 Per 2 Years
1 Per 2 Years
1 Per 2 Years
APL P-8
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-7
N220
$275.22 Max. Each
1-4
P059
$173.55 Each
1-4
P058
$152.27 Each
1-7
P311
$174.42 Each
1-4
P175
$275.22
1-7
P140
$165.86 Each
1-7
N165
$112.25 Max. Each
AADL Price
###
Suction Valves
Generic Suction Valves
1 Suction Valve Per 2
Years
See Generic Pricing Procedure
Icelock Expulsion Valve
TF 542
1 Per 2 Months
TT 541
Ossur Valve
641
1 Per 2 Years
Ottobock Thermal Valve
21Y12
1 Per 2 Years
TEC V5 Expulsion Valve Kit
1 Per 2 Years
Valve Parts
1 Valve Part Per 2 Years
See Generic Pricing Procedure
###
Lock Systems
Fillauer Shuttle Lock
1 Shuttle Lock Per 2
Years
125234
Generic Lock Systems
1-7
E735
$269.29 Each
1-7
N250
$518.83 Max. Each
1-7
P136
$315.55 Each
1-7
P137
$364.27 Each
1-7
P079
$364.27 Each
1-7
P094
$298.19 Each
1-7
P866
$265.22 Each
1 Per 2 Years
See Generic Pricing Procedure
Icelock Clutch
211
1 Per 2 Years
214
Locking Lanyard
1 Per 2 Years
Ossur Ratchet
621
1 Per 2 Years
Pro Advantage Locking Kit
1 Per 2 Years
###
Additions to Lock Systems
Attachment Pin Icelock
211 & 214
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 2 Years
1 - 7, or 9
P138
$96.57 Each
APL P-9
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-7
E736
AADL Price
###
Additions to Lock Systems
Fillauer Clutch Lock Pin
1 Clutch Lock Pin Per 2
Years
$88.39 Each
###
Blocks and Laminate-in Adaptors
Generic Blocks and Laminate-in Adaptors
1 Per 2 Years
1 - 7, or 9
N270
$540.09 Max. Each
1-4
P316
$111.13 Each
1-4
P546
$402.40 Each
1-4
P711
$152.45 Each
1-4
P845
$262.90 Each
1 - 7, or 9
P211
$258.42 Each
1-4
P414
$249.46 Each
See generic pricing procedure
Ossur Alloy 4-hole
674
1 Per 2 Years
Ossur Titanium
4-Hole 675
1 Per 2 Years
Ottobock Attachment Block
5R1
1 Per 2 Years
Ottobock Laminated Pyramid
4R100
1 Per 2 Years
Ottobock Socket Adaptor
4R41
1 Per 2 Years
Ottobock Threaded Ring w/ Lamination
Anchor 4-Prong
4R111
1 Per 2 Years
###
Distal Socket Adaptors
Generic Distal Socket Adaptors
1 Per 2 Years
1-4
N260
$517.69 Max. Each
1-4
P731
$106.65 Each
1-4
P685
$143.34 Each
1-4
P681
$241.05 Each
1-4
P684
$200.73 Each
See Generic Pricing Procedure
Ossur 4-hole Male Pyramid Adaptor
A233100
1 Per 2 Years
Ottobock 4 Bolt Pyramid
4R54
1 Per 2 Years
Ottobock Rotatable Pyramid With Hole
4R77
1 Per 2 Years
Ottobock Rotator
4R51
1 Per 2 Years
###
Knee Axial Rotators
Ottobock A/K Rotation Adaptor
4R57
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 2 Years
1-4
P688
$752.89 Each
APL P-10
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-4
N230
$347.45 Max. Each
1-4
P680
$279.14 Each
1-4
P690
$301.53 Each
AADL Price
###
Proximal Knee Adaptors
Generic Proximal Knee Adaptors
1 Knee Adaptor Per 2
Years
See Generic Pricing Procedure - Max. $347.45
Ossur Total Knee Pyramid
22
1 Per 2 Years
Ottobock Pyramid Adaptor
4R50
1 Per 2 Years
###
Proximal Knee Procedures
Thigh Lacer
5-902A
1 Per 2 Years
With gluteal/ischial moulding
1-4
P164
$571.24 Each
1-4
P165
$927.04 Each
###
Knee Systems
Daw Teh-Lin Knee
4 Bar Pneumatic TGK-4P00
1 Knee Per 2 Years
Graphlite Pneumatic TGK-4P10
Generic Knee
Friction
3-4
P560
$3,400.35 Each
3-4
P561
$3,592.65 Each
1-4
N151
$3,269.35 Max. Each
3-4
N153
$4,973.22 Max. Each
2- 4
N154
$3,827.46 Max. Each
1-4
N150
$1,436.81 Max. Each
1-4
N152
$1,612.59 Max. Each
2- 4
N156
$5,694.77 Max. Each
2- 4
P046
$1,160.45 Each
2- 4
P723
$1,855.22 Each
1 Knee Per 2 Years
See Generic Pricing Procedure
Hydraulic
See Generic Pricing Procedure
Hydraulic
See Generic Pricing Procedure
Knee/Shin
See Generic Pricing Procedure
Locking
See Generic Pricing Procedure
Multifunctional
See Generic Pricing Procedure
Hosmer Durathane Knee Shin for Mauch
SNS
34932
1 Per 2 Years
Medial Lateral Support With BK Suction
Socket
1 Per 2 Years
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-11
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Functional
Level
Cat. No.
3-4
P247
$4,141.06 Each
2- 4
P876
$4,475.94 Each
2- 4
P952
$3,516.37 Each
4
P979
$6,530.29 Each
2- 4
P973
$2,134.40 Each
3-4
P960
$5,694.77 Each
Hydraulic 3R45
3-4
P967
$3,839.78 Each
Hydraulic Knee Disarticulation Titanium 3R46 - to 275 lbs.
3-4
P976
$3,518.34 Each
Pneumatic 3R106=1
3-4
P044
$2,453.22 Each
Polycentric 4 Bar 3R36
1-4
P566
$1,768.16 Each
Polycentric Child's Knee 3R66
2- 4
P950
$1,718.88 Each
Single Axis Hydraulic 3R80
3-4
P968
$5,408.05 Each
Single Axis Locking 3R33
1-4
P565
$1,335.95 Each
Qty. / Freq.
AADL Price
###
Knee Systems
Ossur Mauch Graphite Frame With
Hydraulic SNS
FRM01804U
1 Per 2 Years
Ossur Gaitmaster Knee With Mauch SNS
(250-350 lbs.)
MKN0136
1 Per 2 Years
Ossur Total Knee
Hydraulic 2000
1 Knee Per 2 Years
Hydraulic 2100
High impact, multi speed, heavy duty weight up to 275 lb, knee disarticulate,
with heavy use.
Note criteria on client benefit note.
Pediatric 1100
Ottobock Knee
EBS 3R60
1 Knee Per 2 Years
###
Knee Side Joint
Generic Knee Side Joint
1 Knee Side Joint Per 2
Years
1-4
N159
$1,137.74 Max. Each
1-4
P936
$937.26 Each
See Generic Pricing Procedure
Ottobock Side Joints
7U26
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Knee Side Joint Per 2
Years
APL P-12
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Microprocessor Knees
AADL provides a grant to those clients who are at least a Functional Level 3 and want to upgrade to a
microprocessor knee. The grant will be paid directly to the Specialty Supplier once the micro-rocessor knee has
been provided to the client (service date). The individual will own the microprocessor knee. AADL will not pay for
repairs or maintenance of a micrprocessor knee. The quantity/frequency limit of one microprocessor knee grant per
five years will be strictly enforced. A client declaration for the microprocessor knee must be completed and signed
prior to the authorization being submitted. A copy of this declaration must be kept on the client file in addition to the
AADL client delcaration form. AADL will not replace any prosthetic knee provided within 2 years due to client
preference.
Microprocessor Knee
1 Microprocessor Knee
Per 5 Years
3-4
P925
$6,000.00 Grant
###
Knee Caps
Ossur Knee Cap
Large
1 Cap Per 2 Years
Small
1-4
P126
$206.90 Each
1-4
P124
$167.70 Each
###
Knee Extension Assists
Total Knee Extension Assist
1 Per 2 Years
2- 4
P129
$203.54 Each
###
Shin Ferrules
Ossur Shin Ferrule
1 Per 2 Years
1-4
P123
$141.10 Each
###
Additions to External Knee Joints
Back Check
Joint Covers
1 Per 12 Months
1-4
P168
$192.60 Each
1-4
P162
$102.15 Pair
1 Pair Per 12 Months
###
Hydraulic Cylinders
Catech SNS Hydraulic Cylinder Replacement Only
500R
1 Per 2 Years
1 Per 2 Years
Ossur Mauch
SNS00100U - Cylinder SNS69571 - Black Replacement only
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
3-4
P965
$1,855.26 Each
3-4
P715
$2,096.34 Each
APL P-13
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
1-4
N290
$1,309.53 Max. Each
1-4
N240
$476.82 Max. Each
1-4
P815
$396.18 Each
AADL Price
###
Modular Adaptors/connectors - Adjustable
Generic Adaptor/Connectors - Fixed
1 Per 2 Years
See Generic Pricing Procedure
Generic Components
1 Per 2 Years
See Generic Pricing Procedure
Ottobock Slide Adaptor
4R103
1 Per 2 Years
###
Modular Adaptors/connectors - Fixed
Ottobock 4R72 double tube adaptor
female
Ottobock Double Pyramid Adaptor
4R84
1 Per 2 Years
1-4
P803
$244.41 Each
1-4
P833
$236.57 Each
1 Per 2 Years
###
Tube Clamps
Generic Tube Clamps
1 Tube Clamp Per 2
Years
1-4
N210
$347.45 Max. Each
1-4
P802
$211.93 Each
1 - 7, or 9
P110
$211.93 Each
1-4
P822
$391.70 Each
See Generic Pricing Procedure
Ottobock Tube Clamp
1 Tube Clamp Per 2
Years
34 mm 4R82
4R52 P-LC-336
Sliding Tube Clamp - 34 mm 4R88
###
Tubes
Generic Tubes
1 Tube Per 2 Years
1 - 7, or 9
N200
$477.37 Max. Each
1 - 7, or 9
P108
$205.21 Each
1 - 7, or 9
P107
$185.05 Each
See Generic Pricing Procedure
Ottobock 2R37 Pipe
Long P-LC-338
1 Tube Per 2 Years
Short P-LC337
###
Torque and Shock Absorbers
Century Total Shock
22 4400/4410
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 2 Years
3-4
P851
$1,272.05 Each
APL P-14
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
3-4
N122
$1,765.97 Max. Each
2- 4
P971
$747.89 Each
2- 4
P203
$747.89 Each
2- 4
P827
$671.73 Each
AADL Price
###
Torque and Shock Absorbers
Generic Shock Absorber
1 Shock Absorber Per 2
Years
See Generic Pricing Procedure - Max. $1765.97
Ottobock 4R40 Torsion Plate
1 Per 2 Years
Ottobock Torsion Tube
4R39
1 Per 2 Years
Ottobock Torsion Tube Clamp
4R85
1 Per 2 Years
###
Vacuum Suspension Systems and Replacement Components
Criteria
Must be a non-neuropathic client with full cognitive ability.
Must have reasonable volume management and stump shaping.
Socket Replacement Crriteria
Shrinkage of 3-5 ply as per Otto Bock.
Generic Vacuum System
1 Electric Vacuum
System Per 2 Years
Electric
3-4
N160
$2,875.92 Max. Each
3-4
N161
$3,739.82 Max. Each
3-4
P719
$143.40 Each
3-4
P648
$139.16 Each
3-4
P920
$3,589.74 Each
3-4
P921
$3,589.74 Each
See Generic Pricing Procedure
Standard
See Generic Pricing Procedure
Ottobock Barbed Elbow Connector
4Y350
1 Per 2 Years
Connects suction supension socket to vacuum hose at 90 degrees.
Ottobock Expulsion Valve With Filter
4Y345
Ottobock Harmony System
1 Per 2 Years
1 Electric Vacuum
System Per 2 Years
Heavy Duty 4R150
(1 year warranty), includes cost of V5 valve kit & shock absorbers
P2 (with pyramid and tube clamp) 4R144
(1 year warranty), includes cost of V5 valve kit & shock absorbers
###
Ankles
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Endolite Attachment Plate/Bolt
1 Ankle Per 2 Years
2- 4
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
P871
$190.61 Each
APL P-15
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Ankles
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Endolite Snubber
Heavy Duty
1 Ankle Per 2 Years
Standard
Ohio Willow Wood Impulse Ankle
P212
$388.30 Each
2- 4
P205
$388.30 Each
2- 4
P087
$394.18 Each
2- 4
P874
$148.88 Each
1-4
P556
$168.89 Each
1-4
P190
$267.63 Each
1-4
P867
$390.26 Each
1-4
P555
$493.30 Each
2- 4
P576
$199.09 Each
2- 4
P592
$441.78 Each
1-4
P593
$486.03 Each
1 Ankle Per 2 Years
Ottobock Child SACH Adaptor With
Pyramid
2R40
1 Ankle Per 2 Years
Ottobock SACH
Adaptor With Pyramid Titanium 2R31
1 Ankle Per 2 Years
Shaped Wood Ankle Block 2K35
Ottobock Single Axis Ankle
Aluminium 2R51
2- 4
1 Ankle Per 2 Years
Titanium 2R33
Trulife Ankle
Child's Ankle Block SAB313/312/311
1 Ankle Per 2 Years
Truper Ankle
Endoskeletal Ankle
1 Ankle Per 2 Years
Exoskeletal Ankle
Growth in height/length, expect 3 yr. if start at size 16
###
Feet
College Park Trustep
1 Foot Per 2 Years
2- 4
P890
$1,755.44 Each
3-4
P914
$2,277.36 Each
3-4
P389
$4,607.51 Each
LP Vari-Flex Foot
3-4
P065
$2,047.19 Each
LP Vari-Flex Pyramid
3-4
P066
$2,663.19 Each
Modular III
3-4
P909
$3,055.19 Each
Elation (aka Total Concept)
Flex Foot
Ceterus Foot
1 Foot Per 2 Years
1 Foot Per 2 Years
Shock/Torque Absorber Not Required.
Please note repair criteria at end of schedule. When repair involves removal
of costmetic skin, AADL will pay for only 1 hour to remove and replace
cosmetic skin without prior approval.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-16
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Functional
Level
Cat. No.
4
P885
$4,981.59 Each
Sure Flex With Pyramid
1-4
P901
$780.43 Each
Variflex with split toe
3-4
P900
$2,047.19 Each
3-4
P475
$3,498.71 Each
3-4
N171
$3,726.07 Max. Each
2- 4
N172
$2,091.44 Max. Each
2- 4
N174
$4,981.59 Max. Each
1-4
N170
$3,039.37 Max. Each
1-4
N173
$1,207.15 Max. Each
2- 4
P875
$1,811.15 Each
1-4
P011
$3,004.65 Each
1E50 Advantage DP2
3-4
P026
$2,630.71 Each
Axtion 1E56
2- 4
P521
$2,126.16 Each
Child Dynamic 1K10
2- 4
P891
$425.39 Each
C-Walk Carbon 1C40
3-4
P904
$3,314.48 Each
Dynamic Foot With Toes 1D10
2- 4
P559
$511.63 Each
Trias 1C30
2- 4
P549
$1,268.79 Each
2- 4
P915
$2,259.85 Each
2- 4
P893
$504.57 Each
2- 4
P905
$503.29 Each
2- 4
P894
$478.31 Each
Qty. / Freq.
AADL Price
###
Feet
Flex Foot
Reflex V.S.P. S/T
1 Foot Per 2 Years
Please note repair criteria at end of schedule
Freedom Innovations Renegade
Generic Foot
Adjustable
1 Foot Per 2 Years
1 Foot Per 2 Years
See Generic Pricing Procedure
Articulated
See Generic Pricing Procedure
Complex
See Generic Pricing Procedure
Permanent
See Generic Pricing Procedure
Simple
See generic pricing procedure
Magnum Heavy Duty System
250-350 lbs.
1 Foot Per 2 Years
Ottobock Foot
1C20 Pro Symes
1 Foot Per 2 Years
Springlite Chopart/Syme's
1 Foot Per 2 Years
Trulife
Lifecast SFH110
1 Foot Per 2 Years
Trulife Foot
Carbon Lightfoot SCF185
1 Foot Per 2 Years
Child's Play SLF132
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-17
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
2- 4
P550
AADL Price
###
Feet
Trulife Foot
Lightfoot SLF160
1 Foot Per 2 Years
$503.29 Each
###
Additions to Feet
Spectra sock can be provided in addition to other catalogue items in this group.
College Park Trustep Foot Shell
Flex Foot Spectra Sock
Junior Foot Shell
Ossur Flex Foot Foot Shell
2 Per 12 Months
2- 4
P217
$162.65 Each
1-4
P246
$70.81 Each
2- 4
P043
$198.59 Each
2- 4
P265
$216.41 Each
1-4
P198
$627.56 Each
2- 4
P215
$272.41 Each
3 Per 12 Months
2 Per 12 Months
2 Per 12 Months
Ottobock Syme's Kit
1P5 - 1P9
1 Per 2 Years
Springlite Foot Shell
2 Per 12 Months
###
Foot Plates
Silipos Comfortzone Double Socket Gel
Liner
Springlite Inserts
Foot Plate
6 Per 12 Months
1-4
P678
$107.88 Each
1-4
P675
$264.45 Each
2 Per 12 Months
###
Hip Joints
Any comparable quality system to below listed items may be substituted with AADL prior approval
External Pelvic Joint
1 Hip Joint Per 2 Years
1-4
P392
$749.66 Each
1-4
P850
$3,522.02 Each
1-4
P848
$1,314.16 Each
7E5
1-4
P849
$1,423.92 Each
7E7
1-4
P847
$2,466.64 Each
1-4
P716
$2,110.14 Each
Hip Joint
TGH-01
1 Hip Joint Per 2 Years
Ottobock Hip Joint
7E4
1 Hip Joint Per 2 Years
Trulife Littig Hip Disarticulation System
Adult
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Hip Joint Per 2 Years
APL P-18
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Hip Joints
Any comparable quality system to below listed items may be substituted with AADL prior approval
Trulife Littig Hip Disarticulation System
Pediatric - P28455 to P28464
1 Hip Joint Per 2 Years
1-4
P714
$1,883.01 Each
###
Additions to Hip Joints
Stainless Steel Pelvic Band
1 Per 2 Years
1-4
P177
$80.83 Each
###
Finishing
Endoskeletal Finish
Hip Disarticulation (HD) P-CF-72
1 Finish Per 2 Years
1-4
P082
$1,673.99 Each
Knee Disarticulation (KD) CF-42
1-4
P062
$1,098.74 Each
Proximal Femoral Focal Deficiency (PFFD)
1-4
P034
$1,054.14 Each
Transfemoral (TF)
1-4
P575
$1,142.99 Each
Transtibial (TT)
1-4
P052
$733.40 Each
1-4
P013
$557.73 Each
Knee Disarticulation (KD) P-CF-41
1-4
P025
$1,514.28 Each
Proximal Femoral Focal Deficiency (PFFD) P-CF-61
1-4
P032
$1,514.28 Each
Transfemoral (TF)
1-4
P028
$1,514.28 Each
Transtibial (TT)
1-4
P019
$994.89 Each
Exoskeletal Finish
Ankle Disarticulation (AD) P-CF-21
1 Finish Per 2 Years
###
Additions to Finishing
"Upgrade" indicates a product whose cost exceeds the AADL maximum contribution, and any additional cost is a
client's choice and responsibility.
Generic Cosmetic Skin - Silicone or
Equivalent
AK
4 Cosmetic Skins Per
12 Months
1-4
N183
$410.19 Max. Each
1-4
N182
$342.99 Max. Each
1-4
P495
$80.06 Each
1-4
P488
$74.11 Each
Upgrade
BK
Upgrade
Ottobock Prosthetic Underhose
99B14 TF
99B16 TT
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
4 Per 12 Months
APL P-19
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
5-7
P284
$348.52 Each
5-7
P281
$934.25 Each
AADL Price
##
Additions to Lower/Upper Limb Procedures
1 Per 2 Years
Leather Socket
1 Per 2 Years
Split Socket Design
###
Shrinker Socks - Upper Limb
Shrinker Sock - Upper Limb
3 Socks Per 12 Months
5-7
P534
$165.95 Each
###
Upper Limb Socket Procedures
Please refer to Lower Limb Prosthetic Benefits Section for the following:
 Additions to Upper Limb Procedures
Suspension Sleeves and Additions to Suspensions
Gel Cushion Liners
Gel Locking Liners
Additions to Liners
Spacer Socks
Socket Inserts
Suction Valves
Lock Systems and Additions to Lock Systems
Blocks and Laminate-in Adaptors
Physician Prescription Required (except P122).
Check Socket
2 Check Sockets Per 2
Years
Upper Extremity
5 - 7, or 9
P122
$652.74 Each
5-7
P285
$2,764.71 Each
Fore Quarter
5-7
P294
$4,461.14 Each
Plastic Hand Socket With Wrist and 4 Fingers
5-7
P278
$3,440.02 Max. Each
5-7
P290
$3,288.43 Each
5 - 7, or 9
P287
$2,548.57 Each
5-7
P282
$2,013.60 Each
5 - 7, or 9
P280
$2,273.37 Each
Definitive Socket
Elbow Disarticulation (ED)
1 Procedure Per 2 Years
See generic pricing procedure
Shoulder Disarticulation (SD)
Transhumeral (TH)
Transradial (TR)
Wrist Disarticulation (WD)
###
Terminal Devices
Becker Imperial
50316
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
2 Terminal Devices Per
2 Years
6-7
P351
$961.40 Each
APL P-20
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Functional
Level
Cat. No.
5-7
N181
$718.42 Max. Each
6-7
N180
$1,798.38 Max. Each
Hook - 55009 Model 5X
6-7
P315
$515.48 Each
Hook 55059 Model 555
6-7
P334
$610.40 Each
Passive Hand
5-7
P358
$354.25 Each
Passive Hand 8K18
5-7
P359
$718.42 Each
Physolivo Baby Hand - Hand, glove and wrist unit 8K14=1
6-7
P721
$1,512.56 Each
Voluntary Opening 8K23
6-7
P361
$652.34 Each
Grip Adult
6-7
P367
$1,883.89 Each
Infant Hand-Passive
6-7
P526
$583.83 Each
Qty. / Freq.
AADL Price
###
Terminal Devices
Generic Terminal Device
2 Terminal Devices Per
2 Years
Passive
See Generic Pricing Procedure
Standard
See Generic Pricing Procedure
Hosmer Terminal Device
Ottobock Terminal Device
TRS Terminal Device
2 Terminal Devices Per
2 Years
2 Terminal Devices Per
2 Years
2 Terminal Devices Per
2 Years
###
Gloves for Hands
Generic Multi-Articulating Glove for
Myoelectric Hand
2 Gloves Per 12 Months
9
N186
$1,132.81 Max. Each
5 - 7, or 9
P368
$414.05 Each
5-7
P366
$420.55 Each
5 - 7, or 9
P364
$321.71 Each
5-7
P882
$656.59 Each
See Generic Pricing Procedure
Hosmer Glove
57586
2 Gloves Per 12 Months
Leather Glove
NGL006-PR
2 Gloves Per 12 Months
Ottobock Glove
8S5
2 Gloves Per 12 Months
Regal Passive Glove
2 Gloves Per 12 Months
###
Hand Restoration
Partial Hand
Glove for Thumb or Finger
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Procedure Per 2 Years
5-7
P369
$1,328.12 Each
APL P-21
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
5-7
P370
$1,339.09 Each
5-7
N185
$1,057.82 Max. Each
AADL Price
###
Hand Restoration
Partial Hand
Multiple Fingers
1 Procedure Per 2 Years
Regal Custom Glove
1 Procedure Per 2 Years
See generic pricing procedure
###
Wrist Units
Any comparable quality system to below listed items may be substituted with AADL prior approval
Generic Wrist Unit
1 Wrist Per 2 Years
7
N140
$1,137.98 Max. Each
5-7
P376
$197.90 Each
CAPP Nylon Body 1-3/4" 55109
5-7
P375
$197.90 Each
CAPP Nylon Body 2" 55110
5-7
P374
$197.90 Each
7
P868
$472.31 Each
Flexion Friction Wrist 51100 FW 500 (2")
6-7
P400
$375.53 Each
Nylon Friction Wrist - 52156 WE 200N (1-1/2") or 300N (13/4")
5-7
P388
$199.97 Each
Nylon Friction Wrist - 52160 WE 500N
5-7
P387
$199.97 Each
Quick Disconnect 52127 WD 400
7
P383
$281.13 Each
Quick Disconnect Wrist 51043 FM 100
7
P380
$304.93 Each
Quick Disconnect Wrist All Stainless 53896 WD 400SS
7
P386
$665.73 Each
Quick Disconnect Wrist Stainless Steel 51044 FM 100S
7
P382
$642.05 Each
Quick Disconnect Wrist Stainless Steel 52128 WD 400S
7
P384
$397.33 Each
WE 100N Infant
5-7
P395
$185.24 Each
WE 200N 1-1/2" Nylon Friction 52147
5-7
P390
$199.97 Each
7
P527
$3,127.28 Each
6-7
P528
$174.08 Each
Requires flexion/extension capability combined with rotation/quick
disconnect. Cannot be combined with P377.
See Generic Pricing Procedure
Hosmer Wrist
CAPP Nylon Body 1-1/2" 55108
1 Wrist Per 2 Years
Child Quick Disconnect Wrist 58151
N-Abler Wrist Unit
1 Wrist Per 2 Months
Bi-lateral upper limb, used for dominant hand.
TRS Wrist
Infant Wrist
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Wrist Per 2 Years
APL P-22
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
6-7
P377
$495.43 Each
5-7
P408
$86.56 Each
5-7
P409
$139.20 Each
AADL Price
###
Additions to Wrist Units
Sierra Wrist Flexion - Friction Wrist
52371
1 Per 2 Years
Wrist Unit Inserts
Aluminum - 50527
1 Per 2 Years
Stainless Steel - 50528
###
Elbows
1 Elbow Per 2 Years
Generic Elbow Hinge
Single Axis Below Elbow
6-7
N190
$827.00 Max. Each
6-7
P412
$831.35 Each
50650 E-400
6-7
P411
$912.55 Each
External Locking Elbow Hinges 53885
5-7
P423
$1,327.58 Each
HD 50613 E-200
6-7
P507
$893.06 Each
HD 50653 E-400
6-7
P506
$912.55 Each
Outside Locking Hinge - Heavy Duty 50950
5-7
P420
$1,669.52 Each
Outside Locking Hinge 50776
5-7
P416
$1,277.80 Each
Power Bow 60665 E 400
6-7
P737
$1,703.77 Each
Single Axis Below Elbow Hinge - Long 51856
5-7
P435
$831.48 Each
6-7
E508
$4,377.83 Each
ErgoArm Elbow With Forearm 12K44
6-7
P332
$4,638.79 Each
Modular 12R1
5-7
E512
$557.49 Each
See Generic Pricing Procedure
1 Elbow Per 2 Years
Hosmer Elbow
50606 E-200
Ottobock Elbow
ErgoArm Elbow with Forearm - 12K42
1 Elbow Per 2 Years
###
Shoulder Joint
Generic Shoulder Joint
1 Shoulder Joint Per 2
Years
Abduction
5-7
N191
$672.78 Max. Each
5-7
N192
$666.51 Max. Each
5-7
P444
$683.59 Each
5-7
P447
$663.65 Each
See Generic Pricing Procedure
Flexion - Abduction
See Generic Pricing Procedure
Hosmer Shoulder Joint
Abduction - Adult 51836
Flexion Abduction - Adult 51010
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 2 Years
APL P-23
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
5-7
P449
AADL Price
###
Shoulder Joint
Hosmer Shoulder Joint
Universal - 52028 USJ-100
1 Per 2 Years
$647.58 Each
###
Universal Shoulder Joint
Generic Shoulder Joint
1 Shoulder Joint Per 2
Years
Universal
5-7
N193
$666.51 Max. Each
See Generic Pricing Procedure
###
Control Cables
Hosmer Cable Control
55683
2 Per 2 Years
Hosmer Elbow Cable
50724
2 Per 2 Years
Hosmer Hook To Cable Adaptor
50444
2 Per 2 Years
Teflon Lining
2 Per 2 Years
6-7
P455
$331.21 Each
5-7
P169
$242.68 Each
6-7
P456
$120.78 Each
6-7
P454
$99.22 Each
###
Upper Limb Suspension/Gel Liners
Any comparable quality system to below listed items may be substituted with AADL prior approval
Iceross Upper Limb
Ottobock 14Y1 Silicone Arm Liner
2 Per 12 Months
5 - 7, or 9
P533
$817.42 Each
5-7
P529
$732.30 Each
2 Per 12 Months
###
Upper Prosthetic Suspension
Auxila Loop
50115
2 Per 12 Months
Elbow Hinge - Flexible Using Leather Or
Dacron
LH100
1 Per 2 Years
Epicondylar Suspension
1 Per 2 Years
Expandable Wall Design
Flexible Elbow - Metal
HFH-6
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
5 - 7, or 9
P509
$113.22 Each
5-7
P476
$92.02 Each
5 - 7, or 9
P115
$320.10 Each
5 - 7, or 9
P483
$713.84 Each
5-7
P477
$792.65 Each
1 Per 2 Years
1 Per 2 Years
APL P-24
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Functional
Level
Cat. No.
5-7
P468
$162.32 Each
Figure 8
5-7
P462
$351.56 Each
Figure 8 With Olecrannon
5-7
P464
$395.81 Each
Figure 9
5-7
P463
$301.62 Each
6-7
P478
$306.02 Each
7 or 9
P530
$344.66 Each
5-7
P460
$415.01 Each
6-7
P480
$423.79 Each
7
P532
$126.26 Each
7
P531
$418.58 Each
5 - 7, or 9
P466
$778.73 Each
5-7
P479
$120.75 Each
5 - 7, or 9
P249
$177.01 Each
5-7
P470
$273.39 Each
5-7
P472
$260.38 Each
5-7
P458
$329.33 Each
Qty. / Freq.
AADL Price
###
Upper Prosthetic Suspension
Harness
Chest
2 Per 12 Months
Hosmer 50752 Forearm Lift Assist
E46O R&L
1 Per 2 Years
Icelock Ratchet
721
1 Per 2 Years
North Western Ring Harness
NRH-100
2 Per 12 Months
Nudge Control
52521
1 Per 2 Years
Ottobock Lock Pin
14A107
1 Per 2 Years
Ottobock Lock Set
14A1
1 Per 2 Years
Shoulder Saddle
HD100L
1 Per 12 Months
Suction Housing
20004
1 Per 2 Years
Suction Procedure - Upper Limb
1 Per 2 Years
Tricep Cuff - Full
BEC 360
1 Per 12 Months
Tricep Cuff - Half
BICEPS 320
1 Per 12 Months
Tricep Cuff Laminated
BEC160
1 Per 2 Years
###
Upper Limb Finishing
Endoskeletal Finish
Fore Quarter (FQ)
1 Per 2 Years
5-7
P304
$1,283.04 Each
Shoulder Disarticulation (SD)
5-7
P301
$1,283.04 Each
Transhumeral (TH)
5-7
P298
$973.29 Each
Transradial (TR)
5-7
P279
$629.03 Each
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-25
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Functional
Level
Cat. No.
5-7
P292
$929.04 Each
5-7
P289
$1,658.97 Each
Transradial (TR)
5-7
P277
$859.53 Each
With Arm Sections - Fore Quarter (FQ)
5-7
P302
$2,446.36 Each
With Arm Sections - Shoulder Disarticulation (SD)
5-7
P299
$2,446.36 Each
With Forearm - Transhumeral (TH)
5-7
P293
$1,703.97 Each
Wrist Disarticulation (WD)
5-7
P252
$764.43 Each
Qty. / Freq.
AADL Price
###
Upper Limb Finishing
Endoskeletal Finish
With Forearm - Elbow Disarticulation (ED)
1 Per 2 Years
Exoskeletal Finish
Elbow Disarticulation (ED)
1 Per 2 Years
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-26
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Myoelectric Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Upper Limb Myoelectric Prosthesis
Criteria - Adults
Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be
discussed with AADL.
Criteria - Children
Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.
Must child must be at least 2 years old.
1. Clients are eligible for a conventional OR Myoelectric prosthesis.
2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.
3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by
AADL.
4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception:
Electrodes).
5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for
approval. AADL will provide the maximum contributions and client upgrade costs.
6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement
prosthetic device.
7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.
8. Repairs over $800 contact AADL for prior approval.
1 Per 3 Years
4 Channel Processor
Allows switching of operation modes for control with the wrist
rotator or locking/unlocking the elbow
Batteries
Battery Chargers
Battery Mounting Set
Connection Cables
9
P852
Prior Approval
9
P813
Prior Approval
9
P818
Prior Approval
9
P865
Prior Approval
9
P825
Prior Approval
9
P722
$1,658.34 Each
9
P836
Prior Approval
9
P837
Prior Approval
9
P863
Prior Approval
9
P838
Prior Approval
2 Per 2 Years
1 Per 4 Years
1 Per 3 Years
3 Per 3 Years
1 Per 12 Months
Custom Upper Extremity Liner
- Diagnostic liner (88L3=P)
- TR Silicone liner with Ottobock fixation (88L1=BA)
- TH Silicone liner with OB fixation (88L1=OA)
For use with myeoelectric electrodes.
Elbow
Electric Hands & Hooks
Electric Wrist Rotators
Electrodes
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
1 Per 3 Years
1 Per 3 Years
1 Per 3 Years
2 Per 3 Years
APL P-27
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Myoelectric Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Upper Limb Myoelectric Prosthesis
Criteria - Adults
Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be
discussed with AADL.
Criteria - Children
Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.
Must child must be at least 2 years old.
1. Clients are eligible for a conventional OR Myoelectric prosthesis.
2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.
3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by
AADL.
4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception:
Electrodes).
5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for
approval. AADL will provide the maximum contributions and client upgrade costs.
6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement
prosthetic device.
7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.
8. Repairs over $800 contact AADL for prior approval.
MyoWrist Flexion Unit
10V40
1 Per 3 Years
9
P940
Prior Approval
9
P864
Prior Approval
9
P860
$3,097.50 Each
SH finishing included
9
P862
$4,779.00 Each
TH finishing included
9
P861
$2,964.75 Each
TR finishing included
9
P859
$1,991.25 Each
WD Finishing Included
9
P858
$2,124.00 Each
9
P839
Prior Approval
9
P853
Prior Approval
1 Per 12 Months
Recycle of Myoelectric Component
Cost of rebuilt component by manufacturer, shipping, plus
labour hours to disassemble and install into new prosthesis.
Socket costs above conventional socket
ED finishing included
Switch Control
1 Per 3 Years
1 Per 2 Years
1 Per 3 Years
Wrist Units
Includes: Lamination Ring, Coupling Ring, Coaxial Plug
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-28
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Prosthetic Soft Supplies and Fees
Qty. / Freq.
Functional
Level
Cat. No.
1-7
P783
$113.49 Max. Each
1-7
P583
$40.01 Max. Each
AADL Price
###
Socks
12 Per 12 Months
Prosthetic Socks
Custom-made
See generic pricing procedure
In Catalogue
See generic pricing procedure
###
Donning Aids
2 Per 12 Months
Easy Proth
1-4
P410
$73.22 Each
###
Sheaths
12 Per 12 Months
Daw Prosthetic Sheath
1-7
P489
$35.98 Each
1 - 7, or 9
P486
$18.10 Each
1-7
P580
$52.63 Max. Each
SA332 - Regular
2-7
E700
$49.70 Each
SA333 - Active
2-7
E701
$71.03 Each
12 Per 12 Months
Prosthetic Sheath
12 Per 12 Months
Prosthetic Sheath In Catalogue
Dealer cost plus $11.73
Silo Sheaths
8 Sheaths Per Limb Per
12 Months
###
Other Fees
Consult with Client and Multidisciplinary
Team
4 Per 12 Months
1 - 7, or 9
P937
$177.00 Per Hour
1 - 7, or 9
P938
$177.00 Per Hour
One hour per client at $177.00
Available to private prosthetic facilities only
Off-Site Facility Fee
1 Per 12 Months
One hour per client at $177.00
Invoice for only one off site fee /per client/ per device. Available to all
prosthetic facilities.
Document on the benefit note: the name of off-site facility, device, and reason
for off-site fee.
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-29
#Name?
Alberta- Health
- Professional
Services
and
Health Benefits
Benefits
Alberta Health
Professional
Services
and
Health
Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Prosthetic Soft Supplies and Fees
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
###
Prosthetic Repairs
1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement prosthetic
device.
2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.
3. Repairs over $800 contact AADL for prior approval
4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be
deducted from the initial procedure on the cost of the new device.
5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and
replace cosmetic skin.
6. Activities not considered a repair benefit:
trialling new components.
trimming/mods to NEW gel liners.
gait training.
7. Shipping and Brokerage Fees where a device or component is:
under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials",
and no "shipping or brokerage fees".
under warranty and being replaced, it must be provided under the appropriate AADL catalogue number
(shipping and brokerage fees are already included).
not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included
under P693.
Labour
12 Hours Per 12 Months
1-7
P492
$177.00 Per Hour
1-7
P693
$300.00 Max. Each
9
P855
$177.00 Per Hour
9
P857
$300.00 Each
Indicate on invoice # of hrs. & total $ of hrs. only
Documentation required:
- Describe repair/mods.
- # of hrs. and cost
- Total cost of repair (hrs.+ materials)
- % of total repair cost of device/component
Materials
6 Repairs Materials Per
12 Months
Invoice quantity = 1 per repair/modifications
Qty of 1 is up to a maximum of $300
Documentation required: List of materials and cost
Myoelectric Labour
12 Hours Per 12 Months
Indicate on invoice # of hrs. & total $ of hrs.
Document:- Describe repair/mods.
- # of hrs. and cost
- Cost of materials
- Total cost of repair (hrs.+ materials)
- % of total repair cost of device/component
Myoelectric Materials
6 Repair Materials Per
12 Months
Materials - Invoice qty. = 1 per repair/modifications.
Documentation required:
List of materials and cost
Qty of 1= $300.00
© 2013 Government
of
© 2014 Government of Alberta
Alberta April
1,
2014
April 1, 2014
APL P-30
#Name?