Alberta Health AADL Approved Product List - Seating Benefits Pricing effective April 1, 2014 Revision History Updates to Catalogue Numbers (see inside) 4/1/2014 Updated: Approved Seating Manufacturers 4/1/2014 Updated: APL Format 4/1/2014 © 2013 Government of Alberta April 1, 2014 Alberta Health - Professional Services and Health Benefits AADL Seating Approved Product List General Information for Seating Benefits AADL clients are eligible for one seating system. If clients have more than one mobility base and the components cannot be transferred, the client is responsible for the costs of the duplicate components. Benefits listed on the AADL Seating Approved Product List can only be authorized by designated AADL Seating Authorizers. Two levels of Seating Clinics: Level I Seating Clinics Provide commercially available seating components in conjunction with an AADL Seating Vendor who has a Commercial Seating Technician. Level II Seating Clinics Provide custom-fabricated seating components in conjunction with AADL Seating Vendors who has a Adaptive Seating Technician. The prices listed in the AADL Seating Approved Product List are as follows: Level I The price is the manufacturer retail price less a 5% discount. Level II The price represents the combined cost for materials and labour. Some Level I catalogue numbers are designated as generic catalogue numbers. Generic catalogue numbers are a benchmark pricing model. Each catalogue number has a price maximum. Seating vendors must provide an item that meets the description at or below the price maximum. The price maximum is based on the manufacturer's retail price, less a 5% discount. Seating vendors must apply a 5% discount when using the generic catalogue numbers. Costs over the AADL price maximum are considered an upgrade and are the client's responsibility. © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 2 of 36 APL X-1 Alberta Health - Professional Services and Health Benefits AADL Seating Approved Product List General Catalogue Number Information These catalogue numbers are used to provide commerically-available seating components for which there is no specific catalogue number. The equipment provided using a generic catalogue number must meet the following criteria: Product must be available from an AADL Approved Seating Manufacturer. Product must meet the AADL Commercial Seating Product Minimum Standards. AADL Commercial Seating Product Minimum Standards Warranty – The manufacturer must warrant that the product will be free from defects in material and workmanship for the below noted minimum years from the date the equipment was purchased: Bases: 2 years Lateral Supports: 2 years Headrests: 2 years Pommels: 1 year Straps/Belts: 1 year Bolsters, Adductors/Abductors: 1 year Wedges: 1 year Foot/Leg Supportss: 1 year Arm/Shoulder Supports: 1 year Trays: 1 year Backs: 2 years Equipment Limitations – Equipment must have been in production for a minimum of one year in the North American market. Liability Insurance – Equipment provided must have a minimum two million dollars comprehensive general liability insurance provided by the manufacturer. Fire Retardancy – Materials must meet at least the California 117 Fire Retardancy Standard. Pricing Example: Generic Catalogue Number Y-Belt Manufacturer’s retail price = $85 Pricing procedure: $85 – 5% = $80.75 AADL Maximum Contribution = $80.75 (for cost-share exempt clients) Cost-Share Client portion (25%) = $80.75 x 25% = $20.19 AADL portion for cost-share client = $80.75 x 75% = $60.56 © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 3 of 36 APL X-2 Alberta Health - Professional Services and Health Benefits AADL Seating Approved Product List AADL Approved Seating Manufacturers Manufacturer Manufacturer Representative Contact Email Bodypoint Brandon Strap [email protected] Tom Corbett [email protected] Invacare Power Plus Mobility Jason Mohan [email protected] Brandon Strap [email protected] Braden Hirsch [email protected] ROHO Varilite © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 4 of 36 APL X-3 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 01. Headrests, Neckrests, Hardware & Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X062 $189.70 Max. Each X331 $46.46 Max. Each X045 $186.73 Max. Each Generic Commercial Seating Component - Use generic pricing method Adaptor Kit or Mounting Plate for Headrest/Neckrests Clamp To mount headrest or other seating component Hardware for Headrest/Neckrest 1 Kit or Plate Per 4 Years 2 Clamps Per 4 Years 1 Headrest Hardware Per 4 Years This catalogue number is only for the hardware for a headrest, combine with X015 if required. Headrest/Neckrest Headrest with Lateral Support 1 Headrest Per 4 Years X035 $171.91 Max. Each X040 Prior Approval No hardware included, combine with X045 if required. Specialized Headrest Includes hardward, cannot be combined with X045. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Standard Headrest or Neckrest X015 $153.14 Max. Each X688 $82.76 Each X687 $82.76 Each X690 $174.41 Each X436 $173.85 Each X435 $337.25 Each X437 $52.25 Each X442 $199.50 Each I202 $38.95 Each X486 $285.00 Each No hardware included, combine with X045 if required. Daher Headrest Combination Headrest HC100 1 Headrest Per 4 Years Large Headrest HL100 Headrest Hardware WS10 1 Hardware Per 4 Years Future Mobility Headrest Multi-axial Headrest - On Chair 1 Headrest Per 4 Years Single Multi-axial Headrest, large foam pad and cover (no wings) includes hardware - Off Chair Headrest Extension Multi-axial Headrest Horizontal Extension 1 Extension Per 4 Years Headrest Hardware Multi-axial Universal Hardware 1 Hardware Per 4 Years Invacare Elite Back Headrest Adaptor 1 Adaptor Per 4 Years Jay Headrest Jay 3 AXYS Mount © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Headrest Per 4 Years Page 5 of 36 APL X-4 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 01. Headrests, Neckrests, Hardware & Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X487 $522.50 Each X491 $57.00 Each X463 $342.00 Each X467 $95.00 Each X522 $171.91 Each Soft Headrest 430H2 X391 $153.14 Each Styles Lg/Sm 430C1 = 1-7/3-7, or 430H1 = 1-7/3-7 X069 $105.72 Each X868 $189.70 Each X386 $196.61 Each X078 $186.73 Each Jay Headrest Jay 3 COBRA Mount 1 Headrest Per 4 Years Headrest mount Jay 3 back universal 1 Headrest Mount Per 4 Years Maple Leaf Wheelchair Headrest Mounting plate not included Headrest Mounting Plate 1 Headrest Per 4 Years 1 Plate Per 4 Years Ottobock Headrest Lateral Control Headrest 430C2 1-7/3-7 Headrest Adpator Kit 476D52 SK010/015/020/025/060/065 1 Headrest Per 4 Years 1 Adaptor Kit Per 4 Years 1 Hardware Per 4 Years Headrest Hardware Gooseneck Mounting Kit 476L52-SK030 or Straight Mounting Kit 476L52-SK035 Multi-Axis Offset or Multi-Axis Straight Mounted to wheelchair insert, can be used for neckrest also 476L52-SK020/025/010/015 Headrest Hardware Adaptor Kit 1 Adaptor Kit Per 4 Years X079 $227.24 Each Mounted to wheelchair uprights to back tubes of W/C using STS clamps 476D52-SK020/030/035/040/045/05 Headrest Hardware Clamp For any back (477152=SK039) 1 Clamp Per 4 Years STS Clamps 477D52/434H1 2 Clamps Per 4 Years X969 $47.65 Each X387 $46.46 Each I210 Prior Approval X364 $186.20 Each X365 $376.20 Each To attach headrest hardware Stealth Stealth i2i Headrest 1 Headrest Per 4 Years Prior Approval. Submit spec sheet/pricing and clinical rationale to AADL. Western Home Medical Cane Mount Bracket Bracket Only Including Aspen2 Headrest © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Bracket Per 4 Years Page 6 of 36 APL X-5 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 01. Headrests, Neckrests, Hardware & Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X196 $304.00 Each Adjustable offset. Aspen1 & Aspen2 X195 $333.45 Each With multi-axle hardware 5470 - Aspen1 X428 $337.25 Each With multi-axle hardware 5471 - Aspen2 X429 $337.25 Each Western Home Medical Headrest Adjustable chair mount, Oxford 1 system 1 Headrest Per 4 Years Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X348 $177.93 Each X606 $188.90 Each 1 Headrest Per 4 Years Headrest Headrest with lateral support, wood rigid shell, foam and covering with movable lateral extension X003 $352.33 Each With lateral support, kydex shell, foam and covering with movable lateral extension X378 $508.91 Each X072 $105.93 Each X449 $426.76 Each X010 $361.89 Each Custom-Made Hardware for Custom-Made Headrest Multi-axial 1 Hardware Per 4 Years Standard Headrest Cover (replacement only) Removable Cover 1 Cover Per 12 Months For replacement only Headrest/Neckrest Rigid kydex shell, foam and covering, occipital support Rigid wood shell, foam and covering, occipital support © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Headrest Per 4 Years Page 7 of 36 APL X-6 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 02. Straps, Belts & Kits Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price 1 Strap Per Leg Per 12 Months Calf Strap or H Strap Posterior support for bilateral/positioning of the lower legs. X065 $92.15 Max. Each 1 Chest Strap Per 12 Months Chest Strap Chest Harness, Butterfly Strap, or H-Strap, for torso/thoracic positioning X225 $120.00 Max. Each X954 $28.50 Max. Each X107 $24.70 Max. Each X070 $92.63 Max. Each X227 $156.75 Max. Each X971 $185.25 Per Pair X498 $97.85 Each X393 $192.85 Each X664 $104.50 Each X427 $156.75 Each X426 $127.30 Each X414 $85.50 Each X691 $86.64 Each X347 $99.23 Each X420 $173.85 Each X484 $189.05 Each Generic Commercial Seating Component - Use generic pricing method 1 Footstrap Per Foot Per 12 Months Footstrap/Toe Loop Transverse Strap for positioning of foot 1 Kit Per 12 Months Hardware Kit for Belt Heel Loop/Ankle Strap Strapping mechanism to secure ankle/foot. 2 Per 12 Months Pelvic Strap Y or K Strap/Belt, for pelvic positioning. 1 Per 12 Months Bodypoint Ankle Huggers Medium/large 1 Pair Footstraps Per 12 Months Chest Strap MonoFlex anterior trunk support 1 Chest Strap Per 12 Months Stayflex Anterior Trunk Support - with or without zipper 1 Leg Strap Per 2 Years Leg Harness HB 602/603/604 1 Pelvic Belt Per 12 Months Pelvic Belt 4 point centre pull - small/med/large HB501CHB502C HB503C Padded Hip Belt 2 point centre pull - small/med HB104C Universal Strap 1 Strap Per 2 Years Daher Chest Harness Small, medium, large 1 Chest Strap Per 4 Years Pelvic Belt K/Y Belt - 2" 1 Pelvic Belt Per 12 Months Jay AES Structured Y Shoulder Strap Chest Strap Jay 3 Chest Straps/Harnesses © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Trunk Support Per 12 Months 1 Chest Strap Per 12 Months Page 8 of 36 APL X-7 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 02. Straps, Belts & Kits Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X405 $283.56 Each X998 $66.50 Each X962 $106.88 Each X948 $47.50 Each K Belt, padded/black webbing & hardware N4.027 X944 $114.00 Each K Belt, padded/black webbing N4.028 X945 $109.25 Each Y Belt with safety/black webbing & hardware N4.021 X938 $114.00 Each X445 $74.58 Each X590 $131.10 Each Lecky 1 Chest Strap Per 12 Months Waistcoat Nighthawk Chest Strap Female medium/large, male small/med/large 1 Chest Strap Per 12 Months Padded Chest Strap N4.037 Pelvic Belt Black webbing N4.031 1 Pelvic Strap Per 12 Months Western Home Medical 1 Chest Strap Per 12 Months Chest Strap Butterfly Shoulder Harness - Small, small slim, med., med. slim, large, large slim Hip Belt Padded hip belt dual rear pulll #5035 1 Pelvic Strap Per 12 Months Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X109 $96.02 Each X119 $96.03 Each X117 $96.02 Each X038 $104.29 Each X113 $208.50 Each Horizontal strap to assist upper trunk control X041 $102.26 Each H-Strap, to assist upper trunk control. X031 $164.42 Each V-Strap, to assist upper trunk control X111 $164.42 Each X106 $110.81 Each Custom-Made Abduction Strap 1 Strap Per Leg Per 12 Months Arm Strap To secure arm 1 Strap Per Arm Per 12 Months Axilia Strap Over-the-shoulder strap 1 Strap Per Arm Per 12 Months Calf Strap or H Strap Chest Strap Butterfly Chest Strap 1 Calf Strap Per Leg Per 12 Months 1 Chest Strap Per 12 Months To assist upper trunk control Footstrap/Toe Loop © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Strap Per Foot Per 12 Months Page 9 of 36 APL X-8 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 02. Straps, Belts & Kits Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X073 $119.11 Each X379 $117.18 Each X033 $143.50 Each X042 $110.81 Each X044 $101.90 Each Custom-Made Halo Strap or Fitted Head Strap Attached to headrest Padded option to strap 1 Halo Strap Per 12 Months 1 Padded Option Per Strap Per 12 Months Clients are eligible for a maximum quantity of 3. Pelvic Strap Basic Y-Strap 1 Pelvic Strap Per 12 Months Strap of webbing including closure Safety Strap To secure insert to mobility base © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Safety Strap Per 2 Years Page 10 of 36 APL X-9 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 03. Hooks, Brackets, Clips, Clamps & Links Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X331 $46.46 Max. Each X634 $26.30 Max. Each X108 $60.08 Max. Each X635 $14.90 Max. Each X138 $34.63 Max. Each X505 $46.07 Max. Each X110 $215.65 Max. Per Pair X193 $180.50 Per Pair I227 $142.50 Per Pair X192 $142.50 Per Pair X878 $81.17 Per Pair Generic Commercial Seating Component - Use generic pricing method Clamp To mount headrest or other seating component Drop Base Mount Clips Growth Bracket/Hardware 2 Clamps Per 4 Years 4 Per Back and Per Base Per 4 Years 1 Growth Bracket Per 4 Years 4 Hooks Per Back and Per Base Per 4 Years Twist Release (antigravity hooks), quantity 4 for base, and quantity 4 for back Hooks Locking Suspension Hook (L/R) Prefab component locks, insert to W/C Sliding 90 degree bracket Spacer Hardware 4 Hooks Per 3 Years 1 Sliding Bracket Per 3 Years 1 Pair Per 4 Years Future Mobility Back Mounting Brackets Bariatric 1 Pair Per 4 Years To transfer the back to 2nd W/C Lunar Back Brackets For second wheelchair Standard To transfer the back to 2nd W/C Invacare 2 Pairs of Hooks Per 3 Years Antigravity Hooks Quick Release Rail Clamp (anti-gravity hooks) 1063327 This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base. Twist Release (antigravity hooks) for Ultimate curved/Personal backs cane clamp 1063331/332 X615 $159.60 Per Pair X451 $268.85 Per Pair X452 $381.90 Per Pair X665 $215.65 Per Pair This is for replacement only. Back Mounting Brackets Matrx PB Brackets 1 Pair Per 4 Years To transfer back to 2nd W/C Matrx PB Brackets - heavy duty To transfer back to 2nd W/C. Fixed Spacer Hardware For Elite backs © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Pair of Spacers Per 4 Years Page 11 of 36 APL X-10 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 03. Hooks, Brackets, Clips, Clamps & Links Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X798 $60.08 Each X907 $32.49 Each Invacare Growth Bracket 5500043 1 Growth Bracket Per 4 Years Included with KSS. This is for replacement only. Hooks Drop Hooks 1063290-95 4 Hooks Per 3 Years This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base. Drop Hooks for curved back 1063318 (1") X616 $19.00 Each 1 Pair Per 4 Years Back Mounting Brackets For Jay 2, Jay 2 Deep, Jay Care Back - bottom universal post bracket 680C D395 X685 $89.30 Per Pair For Jay 2, Jay 2 Deep, Jay Care Back - top quick release 1/4 turn bracket 681C X669 $42.75 Per Pair X490 $281.20 Per Pair I216 $180.50 Per Pair X392 $185.25 Per Pair X457 $197.60 Per Pair Each. This is for replacement only. Jay To transfer back to 2nd W/C Jay 3 back hardware To transfer back to 2nd W/C nxt Back Mounting Brackets Back Brackets 1 Pair Per 4 Years To transfer back to 2nd W/C Ottobock Back Mounting Brackets Backrest Hardware 1 Pair Per 4 Years To transfer back to 2nd W/C Pride Mobility Back Mounting Brackets Synergy Shape Back Hardware 1 Pair Per 4 Years To transfer back to 2nd W/C © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 12 of 36 APL X-11 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 04. Lateral Supports, Hardware & Pads Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X214 $217.55 Max. Each X652 $104.50 Each X649 $114.95 Each X607 $435.10 Per Pair X485 $266.00 Per Pair X911 $46.46 Each X812 $118.56 Each X713 $117.57 Each Generic Commercial Seating Component - Use generic pricing method 1 Lateral Per Side Per 4 Years Thoracic Lateral Hardware and pad Invacare Matrx Elite Thoracic Lateral Off-Set 1 Lateral Per Side Per 4 Years Rigid Jay Jay 2 Thoracic Laterals Swing-Away 1 Pair of Laterals Per 4 Years Jay 3 Thoracic Laterals Fixed Laterals 1 Pair of Laterals Per 4 Years Ottobock 1 Clamp Per Side Per 4 Years OB STS Clamp 434H1=1 UPGRADE 1 Lateral Pad Per Side Per 4 Years OB STS Pad Large/med/small 434P1 STS Hardware Rod Assembly 1 Support Hardware Per Side Per 4 Years 434F1 Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X017 $164.39 Each X473 $212.65 Each X349 $349.95 Each Custom-Made Lateral Thoracic Support Lateral Support, rigid support, foam and covering 1 Lateral Per Side Per 4 Years Lateral Thoracic Support Rigid support, foam and covering-kydex curved 1 Lateral Per Side Per 4 Years Swing-Away © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 13 of 36 APL X-12 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 05. Hip Bolsters Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X112 $74.10 Max. Each X198 $74.10 Each Generic Commercial Seating Component - Use generic pricing method Lateral Pelvic Support/Hip Bolster 1 Support Per Leg Per 3 Years Western Home Medical 1 Bolster Per Side Per 3 Years Side Bolster Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X131 $208.15 Each Custom-Made Hip Bolster © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Bolster Per Side Per 3 Years Page 14 of 36 APL X-13 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 06. Wedges, Pommels, Abduction & Adduction Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X114 $142.50 Max. Each X118 $50.35 Max. Each X577 $378.10 Max. Each X115 $124.45 Max. Each X116 $49.40 Max. Each X308 $50.35 Each X306 $50.35 Per Pair Adductor 2" B113J or B163 X307 $58.90 Per Pair Base Wedge B114 X309 $124.45 Each Pelvic obliquity build-up B116R or L X520 $50.35 Each X464 $266.95 Each Generic Commercial Seating Component - Use generic pricing method Lateral Thigh Support/Adductors 1 Thigh Support Per Leg Per 3 Years Price to include pad and hardware if required. Obliquity Pad/Build-up/Fluid Supplement Pommel/Thigh Abductor 1 Addition Per 3 Years 1 Pommel Per 3 Years Price to include pad and hardware if required 1 Wedge Per 3 Years Seat/Base Full Wedge Hemi Wedge Jay Fluid Supplement F119 1 Fluid Supplement Per 3 Years Jay Seat Wedge Adductor 1" B119J 1 Pair of Adductors Per 3 Years Western Home Medical 1 Abductor Per 3 Years Abductor Flip-down Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X053 $178.52 Each X350 $667.46 Each Non-removable Pommel, rigid support foam covering and hardware for attachment of non-removable pommel X133 $226.77 Each Removable Pommel, rigid support foam covering inner/outer hardware X023 $310.18 Each Custom-Made Abduction Stop 1 Abduction Stop Per Side Per 3 Years Rigid shell, foam & covering 1 Pommel Per 3 Years Pommel Flip Down Pommel, rigid support foam covering inner/outer hardware © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 15 of 36 APL X-14 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 07. Sub-ASIS Bars & Belts Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X100 $415.17 Max. Each X105 $223.25 Max. Each X472 $223.25 Each 1 Sub-ASIS Belt/Bar Per 4 Years Swing Away Sub-ASIS Bar With mid relief, includes 2-90 degree Brackets, 1 universal swing away bracket, 1 X580 offset sub-asis bar with mid relief, 2 hours labour $415.17 Each Generic Commercial Seating Component - Use generic pricing method Sub-ASIS Bar Rigid Sub-ASIS pelvic control. 1 Sub-ASIS Belt/Bar Per 4 Years Client eligible for either X100 or X105 Sub-ASIS Belt Soft Sub-ASIS pelvic control. 1 Sub-ASIS Belt/Bar Per 4 Years Client eligible for either X100 or X105 Bodypoint 1 Sub-ASIS Belt/Bar Per 4 Years Sub-ASIS Belt Medial 4pt center pull Metalcraft Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X600 $419.29 Each Custom-Made Sub-ASIS Bar Semi-rigid Sub-ASIS Bar, or ACH Y-belt 1 Sub-ASIS Belt/Bar Per 4 Years To be added to X033 when appropriate. © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 16 of 36 APL X-15 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 08. Foot & Leg Supports & Hardware Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X955 $114.00 Max. Each X080 $79.80 Max. Each Generic Commercial Seating Component - Use generic pricing method Footbox/Foot Pocket Semi-enclosed leg and footrest 1 Footbox Per Foot Per 2 Years If footbox/footpocket is for bilateral feet then use quantity of 2. 1 Support Per Foot Per 4 Years Modified Foot Support Modified/adapted footplate, shoe holders, padded footrests or footboards. Price represents cost for one foot, ie: 1 footboard = quantity of 2, or 1 shoe holder = quantity of 1 Bodypoint 1 Pair Footstraps Per 12 Months Ankle Huggers Medium/large X971 $185.25 Per Pair X415 $92.15 Each X495 $228.00 Each X763 $28.50 Each X771 $56.64 Each X446 $214.70 Each X447 $254.60 Per Pair X519 $159.60 Per Pair X448 $34.30 Each 1 Calf Panel Per 12 Months Calf panel Maple Leaf Wheelchair Footbox Contractive Sling - 1 piece padded footbox 1 Footbox Per 2 Years Nighthawk 1 Toe Loop Per Foot Per 12 Months Toe Loops Variety Village 1 Footpocket Per Foot Per 2 Years Foot Pockets Western Home Medical Footbox One Piece cushioned Footbox #5081 1 Footbox Per Foot Per 2 Years Western Split Cushion Footbox #5082 1 Pair Shoe Holders Per 4 Years Rigid Shoe Holders 1 Toe Loop Per Foot Per 12 Months Toe Loops #5086 Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X061 $231.90 Each Custom-Made Calf Support Rigid shell, foam, covering © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Support Per Leg Per 2 Years Page 17 of 36 APL X-16 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 08. Foot & Leg Supports & Hardware Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X127 $399.45 Each X059 $191.19 Each X057 $163.75 Each X106 $110.81 Each X129 $502.24 Each X468 $105.69 Each Custom-Made Footbox Includes both feet Footpocket Footrest Footstrap/Toe Loop Knee Block Rigid shell, foam, covering and straps Neoprene Padding of Front Rigging © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Footbox Per 4 Years 1 Footpocket Per Foot Per 2 Years 1 Footrest Per Foot Per 4 Years 1 Strap Per Foot Per 12 Months 1 Knee Block Per 4 Years 1 Padding Per Leg Per 3 Years Page 18 of 36 APL X-17 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 09. Arm, Hand & Shoulder Supports Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X166 $334.63 Per Pair X043 $199.51 Each X141 $96.02 Each Custom-Made Armrest with hardware Elbow Stops 1 Pair Per 2 Years 1 Elbow Stop Per Arm Per 2 Years Added to trays Shoulder Protraction Wedges © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 2 Wedges Per 2 Years Page 19 of 36 APL X-18 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 10. Trays Level I Seating - Commercial Seating Components Qty. / Freq. Commercial Tray Customization Cat. No. AADL Price X587 $67.85 Each X068 $213.15 Max. Each X060 $312.31 Max. Each 1 Tray Customization Per 2 Years To accommodate a power wheelchair control box Generic Commercial Seating Component - Use generic pricing method Bayonet Mounting on Tray Communication Board Mount to Seating System 1 Mount Per 2 Years 1 Mount Per 2 Years Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X351 $504.73 Each Including mounting hardware, lexan, added lip X054 $678.81 Each Including mounting hardware, lexan, heavy duty bayonet, added lip X381 $849.00 Each Including mounting hardware, lexan, heavy duty bayonet, no lip X380 $692.19 Each To accommodate communication device, includes mounting hardware X056 $526.83 Each Custom-Made Tray Including mounting hardware - padding © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Tray Per 2 Years Page 20 of 36 APL X-19 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 11. Backs & Replacement Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X124 $646.00 Max. Each < 3" Contour Depth, ≥ 20" Tall, Any width X126 $750.00 Max. Each < 3" Contour Depth, 16" - 19" Tall, Any width X125 $726.75 Max. Each ≥ 6" Contour Depth, ≤ 15" Tall, Any Width X150 $736.25 Max. Each ≥ 6" Contour Depth, ≥ 20" Tall, Any width X155 $864.50 Max. Each ≥ 6" Contour Depth, 16" - 19" Tall, Any width X152 $840.75 Max. Each 3"-5" Contour Depth, ≤ 15" Tall, Any Width X130 $717.25 Max. Each 3"-5" Contour Depth, ≥ 20" Tall, Any width X134 $807.50 Max. Each 3"-5" Contour Depth, 16" - 19" Tall, Any width X132 $783.75 Max. Each Non-Standard/Custom Size X935 Prior Approval Generic Commercial Seating Component - Use generic pricing method Back < 3" Contour Depth, ≤ 15" Tall, Any width 1 Back Per 4 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Cannot be combined with X200. Planar "I"-Shape, ≤ 13" Wide, Any height X120 $755.25 Max. Each Planar "I"-Shape, ≥ 13" Wide Any height X122 $813.25 Max. Each X200 $300.00 Max. Each 3 Bariatric Option Per 4 Years Back Bariatric Option Weight capacity over 300lbs or widths greater than 20" Add to appropriate Back catalogue number. Invoice only for the difference in cost for bariatric size, up to $300 maximum. Combined total quantity of 3 in 4 years for X200 and X333. 1 Replacment Cover Per 4 Years Back Cover Custom size replacement cover for commercial systems for adults & peds. X169 For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL. Standard size back replacement cover for commercial systems for adults & peds. X171 Prior Approval Prior Approval For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL. Future Mobility Air Back 14x14, 17x16, 19x16, 16x18, 18x18, 17x20, 19x20 20x18 1 Back Per 4 Years X412 $902.50 Each 16x16, 18x16, 20x16, 18x20, 20x18, 16X20, 20X20 X411 $760.00 Each Bariatric size X371 $1,140.00 Each I220 $674.50 Each X409 $105.00 Each Lunar Back Mid Back - No Lateral Max Back Option For Prism Air Back and Truefitt 1 Back Per 4 Years 1 Option Per 4 Years Use this catalogue number with the applicable Future Mobilty Air or Truefitt back. $105 is the maximum, not all Max Backs require full amount. Phantom Back 12-18" x 7" © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Back Per 4 Years X443 $379.05 Each Page 21 of 36 APL X-20 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 11. Backs & Replacement Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X369 $584.25 Each 11x12, 11x14, 12x14, 12x16, 13x12, 13x14, 13x16, 14x16, 15x12, 15x14, 15x16, 16x12, 16x14 X279 $679.25 Each 14x14, 16x18, 17x16, 17x20, 18x18, 19x16, 19x20, 20x18 X370 $712.50 Each X417 $831.25 Each 16x18, 16x20, 17x16, 17x20, 18x18, 18x20, 20x18, 20x20 X374 $878.75 Each Bariatric size X375 $1,187.50 Each X431 $680.20 Each Deep Back 13-19" 250 lbs. max. X433 $826.50 Each Heavy Duty Back 19-25" 500 lbs. max. X432 $973.75 Each X199 $850.25 Each X455 $709.65 Each X213 $611.80 Each X368 $905.35 Each X693 $768.55 Each X367 $1,062.10 Each X101 $703.95 Each Fits 20" X659 $785.65 Each Tall - fits 14, 15, 16, 17, 18, 19" W/C X098 $806.55 Each Tall - fits 20" X610 $930.05 Each X970 $734.35 Each X353 $781.85 Each X373 $804.65 Each Future Mobility Prism Basic Back 10x12, 12x12, 16x16, 16x20, 18x16, 18x20, 20x16, 20x20 TrueFitt Back 16x16, 18x16, 20x16 1 Back Per 4 Years 1 Back Per 4 Years Invacare Matrx PB Back 13-20" 250 lbs. max. Matrx PB Elite Back Deep Back 1 Back Per 4 Years 1 Back Per 4 Years Widths 12-20, ht 12, 16, 20 wt capacity 300 lbs. Personal Back 10 Reg. Height or Tall (13-20"), aluminum hardware 1 Back Per 4 Years Reg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. Personal Back 10 Plus 13-20", steel hardware 1 Back Per 4 Years Reg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. Jay J2 Back Fits 12, 13, 14, 15, 16, 17, 18, 19" W/C J2 Deep Contour Back 14, 15, 16, 17, 18, 19" 1 Back Per 4 Years 1 Back Per 4 Years 20" J2 Plus Back 20-23", 23-26" without headrest mounting kit © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Back Per 4 Years Page 22 of 36 APL X-21 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 11. Backs & Replacement Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X421 $532.00 Each Lower Thoracic (6" deep and post contour) -14,16,18,20, (SMT) X413 $617.50 Each Mid Thoracic (2.2" contour) - 12, 14, 16, 18, 20, (SMT) X422 $646.00 Each Mid Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) X423 $717.25 Each Mid Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) X784 $736.25 Each Shoulder Ht. (2.2" contour) 14, 16, 18, 20, (SMT) X476 $750.50 Each Shoulder Ht. (3" contour) 14, 16, 18, 20, (SMT) X477 $807.50 Each Shoulder Ht. (6" contour) 14, 16, 18, 20, (SMT) X478 $864.50 Each Shoulder Ht. (6" deep and post contour) 16,18,20, (SMT) I204 $878.75 Each Upper Thoracic (2.2" contour) 12, 14, 16, 18, 20, (SMT) X424 $726.75 Each Upper Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) X425 $783.75 Each Upper Thoracic (6" contour) 14, 16, 18, 20, (SMT) X475 $840.75 Each Upper Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) X787 $850.25 Each I211 Prior Approval Jay Jay 3 Back Lower Thoracic (2.2" contour) -12, 14, 16, 18, 20, (SMT) Jay 3 Components 1 Back Per 4 Years 3 Components Per 4 Years For base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. 1 Back Per 4 Years Jay Active Back With Quick Release Brackets 520/522/525/527/528 (14", 15", 16", 17", 18") X566 $512.05 Each X093 $629.85 Each X658 $740.05 Each X492 $756.20 Each X465 Prior Approval X461 $799.90 Each ML Deep, Mid or Shallow shell – tall 22”/24 X462 $799.90 Each ML Deep, Mid or Shallow shell 10”-‐20” (1”increments) 18” ht., standard ht. Laterals (10 ½”) X460 $632.70 Each Jay Care Back 3500B/3505B 16" and 18" W/C 1 Back Per 4 Years 3502 - 20" Jay Focus Back 1 Back Per 4 Years Maple Leaf Wheelchair Kyphotic Back Options Laterals ht. and back ht. 1 Option Per 4 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. ML Kyphotic Back ML Deep, Mid or Shallow shell – bariatric width © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Back Per 4 Years Page 23 of 36 APL X-22 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 11. Backs & Replacement Covers Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price I231 $750.50 Each Support Contour or Active Contour I217 $655.50 Each Vicair Contour 16,17,18x16/20 18,19,20x16/20 20,21,22X16/20 I228 $945.25 Each I214 $655.50 Each I215 $684.00 Each X660 $490.05 Each Back 2 - 15-17", 18-20" X978 $627.38 Each Back 3 15-17", 18-20" with or without teardrop laterals X979 $748.90 Each Back 4 - 15-17", 18-20" with or without teardrop laterals X980 $980.10 Each X981 $17.78 Each X434 $759.05 Each X466 $783.75 Each X489 $465.50 Each X488 Prior Approval nxt 1 Back Per 4 Years Fixed Height Plus Contour 1 Back Per 4 Years Height Adjustable Support contour/active countour/plus count HA SC/AC/PC 16-22 Support contour/plus contour HA SC/ PC 22-24 Ottobock 1 Back Per 4 Years Back Back 1 - 15-17", 18-20" 8 Floam Cells Per 4 Years Floam Cells Pride Mobility 1 Back Per 4 Years Synergy Shape 2 Back 14, 16, 18, 19, 20", 300 lbs max. 4" depth adjustment angle adjustment from -33 to +57 degrees Tall 16,18,20,22" X 23" 300 lbs max. 4" depth adjustment, angle adjustment from -33 - +57 degrees Ride Ride Back Corbac Adjustable Contour 1 Back Per 4 Years Custom Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X671 $886.90 Each Lumbar Support X049 $173.15 Each Planar Back Interface System X067 $633.61 Each Pressure reduction back with polymer or air floatation insert X179 Prior Approval Custom-Made Back Contoured 1 Back Per 4 Years Prior Approval. Submit request to AADL. (custom back $493.00 + cost of pressure relief surface) Web Back Box © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 X151 $849.90 Each Page 24 of 36 APL X-23 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 11. Backs & Replacement Covers Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X670 $586.39 Each X469 $105.69 Each X383 $330.41 Each X401 $232.34 Each Custom-Made Back Web Back Sling Neoprene Padding of Back Canes Removable Cover Neoprene option 1 Back Per 4 Years 1 Padding Per 4 Years 1 Cover Per 4 Years Replacement only Standard Replacement only © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 25 of 36 APL X-24 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 12. Bases, Cushions & Replacement Covers Level I Seating - Commercial Seating Components Qty. / Freq. Wheelchair Cushions provided on "V" APL Cat. No. AADL Price X633 $20.00 Each X934 Prior Approval I101 Prior Approval 1 Service Fee Per 3 Years Generic Commercial Seating Component - Use generic pricing method 1 Cushion Per 3 Years Cushion Non-Standard Size Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. 1 Cover Per 12 Months Replacement Cushion Cover for Commercial Custom Cushion For replacment only. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay 1 Seat Insert Per 3 Years Adult Adjustable Solid Seat #270/271/272 (adjusts 15-18", 10-11", 11.5-14.5") 1.5" drop Large 273 (adjusts 18.5-22" wide) 2.5" drop X249 $323.95 Each X384 $399.00 Each I211 Prior Approval 3 Components Per 4 Years Jay 3 Components For base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay 3 Cushion Air or fluid insert with seating component options. 1 Cushion Per 3 Years X496 Prior Approval X497 Prior Approval X430 Prior Approval Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Bariatric, air or fluid insert with seating component options Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Ride 1 Base Per 3 Years Ride Cushion Custom Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X149 $799.62 Each Bariatric - over 250 lbs. X382 $816.65 Each Kid Kart X618 $403.00 Each Pressure Reduction Base (polymer or air floatation insert) X999 Prior Approval Standard Cushion/Base X066 $770.99 Each T-Foam/Sunmate Cushion X051 $209.49 Each Custom-Made Base Anti-thrust Seat or Non-Removable Pommel 1 Base Per 3 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 26 of 36 APL X-25 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 12. Bases, Cushions & Replacement Covers Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X356 $448.36 Each X197 $137.33 Each X383 $330.41 Each X401 $232.34 Each X471 $127.83 Each X470 $542.10 Each Custom-Made Drop Base Padded 1 Drop Base Per 3 Years Standard Hooks not included. Previously X534. Removable Cover Neoprene option 1 Cover Per 4 Years Replacement only Standard Replacement only Solid Seat Insert Pre ischial shelf - for beneath an air floatation cushion With leg channels upholstered to base © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Seat Insert Per 3 Years Page 27 of 36 APL X-26 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 13. Spinal Alignment Assessories Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X333 $47.50 Max. Each Large/Small Lumbar X479 $47.50 Each Lateral Shim X483 $52.25 Each Post/Lateral Pelvic X482 $52.25 Each Wedge X480 $38.00 Each Generic Commercial Seating Component - Use generic pricing method Accessories for Commercial Back 3 Accessories Per 4 Years List each accessory and justification in benefit note on E-business. Jay Jay 3 Spinal Alignment Accessories © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 3 Spinal Alignment Accessories Per 4 Years Page 28 of 36 APL X-27 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 14. Complete Seating Systems Level I Seating - Commercial Seating Components Qty. / Freq. Cat. No. AADL Price X190 Prior Approval Generic Commercial Seating Component - Use generic pricing method Adult Commercial Custom Fit Seating System Must include back, base and all supports 1 Seating System Per 4 Years Must only provided when seating needs cannot be accomodated by off-the-shelf components. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Pediatric Commercial Custom Fit Seating System Must include back, base and all supports. 1 Seating System Per 2 Years I229 Prior Approval For ages 17 years and younger. Must only provided when seating needs cannot be accomodated by off-the-shelf components. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay Additional Seating Components for SureFit System 4 Components Per 4 Years I207 Prior Approval To be used only after original seating provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Lecky 4 Per 4 Years Squiggles Additional Seating Components I201 Prior Approval Components added to Lecky Squiggles seating insert after provision. To be used only after original seating provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Ottobock 1 Cover Per 4 Years Ottobock Shape System Replacement cover X454 $230.85 Each Pattern on client file must be sent to Ottobock Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X024 $2,004.50 Each Custom-Made "Foam-in-Place" Back or Base Custom-made foam back or base. 1 Back or Base Per 4 Years May be custom-made by Adaptive Seating Technician or using computerized scanning/carving. If both back and base required, do not submit QFR. Indicate rationale for override in the Override Notes on Ebusiness. 1 Seating System Per 4 Years ACH - Custom Made Insert for Commercial Stroller Includes custom made headrest/neckrest, foam and covering and pelvic strap. X036 $1,092.95 Each X044 Custom-Made Safety Strap used to secure insert to mobility base added as separate catalogue number. Base Kid Kart Commode Insert Includes: back, laterals, footstraps, chest straps - no seat. 1 Cushion Per 3 Years X618 $403.00 Each X047 Prior Approval 1 Insert Per 4 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 29 of 36 APL X-28 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 14. Complete Seating Systems Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. AADL Price X636 $1,092.95 Each Custom-Made 1 Seating System Per 4 Years Glenrose Infant Seat Custom made insert for commercial stroller, includes custom made headrest/neckrest, foam and covering and pelvic strap. X044 CUSTOM MADE Safety Strap used to secure insert to mobility base added as separate cat# GRIP Seat Floor Sitter © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 1 Floor Sitting Per 4 Years X474 $172.00 Each Page 30 of 36 APL X-29 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 15. Service Fees Level I Seating - Commercial Seating Components Qty. / Freq. Commercial Tray Customization AADL Price X587 $67.85 Each X632 $15.00 Each 1 Tray Customization Per 2 Years To accommodate a power wheelchair control box Hand/Arm/Shoulder Supports as provided from "V" APL Cat. No. 1 Service Fee Per 2 Years 50% of Replacement Cost Per 4 Years Repairs/modifications to an existing seating system; transferring seating system to X964 another mobility base. Price includes labour and materials. If authorized on Ebusiness, document type of repairs and cost breakdown. Level I - Repairs/Modifications $67.85 Per Hour Invoiced in 1/4 hour Increments - Cost under $25 are client's responsibility - Not to be used for repairs due to misuse of equipment - Each increment of $67.85 = Quantity of 1. Total materials/labour of $185 = Qty 3 (2 @ $67.85, 1 @ $49.30) Recycle Fee for Seating Benefits 1 Recycle Fee Per Seating System List recycled components in Benefit Note X651 $67.85 Per HourPer Hour Invoiced in 1/4 hour Increments X357 Prior Approval X783 $57.00 X633 $20.00 Each - Maximum 4 hours Shipping Fee Commercial Seating Components/System Repairs 1 Fee Per Component Submit invoice to AADL Retrieval of Trial Seating Equipment Rural - One way Wheelchair Cushions provided on "V" APL 1 Service Fee Per 3 Years Level II Seating - Custom-Made Seating Components Qty. / Freq. Cat. No. 50% of Replacement Cost Per 4 Years Repairs/modifications to an existing seating system; transferring seating system to X172 another mobility base. Price includes labour and materials. If authorized on Ebusiness, document type of repairs and cost breakdown. AADL Price Level II - Repairs/Modifications $67.85 Per Hour Invoiced in 1/4 hour Increments - Cost under $25 are client's responsibility - Not to be used for repairs due to misuse of equipment - Each increment of $67.85 = Quantity of 1. Total materials/labour of $185 = Qty 3 (2 @ $67.85, 1 @ $49.30) Recycle Fee for Custom Seating Benefits List recycled components in Benefit Note 4 Hours Per Seating System X377 $67.85 Per Hour Invoiced in 1/4 hour Increments - Maximum 4 hours © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 31 of 36 APL X-30 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 15. Service Fees Level II Seating - Custom-Made Seating Components Qty. / Freq. Shipping Fee Custom-Made Seating Components/System Repairs Cat. No. AADL Price X358 Prior Approval 1 Fee Per Component Submit invoice to AADL © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 32 of 36 APL X-31 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List 2014 Catalogue Number Updates I204 Jay 3 Back Shoulder Ht. (6" deep and post contour) 16,18,20, (SMT) Price Change I205 Synergy Shape 2 Back Low back 14,16,18, 20" 16" ht 300lbs max. 4" depth adjustment, angle adjustment from -33 - +57 degrees Deleted: Falls under generic back code; 0 consumption in 3 years I208 Lunar Back Heavy Duty - Mid Back Deleted: Falls under generic back code; 0 consumption in 3 years I209 Lunar Back Heavy Duty - Full Back Deleted: Falls under generic back code; 0 consumption in 3 years I212 Heel Loop and Ankle Strap Deleted: Falls under X070; 0 consumption in 3 years I213 Back Accessories Lumbar support pads; lateral support pads. Deleted: Falls under X333; 0 consumption in 3 years I218 Lunar Back Low Back - No Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I219 Lunar Back Low Back - Basic Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I221 Lunar Back Mid Back - Basic Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I222 Lunar Back Mid Back - Ultra Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I223 Lunar Back Full Back - No Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I224 Lunar Back Full Back - Basic Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I225 Lunar Back Full Back - Ultra Lateral Deleted: Falls under generic back code; 0 consumption in 3 years I226 Lunar Back - Swing-away Laterals Deleted: Falls under generic back code; 0 consumption in 3 years I229 Pediatric Commercial Custom Fit Seating System Must include back, New base and all supports. X015 Headrest/Neckrest Standard Headrest or Neckrest Price Change X035 Headrest/Neckrest Headrest with Lateral Support Price Change X045 Hardware for Headrest/Neckrest Price Change X062 Adaptor Kit or Mounting Plate for Headrest/Neckrests Price Change X069 Headrest Styles Lg/Sm 430C1 = 1-7/3-7, or 430H1 = 1-7/3-7 Price Change X070 Heel Loop/Ankle Strap Strapping mechanism to secure ankle/foot. Price Change X078 Headrest Hardware Multi-Axis Offset or Multi-Axis Straight Price Change X079 Headrest Hardware Adaptor Kit Price Change X093 Jay Care Back 3500B/3505B 16" and 18" W/C Price Change X098 J2 Back Tall - fits 14, 15, 16, 17, 18, 19" W/C Price Change X101 J2 Back Fits 12, 13, 14, 15, 16, 17, 18, 19" W/C Price Change X115 Seat/Base Full Wedge Price Change © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 33 of 36 APL X-32 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List X118 Obliquity Pad/Build-up/Fluid Supplement Price Change X150 Back ≥ 6" Contour Depth, ≤ 15" Tall, Any Width Price Change X152 Back ≥ 6" Contour Depth, 16" - 19" Tall, Any width Price Change X155 Back ≥ 6" Contour Depth, ≥ 20" Tall, Any width Price Change X189 AES SureFit (Li'l Kiddos) Seating System - Size 14" or less. Complete seating system including back, base, headreat and all supports. Deleted: Falls under X190 X194 Squiggles Seating Insert Deleted: Falls under X190 X249 Adult Adjustable Solid Seat #270/271/272 (adjusts 15-18", 10-11", 11.5-14.5") 1.5" drop Price Change X305 J2 Abductor Build-up 2" B118 or B168 Deleted: Falls under X118; 0 consumption in 3 years X306 Jay Seat Wedge Adductor 1" B119J Price Change X307 Jay Seat Wedge Adductor 2" B113J or B163 Price Change X308 Fluid Supplement F119 Price Change X309 Jay Seat Wedge Base Wedge B114 Price Change X331 Clamp To mount headrest or other seating component Price Change X353 J2 Deep Contour Back 20" Price Change X360 Back Mounting Brackets Infinity Back 1109570 Deleted: Discontinued X361 Pelvic Belt K Belt 5065 or Y Belt 5067 padded Deleted: Falls under X227; 0 consumption in 3 years X363 Neckrest 430N1, Large, Medium, Small Deleted: Discontinued X372 Prism Basic Back Bariatric, max. 24" width, min. 14" height Deleted: Falls under generic back code; 0 consumption in 3 years X373 J2 Plus Back 20-23", 23-26" without headrest mounting kit Price Change X376 Back Mounting Brackets Personal Back 10 1116448 - 13-20", 22-26" Deleted: Discontinued W/C X385 Ottobock Shape System Soft Spot Foam Deleted: Falls under X190 X385 Ottobock Shape System Soft Spot Foam Price Change X386 Headrest Hardware Gooseneck Mounting Kit 476L52-SK030 or Straight Mounting Kit 476L52-SK035 Price Change X387 STS Clamps 477D52/434H1 Price Change X389 Ottobock Shape System Finished back with spray coating. Removable cover and cover pattern. Deleted: Falls under X190 X390 Ottobock Shape System Unfinished back. Removable cover and cover pattern. Deleted: Falls under X190 X391 Headrest Soft Headrest 430H2 Price Change X394 Ottobock Shape System Plywood Mounting Surface - Back or seat Deleted: Falls under X190 X395 Ottobock Shape System Finished seat with spray coating. Removable cover and cover pattern. Deleted: Falls under X190 X396 Ottobock Shape System Unfinished seat. Removable cover and cover pattern. Deleted: Falls under X190 © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 34 of 36 APL X-33 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List X397 Ottobock Shape System Plastic (ABS) Mounting Surface - back or seat Deleted: Falls under X190 X398 Hardware Kit 5069 - includes 4 chafes and 4 slides per pkg. Deleted: Falls under X107; 0 consumption in 3 years X405 Waistcoat Price Change X416 Matrx Flo-Tech Seat Wedge Adductor - Front or rear Deleted: Falls under X114; 0 consumption in 3 years X420 AES Structured Y Shoulder Strap Price Change X453 Ottobock Shape System Additional components Deleted: Falls under X190; 1 consumption in 3 years X454 Ottobock Shape System Replacement cover Price Change X458 Ottobock Shape System T-Nuts Deleted: Falls under X190 X458 Ottobock Shape System T-Nuts Price Change X460 ML Kyphotic Back ML Deep, Mid or Shallow shell 10”--‐20” (1”increments) 18” ht., standard ht. Laterals (10 ½”) Price Change X461 ML Kyphotic Back ML Deep, Mid or Shallow shell – bariatric width Price Change X462 ML Kyphotic Back ML Deep, Mid or Shallow shell – tall 22”/24 Price Change X472 Sub-ASIS Belt Medial 4pt center pull Price Change X475 Jay 3 Back Upper Thoracic (6" contour) 14, 16, 18, 20, (SMT) Price Change X478 Jay 3 Back Shoulder Ht. (6" contour) 14, 16, 18, 20, (SMT) Price Change X481 Jay 3 Spinal Alignment Accessories Curved Shim or Flat Shim Deleted: Falls under X333; 0 consumption in 3 years X482 Jay 3 Spinal Alignment Accessories Post/Lateral Pelvic Price Change X483 Jay 3 Spinal Alignment Accessories Lateral Shim Price Change X484 Chest Strap Jay 3 Chest Straps/Harnesses Price Change X486 Headrest Jay 3 AXYS Mount Price Change X487 Headrest Jay 3 COBRA Mount Price Change X490 Back Mounting Brackets Jay 3 back hardware Price Change X492 Jay Focus Back Price Change X493 U-Shape Back Shallow Deleted: Falls under generic back code; 1 consumption in 3 years X494 U-shape Back Deep Deleted: Falls under generic back code; 1 consumption in 3 years X498 Chest Strap MonoFlex anterior trunk support Price Change X499 Signature-Fit Deleted: Falls under X190 X514 Matrx Flo-Tech Fluid Supplement Deleted: Falls under X118; 0 consumption in 3 years X515 Matrx Flo-Tech Seat Wedge Full Deleted: Falls under X115; 0 consumption in 3 years X516 Matrx Flo-Tech Seat Wedge Hemi Deleted: Falls under X116; 0 consumption in 3 years © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 35 of 36 APL X-34 Alberta Health - Professional Services HealthBenefits Benefits Alberta Health - Professional Services andand Health AADL Seating Approved Product List Alberta Aids to Daily Living - Manual X - Seating Approved Product List X517 Matrx Flo-Tech Seat Wedge Tapered Deleted: Falls under X115; 0 consumption in 3 years X518 Matrx Flo-Tech Seat Wedge Pelvic obliquity 1" Deleted: Falls under X118; 0 consumption in 3 years X520 Jay Seat Wedge Pelvic obliquity build-up B116R or L Price Change X521 Hip Guide Jay, J2, GS - B1167 Deleted: Falls under X112; 1 consumption in 3 years X522 Headrest Lateral Control Headrest 430C2 1-7/3-7 Price Change X610 J2 Back Tall - fits 20" Price Change X649 Matrx Elite Thoracic Lateral Rigid Price Change X652 Matrx Elite Thoracic Lateral Off-Set Price Change X658 Jay Care Back 3502 - 20" Price Change X659 J2 Back Fits 20" Price Change X660 Back Back 1 - 15-17", 18-20" Price Change X713 STS Hardware Rod Assembly 434F1 Price Change X787 Jay 3 Back Upper Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) Price Change X788 Headrest Clamp Invacare Universal / Whitmeyer Headrest Clamp Deleted: Discontinued X812 OB STS Pad Large/med/small 434P1 Price Change X868 Headrest Adpator Kit 476D52 SK010/015/020/025/060/065 Price Change X907 Hooks Drop Hooks 1063290-95 Price Change X911 OB STS Clamp 434H1=1 Price Change X942 Pelvic Belt Y Belt, black webbing N4.025 Deleted: Falls under X227; 0 consumption in 3 years X969 Headrest Hardware Clamp For any back (477152=SK039) Price Change X970 J2 Deep Contour Back 14, 15, 16, 17, 18, 19" Price Change X971 Ankle Huggers Medium/large Price Change X978 Back Back 2 - 15-17", 18-20" Price Change X979 Back Back 3 15-17", 18-20" with or without teardrop laterals Price Change X980 Back Back 4 - 15-17", 18-20" with or without teardrop laterals Price Change X981 Floam Cells Price Change © 2013 © Government of 2014 Government of Alberta Alberta April April1,1,2014 2014 Page 36 of 36 APL X-35
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