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Alberta Health
AADL Approved Products List – Medical Surgical Supplies
Pricing effective July 1, 2014 to June 30, 2015
Briefs, Diapers and Liners ............................................................... APL M-1
Catheter Supplies ............................................................................ APL M-3
Dressing Supplies ............................................................................ APL M-7
Injection Supplies............................................................................. APL M-10
Ostomy Supplies.............................................................................. APL M-11
Discontinued Supplies ..................................................................... APL M-16
July 1, 2014
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
BRIEFS, DIAPERS AND LINERS
Generic description, uses and restrictions
Benefit Specific Eligibility:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantities or frequencies listed.
Pricing:
• Based on a tab style diaper however, the client and authorizer has the choice of a button, Velcro or pull-up garment provided the product
meets AADL’s standards.
Quantities:
• Quantity and frequency limits are maximums and not to be considered automatically. Determine quantity based on client’s basic need.
• Clients may be eligible for a combined maximum of 400 diapers/briefs/liners every two months.
Sizing:
• The size of brief or liner authorized is based on the client’s waist or hip measurement at the trochanter, whichever is larger.
BRIEFS/DIAPERS – Minimal 600mL absorbency
Incontinence briefs/diapers must:
• Meet minimal absorbency criteria
• Have re-usable fasteners
• Consist of soft woven material that promotes skin integrity
• Have a wetness indicator on the package to identify absorption levels
Cat.
No.
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M200
Disposable Adult Diapers – Small or Youth
• Fits hips/waist 20” to 31”
400/2 mo.
$0.94
M203
Disposable Adult Diapers – Medium
• Fits hips/waist 32” to 44”
400/2 mo.
$1.02
M207
Disposable Adult Diapers - Large to XX-Large
• Fits hips/waist 45” to 65”
400/2 mo.
$1.34
M205
Disposable Child Diapers
• Includes all pediatric sizes
400/2 mo.
$1.25
M214
Disposable Adult Briefs – Bariatric
• Fits hips/waist 65” and up (document on 1250
form)
400/2mo.
$3.71
© 2014 Government of Alberta
July 1, 2014
APL M-1
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
LINERS
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Determined on client’s basic need, not quantity maximum. Quantities must be supported by assessment/diary.
• Clients are eligible for a combined maximum of 400 diapers/briefs/liners every two months.
CAT.
No.
Description of Benefit
Additional Details
•
M240
Disposable Large Hour Glass Plastic Back/
Waterproof Liner
•
•
•
M242
•
•
Disposable Incontinence Liners
Quantity and
Frequency Limit
Price
Maximum
An alternative product to a full brief or diaper;
not to be used inside a brief or diaper.
Absorbs a minimal 800 ml at the target area.
With or without self-adhesive strip.
400/2 mo.
$0.87
An alternative product to a full brief or diaper;
not to be used inside a brief or diaper.
Absorbs a minimal 400 ml at the target area.
With self-adhesive plastic back.
400/2 mo.
$0.57
Non-plastic back.
Designed to be worn inside full brief or diaper to
increase absorbency at night
Provides uninterrupted sleep for
client/caregiver (document on 1250 form)
Absorbs a minimal 250 ml at the target area.
60/2 mo.
$0.80
Designed to be washed and reused.
For severe incontinence (document on 1250
form)
2/4mo.
$14.36
BOOSTER LINERS AND UNDERPADS
•
•
M243
Disposable Booster Liners – 3 ½ “ x 12”
•
•
M263
Reusable Washable Underpads - minimal size
of 43 x 51 cm
© 2014 Government of Alberta
July 1, 2014
•
•
APL M-2
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
CATHETER SUPPLIES
Generic description, uses and restrictions
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Determined on client’s basic need, not quantity maximum.
• Clients may be eligible for a combined maximum of catheters at 70 every 2 months.
• Quantities are based on current research and best practice.
CATHETERS
Cat.
No.
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M300
External Catheter – Latex
• No internal adhesive.
• Packaged with a separate adhesive strip to hold
them in place.
70/2 mo
$2.17
M301
External Catheter – Latex, non-latex
• Has internal adhesive.
• Includes both latex and non-latex products.
70/2 mo
$2.61
M302
External Catheter – Heavy Latex
• Has internal adhesive.
• Heavy latex construction.
• Has extended wearing time.
30/2 mo
$3.71
M328
Intermittent Catheter – Plastic
•
•
Clean intermittent catheterization.
Provided with cleaning instructions.
70/2 mo
$1.66
M329
Intermittent Catheter – Latex
•
•
Clean intermittent catheterization.
Provided with cleaning instructions.
70/2 mo
$3.01
© 2014 Government of Alberta
July 1, 2014
APL M-3
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
CATHETERS
Cat.
No.
M341
M345
Description of Benefit
Foley Catheter – Latex or Latex with Silicone
Coating
Additional Details
Quantity and
Frequency Limit
Price
Maximum
•
•
Indwelling catheter
Latex with coating used for clients with sensitivity
to latex (document on 1250 form)
12/2 mo
$10.82
•
Indicated for:
 Unresolved bypassing.
 Frequent blockages (more than once a week).
 Documented latex allergy (include copy)
 Document rationale on 1250 form)
4/2 mo
$28.53
4/2 mo
$22.94
Foley Catheter – 100% Silicone
•
M347
Foley Catheter – 100% Silicone/Coudé Tip
Indicated for:
 Unresolved bypassing.
 Frequent blockages (more than once a week).
 Documented latex allergy (include copy)
 Document rationale on 1250 form.
M381
Intermittent Catheter – Plastic/ Coudé Tip
• Curved tip - for difficulty inserting with regular tip
(document on 1250 form).
70/2 mo
$2.75
M382
Intermittent Catheter – Latex/Coudé Tip
• Curved tip - for difficulty inserting with regular tip
(document on 1250 form)
70/2 mo
$4.01
M383
Foley Catheter – Latex or Latex with Silicone
Coating/Coudé Tip
• Curved tip - for difficulty inserting with regular tip
• Silicone coating for clients with sensitivity to latex
• Document rationale on 1250 form.
4/2 mo
$37.86
© 2014 Government of Alberta
July 1, 2014
APL M-4
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
CATHETER TUBING, SECURES, TRAYS AND BAGS
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Determined on client’s basic need, not quantity maximum.
• Quantities of catheter tubing, secures, trays and bags must match corresponding catheter quantities. Example
Example: Number of trays authorized must match number of indwelling catheters authorized per 2 month period up to maximum limit.
• Quantities are based on current research and best practice.
Cat.
No.
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
•
Includes thumb clamp & connector
3/2 mo
$12.76
•
For external catheters without adhesive strip in
package.
70/2 mo
$6.07
Urinary Tape – 1 or 2 inch
•
Alternative to catheter secures
5/2 mo
$6.66
M312
Catheter Secures
•
Designed to last 7-10 days
10/2 mo
$3.75
M313
Catheter Secure straps - reusable
•
Indicated for clients with documented latex
allergy (Document on 1250 form)
1/2 mo
$12.95
2/1 yr
$33.86
M016
Rubber Extension Tubing for M356
M305
Adhesive Strips for External Catheters
M307
M322
Quick Drain Valve
• For draining urinary leg bags.
• Clamp is lever operated.
• For client with limited finger/hand control
(Document on 1250 form)
M348
Foley Catheter Tray without catheter
•
•
For inserting indwelling catheter
Includes pre-filled inflation syringe
12/2 mo
$5.50
M352
Bedside Urinary Drainage
•
Includes drainage tube, adapter, bottom drain
clamp and hanger.
8/2 mo
$9.20
© 2014 Government of Alberta
July 1, 2014
APL M-5
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
CATHETER TUBING, SECURES, TRAYS AND BAGS
Cat.
No.
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
20/2 mo
$11.97
M354
Urinary Leg Bag – Vinyl
•
•
•
•
M356
Urinary Leg Bag – Latex
•
•
Option to add M016 - Rubber Extension Tubing
Heavy duty
3/2 mo
M364
Male Urinal Suspensory Garment and Sheath
•
•
Used with external catheter
Garment and sheath are washable and reusable
1/2 mo
M370
Urinary Irrigation Tray
•
Used with indwelling catheters
8/2 mo
© 2014 Government of Alberta
July 1, 2014
Includes extension tubing and leg straps.
Comes in a variety of sizes.
May have anti-reflux or flip-flow valves.
Can be washed and reused several times.
$63.47
$115.11
$4.85
APL M-6
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
DRESSING SUPPLIES
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum, number of dressing changes support quantities needed.
• Clients are eligible for one type of dressing per wound – dry, interactive foam or interactive hydrocolloid.
• Dressings are matched to each separate wound by wound number (e.g. #1,#2) and described by location & duration.
• Identify which dressings are for which wound on 1250.
DRESSINGS: INTERACTIVE HYDROCOLLOID
AADL
Cat #
Description of Benefit
M776
Interactive Hydrocolloid Dressing 10 x 10 cm
M777
M778
M792
Quantity and
Frequency Limit
Price
Maximum
• Maintains moisture
12/2 mo
$12.73
Interactive Hydrocolloid Dressing 20 x 20 cm
• Maintains moisture
12/2 mo
$50.04
Interactive Hydrocolloid Dressing 15 x 15 cm
• Maintains moisture
12/2 mo
$25.17
• Foam or hydrocolloid
12/2 mo
$28.26
Coccyx Interactive Dressings
© 2014 Government of Alberta
July 1, 2014
Additional Details
APL M-7
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
DRESSINGS: INTERACTIVE FOAM
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
$29.60
M767
Interactive Foam Dressing 15 x 20 cm
• Absorbs drainage, exudate
12/2 mo
M772
Interactive Foam Dressing 10 x 10 cm
• Absorbs drainage, exudate
12/2 mo
M773
Interactive / Alginate Dressing 10 x 10 cm
• Absorbs drainage, exudate
12/2 mo
$15.92
M775
Interactive Foam Dressing 20 x 20 cm
• Absorbs drainage, exudate
12/2 mo
$39.41
M793
Interactive Foam Dressing 15 x 15 cm
• Absorbs drainage, exudate
12/2 mo
M794
Interactive / Alginate Dressing 15 x 15 cm
• Absorbs drainage, exudate
12/2 mo
© 2014 Government of Alberta
July 1, 2014
$9.00
$38.35
$33.66
APL M-8
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
DRESSINGS: DRY
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum, number of dressing changes support quantities needed.
• Clients are eligible for one type of dressing per wound – dry, interactive foam or interactive hydrocolloid.
• Dressings are matched to each separate wound by wound number (e.g. #1,#2) and described by location & duration.
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price Maximum
5/2 mo
$6.50
M665
Dressing Tape – 1 or 2"
M715
Dry Gauze – Clean - 10 cm x 10 cm
• Equivalent to 4” x 4”.
400/2 mo
$0.06
M717
Dry Gauze – Sterile – 10cm x 10 cm
• Equivalent to 4“ x 4”.
• For immuno-suppressed client (document on
1250 form).
400/2 mo
$0.13
M730
“ABD” pads - Heavy Drainage Dressings–Clean
• Includes rolls of absorbent pad cotton with outer
covering
• 20 cm wide or variation
• 26 cm of roll is equivalent to one precut ABD
60/2 mo
$0.45
M735
“ABD” Pads - Heavy Drainage Dressings –
Sterile
• For immuno-suppressed client (document on
1250 form).
60/2 mo
$0.77
M750
Gauze Roll – Stretch
• Does not include zinc impregnated gauze wrap.
100/2 mo
Booster Liners – 7.5 cm x 25 cm or larger
• Equivalent to 3” x 10” or larger
• Absorbency of 250 mls at the targeted area
• For client with highly draining non-resolving
wounds (document on 1250 form)
• Alternative to “ABD” pads
• Must be authorized by Palliative RN or ETRN.
250/2 mo
M246
© 2014 Government of Alberta
July 1, 2014
$1.67
$0.83
APL M-9
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
INJECTION SUPPLIES
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum.
• Quantities are determined based on prescription – must be indicated on prescription as OD, BID, TID or QID for each drug
• Combinations may be permitted – total not to exceed maximum 500 for 2 months.
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M403
Syringe with Needle Attached - ½ cc or 1 cc
• For intramuscular or subcutaneous injections
500/2 mo
$0.50
M415
Syringe with Needle Attached - 3 cc
• For intramuscular or subcutaneous injections
500/2 mo
$0.67
© 2014 Government of Alberta
July 1, 2014
APL M-10
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
OSTOMY SUPPLIES
Generic description, uses and restrictions
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum.
• Different types of pouches may be authorized for same client – total quantity must not exceed maximum limit of single type
• Quantities of pouches cannot be added together to increase quantity limit.
Pricing:
• Pricing for all pouches is based on products with filters.
• Open end pouch prices are based on self-closure products.
OSTOMY POUCHES
CAT.
No.
Description of Benefit
M001
One Piece Colostomy/Ileostomy Pouch
M003
Quantity and
Frequency Limit
Price
Maximum
• Closed end with seal
210/2 mo
$5.10
Two-Piece Colostomy/Illeostomy Pouch
• Closed end
210/2 mo
$3.02
$7.79
One-Piece Colostomy/Ileostomy Pouch
• Drainable
• Self-closure
30/2 mo
M005
$6.64
Two-Piece Colostomy/Ileostomy Pouch
• Drainable
• Self-closure
30/2 mo
M006
M008
Two-Piece Urostomy Pouch
• Regular Wear
30/2 mo
$7.63
M009
One-Piece Urostomy Pouch
• Regular Wear
30/2 mo
$13.42
M010
Vinyl Reusable Ileostomy/Urostomy
Pouch
• Requires separate faceplate
• Available only to AADL clients previously approved for
product
20/2 mo
$9.65
© 2014 Government of Alberta
July 1, 2014
Additional Details
APL M-11
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
OSTOMY POUCHES
AADL cat. #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M011
One Piece Colostomy/Ileostomy Pouch
• Drainable
• Extended wear with convexity
20/2 mo
$13.76
M012
One Piece Urostomy/Ileostomy Pouch
• Regular wear without convexity
30/2 mo
$14.87
M013
One Piece Urostomy Pouch
• Extended wear without convexity
20/2 mo
$13.95
M020
Reusable Rubber
Colostomy/Ileostomy/Urostomy Pouches
• For use with faceplate
• Available only to clients previously authorized for
product
1/2 mo
$96.53
M022
High Output Urostomy Night Drainage
Pouch
• For output not managed with use of regular pouch
(document on 1250 form).
30/2 mo
$9.82
M024
High Output Pouch
• For output not managed with use of regular pouch
(document on 1250 form).
30/2 mo
$17.14
M035
Pediatric Colostomy/ Urostomy/
Ileostomy Two Piece Pouch
• Drainable
50/2 mo
$4.50
M037
One Piece closed end pouch
• Closed end with seal
• With convexity
210/2mo
$7.47
M063
One Piece Colostomy/Ileostomy Pouch
• Drainable
• Regular wear with convexity
30/2 mo
$11.54
M170
One Piece Colostomy/Ileostomy Pouch
• Drainable
• Extended wear
20/2 mo
$9.09
M171
One Piece Colostomy/Ileostomy Pouch
• Drainable
• Extended wear with convexity
20/2 mo
$16.05
M172
Pediatric One piece drainable Pouch
• Colostomy/ Urostomy/ Ileostomy Pouch
50/2mo
$8.14
M174
Pediatric One-Piece Colostomy Pouch
• Closed end with seal
300/2 mo
$6.48
© 2014 Government of Alberta
July 1, 2014
APL M-12
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
OSTOMY SUPPLIES
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum.
• If a client clinically requires a combination of paste and strips, the client may have proportional quantities.
INSERTS, FACEPLATES, SKIN BARRIER WAFERS/FLANGES
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M018
Convex Inserts
• Improves seal around a problem stoma
• Increases wafer wearing time
30/2 mo
$4.88
M025
Plastic Faceplate for M 020
• Grand fathered product - for AADL clients previously
authorized for product
2/2 mo
$24.80
M026
Rubber Faceplate for M 010
• Grand fathered product - for AADL clients previously
authorized for product
1/2 mo
$60.75
M036
Stoma Collar
• Improves wear time to minimum 3-5 days
(document on 1250 form).
20/2 mo
$8.00
M073
Skin Barrier Wafer
• Regular Wear with Flange
30/2 mo
$9.16
M078
Skin Barrier Wafer - Convexity
• Regular Wear with Flange
30/2 mo
$12.69
M079
Skin Barrier Wafer – Extended wear
• With or without flange
20/2 mo
$11.30
M173
Pediatric Skin Barrier Wafer – regular wear
• For pediatric clients
50/2 mo
$9.60
M175
Pediatric Skin Barrier Wafer – extended wear
• For pediatric clients
50/2 mo
$11.30
M180
Skin Barrier Wafer
• Extended wear with Convexity
20/2 mo
$18.00
© 2014 Government of Alberta
July 1, 2014
APL M-13
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
OSTOMY SUPPLIES
Benefit Specific Eligibility Criteria:
• Noted in bold underlined print – must be documented on authorization (1250) form.
AADL vendors:
• Offer clients a choice of products that meets AADL generic description and product standards at or below AADL’s price.
• Only provide 2 months’ supply at a time and may not submit claims for over quantity.
Quantities:
• Are determined on client’s basic need, not quantity maximum.
• Quantities of paste and strips cannot be added together to increase quantity limit.
If a client clinically requires a combination of paste and strips, the client may have proportional quantities.
SKIN BARRIER ACCESSORIES
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M069
Skin Barrier Seals/Rings/Sheets
• Protects area around stoma
• Includes Eakin Seals, Karaya washers, rings and
wafers
• Without flange
20/2 mo
$9.06
M080
Skin Barrier Paste
• 57 gram tube or larger
3/2 mo
$21.37
M121
Ostomy Tape – 1 or 2”
• Price based on 2” tape
5/2 mo
$6.50
M126
Adhesive Disc
• Plastic/Rubber
• Used with faceplate (M026)
• Grandfathered product – for AADL clients previously
authorized for product
20/2 mo
$1.78
M181
Ostomy Barrier Strips
• Box of 10 strips
3 boxes/2 mo
$31.30
1/2 mo
$39.14
OSTOMY ODOR CONTROL
M049
Appliance Odor Control – liquid
© 2014 Government of Alberta
July 1, 2014
• Based on 8 oz. bottle
• Does not include room deodorants
APL M-14
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
OSTOMY SUPPLIES FOR IRRIGATION/DIVERSION
AADL
Cat #
Description of Benefit
Additional Details
Quantity and
Frequency Limit
Price
Maximum
M030
Ostomy Irrigation Kits
• Includes reusable bag, irrigator tip (cone or
catheter), and tubing.
1/2 mo
$65.14
M031
Reusable Ostomy Irrigation Sleeves
• Used in conjunction with M030 irrigation kit
30/2 mo
$10.99
M136
Continent Ostomy Diversion Catheters
• Used for irrigation or drainage of continent diversion
• Large bore catheters drain stool from an Indiana or
Koch pouch (document on 1250 form).
2/2 mo
$7.96
Continent Diversion Dressings – adhesive pad
• Adhesive dressings with a built-in absorbent pad
• Approximately 5 cm x 7.5 cm (2” x 3”)
• For client with a functioning stoma (document on
1250 form).
• Alternative to pouch
300/2 mo
$1.09
Continent Diversion Dressing – clean gauze
• 10cm x 10 cm (4” x 4”)
• For client with a functioning stoma (document on
1250 form).
• Alternative to pouch
400/2 mo
$0.06
2/12 mo
$277.95
M160
M164
OSTOMY HERNIA BELTS
M041
Ostomy Hernia Belt - Custom
• For difficult to fit clients when ready-made option does
not meet the client’s basic need
• For client with abdominal girth greater than
52”(document on 1250 form).
M115
Ostomy Hernia Belt - Customized ready-made
• For client with inoperable parastomal or incisional
hernias. (Document on 1250 form).
• Fits clients with abdominal girth less than 52”
2/12 mo
$189.10
M117
Ostomy Belt – extended wear
• Extends pouch wear time to a minimum 3-5 days
(Document on 1250 form).
2/12 mo.
$15.50
© 2014 Government of Alberta
July 1, 2014
APL M-15
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual M - Medical Surgical Approved Product List
Prices reflect the maximum contribution by the
Alberta Aids to Daily Living (AADL) program
and is subject to COST SHARE
DISCONTINUED MEDICAL SURGICAL SUPPLIES CATALOGUE NUMBERS
AADL
Cat #
Type of Benefit
Description of Benefit
M304
Catheters
External Catheter, Reusable, Latex
M768
Dressings
Special Interactive/Alginate Dressing 15 cm x 20 cm
M771
Dressings
Special Interactive/Hydrocolloid Dressing 15cm x 20 cm
© 2014 Government of Alberta
July 1, 2014
APL M-16