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Alberta Health

AADL Approved Product List - Seating Benefits

Pricing effective May 1, 2015

Revision History

5/1/2015X964: Update to process. See description inside.

5/1/2015Updates to Catalogue Numbers (highlighted in yellow)

5/1/2015Updated: Approved Seating Manufacturers

4/1/2014Updated: APL Format

© 2013 Government of Alberta April 1, 2014

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 ClinicsProvide commercially available seating components in conjunction with an AADL Seating Vendor who has a Commercial Seating Technician.

Level II Seating ClinicsProvide 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 IThe price is the manufacturer retail price less a 5% discount.

Level IIThe 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.


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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual X - Seating Approved Product List

© 2015 Government of Alberta May 1, 2015

APL X-1

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 = $85Pricing procedure: $85 – 5% = $80.75AADL Maximum Contribution = $80.75 (for cost-share exempt clients)Cost-Share Client portion (25%) = $80.75 x 25% = $20.19AADL portion for cost-share client = $80.75 x 75% = $60.56


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APL X-2

AADL Approved Seating Manufacturers

Manufacturer Manufacturer Representative Contact Email

Bodypoint

[email protected] Alexander

Invacare

[email protected] Corbett

nxt

[email protected] Strap

Ottobock

[email protected] Royal

Power Plus Mobility

[email protected] Mohan

ROHO

[email protected] Alexander

Sunrise Medical

[email protected] Mueller

Varilite

[email protected] Hirsch


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APL X-3

Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual X - Seating Approved Product List

01. Headrests, Neckrests, Hardware & Covers

Level I Seating - Commercial Seating Components

Cat. No.Qty. / Freq. AADL Price

Generic Commercial Seating Component - Use generic pricing method

Adaptor Kit or Mounting Plate for

Headrest/Neckrests

1 Kit or Plate Per 4 Years

False $189.70 Max. EachX062

Clamp 2 Clamps Per 4 Years

False $46.46 Max. EachTo mount headrest or other seating component X331

Hardware for Headrest/Neckrest 1 Headrest Hardware Per 4 Years

False $186.73 Max. EachThis catalogue number is only for the hardware for a headrest, combine with X015 if required.

X045

Headrest/Neckrest 1 Headrest Per 4 Years

False $171.91 Max. EachHeadrest with Lateral SupportNo hardware included, combine with X045 if required.

X035

False Prior ApprovalSpecialized HeadrestIncludes hardward, cannot be combined with X045. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X040

False $153.14 Max. EachStandard Headrest or NeckrestNo hardware included, combine with X045 if required.

X015

Daher

Headrest 1 Headrest Per 4 Years

False $82.76 EachCombination Headrest HC100 X688

False $82.76 EachLarge Headrest HL100 X687

Headrest Hardware 1 Hardware Per 4 Years

False $174.41 EachWS10 X690

Future Mobility


False $173.85 EachMulti-axial Headrest - On Chair X436

False $337.25 EachSingle Multi-axial Headrest, large foam pad and cover (no wings) includes hardware - Off Chair

X435

Headrest Extension 1 Extension Per 4 Years

False $52.25 EachMulti-axial Headrest Horizontal Extension X437


False $199.50 EachMulti-axial Universal Hardware X442

Invacare

Elite Back Headrest Adaptor 1 Adaptor Per 4 Years

False $38.95 EachI202

Jay


True $460.75 EachJay 3 AXYS Mount X486


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APL X-4





Jay


True $509.20 EachJay 3 COBRA Mount X487

Headrest mount 1 Headrest Mount Per 4 Years

True $57.95 EachJay 3 back universal X491

Maple Leaf Wheelchair


False $342.00 EachMounting plate not included X463

Headrest Mounting Plate 1 Plate Per 4 Years

False $95.00 EachX467

Ottobock


False $171.91 EachLateral Control Headrest 430C2 1-7/3-7 X522

False $153.14 EachSoft Headrest 430H2 X391

False $105.72 EachStyles Lg/Sm 430C1 = 1-7/3-7, or 430H1 = 1-7/3-7 X069

Headrest Adpator Kit 1 Adaptor Kit Per 4 Years

False $189.70 Each476D52 SK010/015/020/025/060/065 X868


False $196.61 EachGooseneck Mounting Kit 476L52-SK030 or Straight Mounting Kit 476L52-SK035 X386

False $186.73 EachMulti-Axis Offset or Multi-Axis StraightMounted to wheelchair insert, can be used for neckrest also 476L52-SK020/025/010/015

X078

Headrest Hardware Adaptor Kit 1 Adaptor Kit Per 4 Years

False $227.24 EachMounted to wheelchair uprights to back tubes of W/C using STS clamps 476D52-SK020/030/035/040/045/05

X079

Headrest Hardware Clamp 1 Clamp Per 4 Years

False $47.65 EachFor any back (477152=SK039) X969

STS Clamps 2 Clamps Per 4 Years

False $46.46 Each477D52/434H1To attach headrest hardware

X387

Stealth

Stealth i2i Headrest 1 Headrest Per 4 Years

False Prior ApprovalPrior Approval. Submit spec sheet/pricing and clinical rationale to AADL.

I210

Western Home Medical

Cane Mount Bracket 1 Bracket Per 4 Years

True $176.70 EachBracket Only X364

True $357.20 EachIncluding Aspen2 Headrest X365


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APL X-5







False $304.00 EachAdjustable chair mount, Oxford 1 system X196

False $333.45 EachAdjustable offset. Aspen1 & Aspen2 X195

True $347.70 EachWith multi-axle hardware 5470 - Aspen1 X428

True $347.70 EachWith multi-axle hardware 5471 - Aspen2 X429

Level II Seating - Custom-Made Seating Components


Custom-Made

Hardware for Custom-Made Headrest 1 Hardware Per 4 Years

False $177.93 EachMulti-axial X348

True $192.61 EachStandard X606


True $355.05 EachHeadrest with lateral support, wood rigid shell, foam and covering with movable lateral extension

X003

True $511.43 EachWith lateral support, kydex shell, foam and covering with movable lateral extension X378

Headrest Cover (replacement only) 1 Cover Per 12 Months

True $107.14 EachRemovable CoverFor replacement only

X072

Headrest/Neckrest 1 Headrest Per 4 Years

True $428.78 EachRigid kydex shell, foam and covering, occipital support X449

True $363.92 EachRigid wood shell, foam and covering, occipital support X010


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APL X-6


02. Straps, Belts & Kits




Calf Strap or H Strap 1 Strap Per Leg Per 12 Months

False $92.15 Max. EachPosterior support for bilateral/positioning of the lower legs. X065

Chest Strap 1 Chest Strap Per 12 Months

False $120.00 Max. EachChest Harness, Butterfly Strap, or H-Strap, for torso/thoracic positioning X225

Footstrap/Toe Loop 1 Footstrap Per Foot Per 12 Months

False $28.50 Max. EachTransverse Strap for positioning of foot X954

Hardware Kit for Belt 1 Kit Per 12 Months


Heel Loop/Ankle Strap 2 Per 12 Months

False $92.63 Max. EachStrapping mechanism to secure ankle/foot. X070

Pelvic Strap 1 Per 12 Months

False $156.75 Max. EachY or K Strap/Belt, for pelvic positioning. X227

Bodypoint

Ankle Huggers 1 Pair Footstraps Per 12 Months

False $185.25 Per PairMedium/large X971


False $97.85 EachMonoFlex anterior trunk support X498

False $192.85 EachStayflex Anterior Trunk Support - with or without zipper X393

Leg Harness 1 Leg Strap Per 2 Years

False $104.50 EachHB 602/603/604 X664

Pelvic Belt 1 Pelvic Belt Per 12 Months

False $156.75 Each4 point centre pull - small/med/large HB501CHB502C HB503C X427

False $127.30 EachPadded Hip Belt 2 point centre pull - small/med HB104C X426

Universal Strap 1 Strap Per 2 Years


Daher

Chest Harness 1 Chest Strap Per 12 Months

False $86.64 EachSmall, medium, large X691

Pelvic Belt 1 Pelvic Belt Per 12 Months

False $99.23 EachK/Y Belt - 2" X347

Jay

AES Structured Y Shoulder Strap 1 Trunk Support Per 12 Months

True $177.65 EachX420


True $193.80 EachJay 3 Chest Straps/Harnesses X484


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APL X-7





Lecky

Waistcoat 1 Chest Strap Per 12 Months


Nighthawk


False $66.50 EachFemale medium/large, male small/med/large X998

False $106.88 EachPadded Chest Strap N4.037 X962

Pelvic Belt 1 Pelvic Strap Per 12 Months

False $47.50 EachBlack webbing N4.031 X948

False $114.00 EachK Belt, padded/black webbing & hardware N4.027 X944

False $109.25 EachK Belt, padded/black webbing N4.028 X945

False $114.00 EachY Belt with safety/black webbing & hardware N4.021 X938



True $83.60 EachButterfly Shoulder Harness - Small, small slim, med., med. slim, large, large slim X445

Hip Belt 1 Pelvic Strap Per 12 Months

False $131.10 EachPadded hip belt dual rear pulll #5035 X590



Custom-Made

Abduction Strap 1 Strap Per Leg Per 12 Months


Arm Strap 1 Strap Per Arm Per 12 Months

True $96.94 EachTo secure arm X119

Axilia Strap 1 Strap Per Arm Per 12 Months

True $96.94 EachOver-the-shoulder strap X117

Calf Strap or H Strap 1 Calf Strap Per Leg Per 12 Months



True $209.85 EachButterfly Chest StrapTo assist upper trunk control

X113

True $103.37 EachHorizontal strap to assist upper trunk control X041

True $165.43 EachH-Strap, to assist upper trunk control. X031

True $165.43 EachV-Strap, to assist upper trunk control X111

Footstrap/Toe Loop 1 Strap Per Foot Per 12 Months



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APL X-8





Custom-Made

Halo Strap or Fitted Head Strap 1 Halo Strap Per 12 Months

True $120.72 EachAttached to headrest X073

Padded option to strap 1 Padded Option Per Strap Per 12 Months

True $120.69 EachClients are eligible for a maximum quantity of 3.

X379

Pelvic Strap 1 Pelvic Strap Per 12 Months

True $144.86 EachBasic Y-Strap X033

True $112.17 EachStrap of webbing including closure X042

Safety Strap 1 Safety Strap Per 2 Years

True $103.00 EachTo secure insert to mobility base X044


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APL X-9


03. Hooks, Brackets, Clips, Clamps & Links




Clamp 2 Clamps Per 4 Years

False $46.46 Max. EachTo mount headrest or other seating component X331

Drop Base Mount Clips 4 Per Back and Per Base Per 4 Years


Growth Bracket/Hardware 1 Growth Bracket Per 4 Years


Hooks 4 Hooks Per Back and Per Base Per 4 Years

False $14.90 Max. EachTwist Release (antigravity hooks), quantity 4 for base, and quantity 4 for back X635

Locking Suspension Hook (L/R) 4 Hooks Per 3 Years

False $34.63 Max. EachPrefab component locks, insert to W/C X138

Sliding 90 degree bracket 1 Sliding Bracket Per 3 Years


Spacer Hardware 1 Pair Per 4 Years

False $215.65 Max. Per Pair

X110

Future Mobility

Back Mounting Brackets 1 Pair Per 4 Years

False $180.50 Per PairBariatricTo transfer the back to 2nd W/C

X193

False $142.50 Per PairLunar Back BracketsFor second wheelchair

I227

False $142.50 Per PairStandardTo transfer the back to 2nd W/C

X192

Invacare

Antigravity Hooks 2 Pairs of Hooks Per 3 Years

False $81.17 Per PairQuick Release Rail Clamp (anti-gravity hooks) 1063327This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base.

X878

False $159.60 Per PairTwist Release (antigravity hooks) for Ultimate curved/Personal backs cane clamp 1063331/332

This is for replacement only.

X615


False $268.85 Per PairMatrx PB BracketsTo transfer back to 2nd W/C

X451

False $381.90 Per PairMatrx PB Brackets - heavy dutyTo transfer back to 2nd W/C.

X452

Fixed Spacer Hardware 1 Pair of Spacers Per 4 Years

False $215.65 Per PairFor Elite backs X665


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APL X-10


03. Hooks, Brackets, Clips, Clamps & Links



Invacare

Growth Bracket 1 Growth Bracket Per 4 Years

False $60.08 Each5500043Included with KSS. This is for replacement only.

X798

Hooks 4 Hooks Per 3 Years

False $32.49 EachDrop Hooks 1063290-95This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base.

X907

False $19.00 EachDrop Hooks for curved back 1063318 (1")Each. This is for replacement only.

X616

Jay


True $91.20 Per PairFor Jay 2, Jay 2 Deep, Jay Care Back - bottom universal post bracket 680C D395 X685

True $43.70 Per PairFor Jay 2, Jay 2 Deep, Jay Care Back - top quick release 1/4 turn bracket 681CTo transfer back to 2nd W/C

X669

True $286.90 Per PairJay 3 back hardwareTo transfer back to 2nd W/C

X490

nxt


False $180.50 Per PairBack BracketsTo transfer back to 2nd W/C

I216

Ottobock


False $185.25 Per PairBackrest HardwareTo transfer back to 2nd W/C

X392

Pride Mobility


False $197.60 Per PairSynergy Shape Back HardwareTo transfer back to 2nd W/C

X457


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APL X-11


04. Lateral Supports, Hardware & Pads




Thoracic Lateral 1 Lateral Per Side Per 4 Years

True $221.83 Max. EachHardware and pad X214

Invacare

Matrx Elite Thoracic Lateral 1 Lateral Per Side Per 4 Years

False $104.50 EachOff-Set X652

False $114.95 EachRigid X649

Jay

Jay 2 Thoracic Laterals 1 Pair of Laterals Per 4 Years

True $443.65 Per PairSwing-Away X607

Jay 3 Thoracic Laterals 1 Pair of Laterals Per 4 Years

True $271.70 Per PairFixed Laterals X485

Ottobock

OB STS Clamp 1 Clamp Per Side Per 4 Years

False $46.46 Each434H1=1UPGRADE

X911

OB STS Pad 1 Lateral Pad Per Side Per 4 Years

False $118.56 EachLarge/med/small 434P1 X812

STS Hardware Rod Assembly 1 Support Hardware Per Side Per 4 Years

False $117.57 Each434F1 X713



Custom-Made

Lateral Thoracic Support 1 Lateral Per Side Per 4 Years

True $166.38 EachLateral Support, rigid support, foam and covering X017

Lateral Thoracic Support 1 Lateral Per Side Per 4 Years

True $215.11 EachRigid support, foam and covering-kydex curved X473

True $357.51 EachSwing-Away X349


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APL X-12


05. Hip Bolsters




Lateral Pelvic Support/Hip Bolster 1 Support Per Leg Per 3 Years

True $77.90 Max. EachX112


Side Bolster 1 Bolster Per Side Per 3 Years




Custom-Made

Hip Bolster 1 Bolster Per Side Per 3 Years



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APL X-13


06. Wedges, Pommels, Abduction & Adduction




Lateral Thigh Support/Adductors 1 Thigh Support Per Leg Per 3 Years

True $138.08 Max. EachPrice to include pad and hardware if required.

X114

Obliquity Pad/Build-up/Fluid Supplement 1 Addition Per 3 Years

True $51.30 Max. EachX118

Pommel/Thigh Abductor 1 Pommel Per 3 Years

False $378.10 Max. EachPrice to include pad and hardware if required

X577

Seat/Base 1 Wedge Per 3 Years

True $127.30 Max. EachFull Wedge X115

False $49.40 Max. EachHemi Wedge X116

Jay

Fluid Supplement 1 Fluid Supplement Per 3 Years

True $51.30 EachF119 X308

Jay Seat Wedge 1 Pair of Adductors Per 3 Years

True $51.30 Per PairAdductor 1" B119J X306

True $62.70 Per PairAdductor 2" B113J or B163 X307

True $127.30 EachBase Wedge B114 X309

True $51.30 EachPelvic obliquity build-up B116R or L X520


Abductor 1 Abductor Per 3 Years

True $280.25 EachFlip-down X464



Custom-Made

Abduction Stop 1 Abduction Stop Per Side Per 3 Years

True $179.86 EachRigid shell, foam & covering X053

Pommel 1 Pommel Per 3 Years

True $675.71 EachFlip Down Pommel, rigid support foam covering inner/outer hardware X350

True $227.69 EachNon-removable Pommel, rigid support foam covering and hardware for attachment of non-removable pommel

X133

True $315.56 EachRemovable Pommel, rigid support foam covering inner/outer hardware X023


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APL X-14


07. Sub-ASIS Bars & Belts




Sub-ASIS Bar 1 Sub-ASIS Belt/Bar Per 4 Years

False $415.17 Max. EachRigid Sub-ASIS pelvic control.Client eligible for either X100 or X105

X100

Sub-ASIS Belt 1 Sub-ASIS Belt/Bar Per 4 Years

False $223.25 Max. EachSoft Sub-ASIS pelvic control.Client eligible for either X100 or X105

X105

Bodypoint

Sub-ASIS Belt 1 Sub-ASIS Belt/Bar Per 4 Years

False $223.25 EachMedial 4pt center pull X472

Metalcraft

Swing Away Sub-ASIS Bar 1 Sub-ASIS Belt/Bar Per 4 Years

False $415.17 EachWith mid relief, includes 2-90 degree Brackets, 1 universal swing away bracket, 1 offset sub-asis bar with mid relief, 2 hours labour

X580



Custom-Made

Sub-ASIS Bar 1 Sub-ASIS Belt/Bar Per 4 Years

True $431.86 EachSemi-rigid Sub-ASIS Bar, or ACH Y-beltTo be added to X033 when appropriate.

X600


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APL X-15


08. Foot & Leg Supports & Hardware




Footbox/Foot Pocket 1 Footbox Per Foot Per 2 Years

False $114.00 Max. EachSemi-enclosed leg and footrestIf footbox/footpocket is for bilateral feet then use quantity of 2.

X955

Modified Foot Support 1 Support Per Foot Per 4 Years

True $179.55 Max. EachModified/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

X080

Bodypoint

Ankle Huggers 1 Pair Footstraps Per 12 Months

False $185.25 Per PairMedium/large X971

Calf panel 1 Calf Panel Per 12 Months



Footbox 1 Footbox Per 2 Years

False $228.00 EachContractive Sling - 1 piece padded footbox X495

Nighthawk

Toe Loops 1 Toe Loop Per Foot Per 12 Months


Variety Village

Foot Pockets 1 Footpocket Per Foot Per 2 Years



Footbox 1 Footbox Per Foot Per 2 Years

True $228.95 EachOne Piece cushioned Footbox #5081 X446

True $269.80 Per PairWestern Split Cushion Footbox #5082 X447

Rigid Shoe Holders 1 Pair Shoe Holders Per 4 Years

True $179.55 Per PairX519

Toe Loops 1 Toe Loop Per Foot Per 12 Months

True $35.34 Each#5086 X448



Custom-Made

Calf Support 1 Support Per Leg Per 2 Years

True $234.94 EachRigid shell, foam, covering X061


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APL X-16


08. Foot & Leg Supports & Hardware



Custom-Made

Footbox 1 Footbox Per 4 Years

True $403.59 EachIncludes both feet X127

Footpocket 1 Footpocket Per Foot Per 2 Years


Footrest 1 Footrest Per Foot Per 4 Years


Footstrap/Toe Loop 1 Strap Per Foot Per 12 Months


Knee Block 1 Knee Block Per 4 Years

True $505.54 EachRigid shell, foam, covering and straps X129

Neoprene Padding of Front Rigging 1 Padding Per Leg Per 3 Years



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APL X-17


09. Arm, Hand & Shoulder Supports



Custom-Made

Armrest with hardware 1 Pair Per 2 Years

True $336.82 Per PairX166

Elbow Stops 1 Elbow Stop Per Arm Per 2 Years

True $201.58 EachAdded to trays X043

Shoulder Protraction Wedges 2 Wedges Per 2 Years



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APL X-18


10. Trays



Commercial Tray Customization 1 Tray Customization Per 2 Years

False $67.85 EachTo accommodate a power wheelchair control box X587


Bayonet Mounting on Tray 1 Mount Per 2 Years


Communication Board Mount to Seating System 1 Mount Per 2 Years




Custom-Made

Tray 1 Tray Per 2 Years

True $510.07 EachIncluding mounting hardware - padding X351

True $687.41 EachIncluding mounting hardware, lexan, added lip X054

True $862.70 EachIncluding mounting hardware, lexan, heavy duty bayonet, added lip X381

True $705.11 EachIncluding mounting hardware, lexan, heavy duty bayonet, no lip X380

True $534.79 EachTo accommodate communication device, includes mounting hardware X056


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APL X-19


11. Backs & Replacement Covers




Back 1 Back Per 4 Years

True $659.30 Max. Each< 3" Contour Depth, ≤ 15" Tall, Any width X124

True $741.00 Max. Each< 3" Contour Depth, ≥ 20" Tall, Any width X126

True $765.70 Max. Each< 3" Contour Depth, 16" - 19" Tall, Any width X125

True $751.45 Max. Each≥ 6" Contour Depth, ≤ 15" Tall, Any Width X150

True $857.85 Max. Each≥ 6" Contour Depth, ≥ 20" Tall, Any width X155

True $881.60 Max. Each≥ 6" Contour Depth, 16" - 19" Tall, Any width X152

True $731.50 Max. Each3"-5" Contour Depth, ≤ 15" Tall, Any Width X130

True $799.90 Max. Each3"-5" Contour Depth, ≥ 20" Tall, Any width X134

True $823.65 Max. Each3"-5" Contour Depth, 16" - 19" Tall, Any width X132

False Prior ApprovalNon-Standard/Custom SizePrior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Cannot be combined with X200.

X935

True $770.36 Max. EachPlanar "I"-Shape, ≤ 13" Wide, Any height X120

True $828.50 Max. EachPlanar "I"-Shape, ≥ 13" Wide Any height X122

Back Bariatric Option 3 Bariatric Option Per 4 Years

False $300.00 Max. EachWeight 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.

X200

Back Cover 1 Replacment Cover Per 4 Years

False Prior ApprovalCustom size replacement cover for commercial systems for adults & peds.For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL.

X169

False Prior ApprovalStandard size back replacement cover for commercial systems for adults & peds.For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL.

X171

Future Mobility

Air Back 1 Back Per 4 Years

False $902.50 Each14x14 16x18 17x16 17x20 18x18 19x16 19x20 20x18 X412

False $760.00 Each16x16 16x20 18x16 18x20 20x16 20x20 X411

False $1,140.00 EachBariatric size X371

Lunar Back 1 Back Per 4 Years

False $674.50 EachMid Back - No Lateral I220

Max Back Option 1 Option Per 4 Years

False $105.00 EachFor Prism Air Back and TruefittUse this catalogue number with the applicable Future Mobilty Air or Truefitt back. $105 is the maximum, not all Max Backs require full amount.

X409

Phantom Back 1 Back Per 4 Years

False $379.05 Each12-18" x 7" X443


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APL X-20





Future Mobility

Prism Basic Back 1 Back Per 4 Years

False $584.25 Each10x12, 12x12, 16x16, 16x20, 18x16, 18x20, 20x16, 20x20 X369

False $679.25 Each11x12, 11x14, 12x14, 12x16, 13x12, 13x14, 13x16, 14x16, 15x12, 15x14, 15x16, 16x12, 16x14

X279

False $712.50 Each14x14, 16x18, 17x16, 17x20, 18x18, 19x16, 19x20, 20x18 X370

TrueFitt Back 1 Back Per 4 Years

False $831.25 Each16x16, 18x16, 20x16 X417

False $878.75 Each16x18 16x20 17x16 17x20 18x18 18x20 20x18 20x20 X374

False $1,187.50 EachBariatric size X375

Invacare

Matrx PB Back 1 Back Per 4 Years

False $680.20 Each13-20" 250 lbs. max. X431

False $826.50 EachDeep Back 13-19" 250 lbs. max. X433

False $973.75 EachHeavy Duty Back 19-25" 500 lbs. max. X432

Matrx PB Elite Back 1 Back Per 4 Years

False $850.25 EachDeep Back X199

False $709.65 EachWidths 12-20, ht 12, 16, 20 wt capacity 300 lbs. X455

Personal Back 10 1 Back Per 4 Years

False $611.80 EachReg. Height or Tall (13-20"), aluminum hardware X213

False $905.35 EachReg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. X368

Personal Back 10 Plus 1 Back Per 4 Years

False $768.55 Each13-20", steel hardware X693

False $1,062.10 EachReg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. X367

Jay

J2 Back 1 Back Per 4 Years

True $718.20 EachFits 12-20" W/C X101

True $822.70 EachFits 20" X659

True $822.70 EachTall - fits 14, 15, 16, 17, 18, 19" W/C X098

True $949.05 EachTall - fits 20" X610

J2 Deep Contour Back 1 Back Per 4 Years

True $748.60 Each14, 15, 16, 17, 18, 19" X970

True $797.05 Each20" X353

J2 Plus Back 1 Back Per 4 Years

True $1,406.00 Each20-23", 23-26" without headrest mounting kit X373


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APL X-21





Jay

Jay 3 Back 1 Back Per 4 Years

True $542.45 EachLower Thoracic (2.2" contour) -12, 14, 16, 18, 20, (SMT) X421

True $629.85 EachLower Thoracic (6" deep and post contour) -14,16,18,20, (SMT) X413

True $659.30 EachMid Thoracic (2.2" contour) - 12, 14, 16, 18, 20, (SMT) X422

True $731.50 EachMid Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) X423

True $751.45 EachMid Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) X784

True $741.00 EachShoulder Ht. (2.2" contour) 14, 16, 18, 20, (SMT) X476

True $799.90 EachShoulder Ht. (3" contour) 14, 16, 18, 20, (SMT) X477

True $857.85 EachShoulder Ht. (6" contour) 14, 16, 18, 20, (SMT) X478

True $867.35 EachShoulder Ht. (6" deep and post contour) 16,18,20, (SMT) I204

True $765.70 EachUpper Thoracic (2.2" contour) 12, 14, 16, 18, 20, (SMT) X424

True $823.65 EachUpper Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) X425

True $881.60 EachUpper Thoracic (6" contour) 14, 16, 18, 20, (SMT) X475

True $896.80 EachUpper Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) X787

Jay 3 Components 3 Components Per 4 Years

False Prior ApprovalFor base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

I211

Jay Active Back 1 Back Per 4 Years

False $512.05 EachWith Quick Release Brackets 520/522/525/527/528 (14", 15", 16", 17", 18") X566

Jay Care Back 1 Back Per 4 Years

True $642.20 Each3500B/3505B 16" and 18" W/C X093

True $755.25 Each3502 - 20" X658

Jay Focus Back 1 Back Per 4 Years



Kyphotic Back Options 1 Option Per 4 Years

False Prior ApprovalLaterals ht. and back ht.Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X465

ML Kyphotic Back 1 Back Per 4 Years

False $799.90 EachML Deep, Mid or Shallow shell – bariatric width X461

False $799.90 EachML Deep, Mid or Shallow shell – tall 22”/24 X462

False $632.70 EachML Deep, Mid or Shallow shell 10”-‐20” (1”increments) 18” ht., standard ht. Laterals (10 ½”)

X460


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APL X-22





nxt

Fixed Height 1 Back Per 4 Years

False $750.50 EachPlus Contour I231

False $655.50 EachSupport Contour or Active Contour I217

False $945.25 EachVicair Contour 16,17,18x16/20 18,19,20x16/20 20,21,22X16/20 I228

Height Adjustable 1 Back Per 4 Years

False $655.50 EachSupport contour/active countour/plus count HA SC/AC/PC 16-22 I214

False $684.00 EachSupport contour/plus contour HA SC/ PC 22-24 I215

Ottobock


False $490.05 EachBack 1 - 15-17", 18-20" X660

False $627.38 EachBack 2 - 15-17", 18-20" X978

False $748.90 EachBack 3 15-17", 18-20" with or without teardrop laterals X979

False $980.10 EachBack 4 - 15-17", 18-20" with or without teardrop laterals X980

Floam Cells 8 Floam Cells Per 4 Years


Pride Mobility

Synergy Shape 2 Back 1 Back Per 4 Years

False $759.05 Each14, 16, 18, 19, 20", 300 lbs max. 4" depth adjustment angle adjustment from -33 to +57 degrees

X434

False $783.75 EachTall 16,18,20,22" X 23" 300 lbs max. 4" depth adjustment, angle adjustment from -33 - +57 degrees

X466

Ride

Ride Back 1 Back Per 4 Years

False $465.50 EachCorbac Adjustable Contour X489

False Prior ApprovalCustomPrior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X488



Custom-Made


True $894.87 EachContoured X671

True $174.42 EachLumbar Support X049

True $640.85 EachPlanar Back Interface System X067

False Prior ApprovalPressure reduction back with polymer or air floatation insertPrior Approval. Submit request to AADL. (custom back $493.00 + cost of pressure relief surface)

X179

True $855.79 EachWeb Back Box X151


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APL X-23





Custom-Made


True $590.25 EachWeb Back Sling X670

Neoprene Padding of Back Canes 1 Padding Per 4 Years


Removable Cover 1 Cover Per 4 Years

True $333.45 EachNeoprene optionReplacement only

X383

True $235.39 EachStandardReplacement only

X401


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APL X-24


12. Bases, Cushions & Replacement Covers



Wheelchair Cushions provided on "V" APL 1 Service Fee Per 3 Years



Cushion 1 Cushion Per 3 Years

False Prior ApprovalNon-Standard SizePrior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X934

Replacement Cushion Cover for Commercial

Custom Cushion

1 Cover Per 12 Months

False Prior ApprovalFor replacment only. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

I101

Jay

Adult Adjustable Solid Seat 1 Seat Insert Per 3 Years

True $330.60 Each#270/271/272 (adjusts 15-18", 10-11", 11.5-14.5") 1.5" drop X249

True $406.60 EachLarge 273 (adjusts 18.5-22" wide) 2.5" drop X384

Jay 3 Components 3 Components Per 4 Years

False Prior ApprovalFor base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

I211

Jay 3 Cushion 1 Cushion Per 3 Years

False Prior ApprovalAir or fluid insert with seating component options.Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X496

False Prior ApprovalBariatric, air or fluid insert with seating component optionsPrior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X497

Ride

Ride Cushion 1 Base Per 3 Years

False Prior ApprovalCustomPrior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X430



Custom-Made

Base 1 Base Per 3 Years

True $805.95 EachAnti-thrust Seat or Non-Removable Pommel X149

True $823.49 EachBariatric - over 250 lbs. X382

True $485.66 EachKid Kart X618

False Prior ApprovalPressure Reduction Base (polymer or air floatation insert)Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X999

True $776.47 EachStandard Cushion/Base X066

True $211.85 EachT-Foam/Sunmate Cushion X051


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APL X-25


12. Bases, Cushions & Replacement Covers



Custom-Made

Drop Base 1 Drop Base Per 3 Years

True $455.92 EachPadded X356

True $139.49 EachStandardHooks not included. Previously X534.

X197

Removable Cover 1 Cover Per 4 Years

True $333.45 EachNeoprene optionReplacement only

X383

True $235.39 EachStandardReplacement only

X401

Solid Seat Insert 1 Seat Insert Per 3 Years

True $128.73 EachPre ischial shelf - for beneath an air floatation cushion X471

True $549.54 EachWith leg channels upholstered to base X470


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APL X-26


13. Spinal Alignment Assessories




Accessories for Commercial Back 3 Accessories Per 4 Years

True $48.45 Max. EachList each accessory and justification in benefit note on E-business.

X333

Jay

Jay 3 Spinal Alignment Accessories 3 Spinal Alignment Accessories Per 4 Years

True $48.45 EachLarge/Small Lumbar X479

True $42.75 EachLateral Shim X483

True $42.75 EachPost/Lateral Pelvic X482

True $38.95 EachWedge X480


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APL X-27


14. Complete Seating Systems




Adult Commercial Custom Fit Seating System 1 Seating System Per 4 Years

False Prior ApprovalMust include back, base and all supportsMust only provided when seating needs cannot be accomodated by off-the-shelf components. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X190

Pediatric Commercial Custom Fit Seating System 1 Seating System Per 2 Years

False Prior ApprovalMust include back, base and all supports.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.

I229

Jay

Additional Seating Components for SureFit System 4 Components Per 4 Years

False Prior ApprovalTo be used only after original seating provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

I207

Lecky

Squiggles Additional Seating Components 4 Per 4 Years

False Prior ApprovalComponents 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.

I201

Ottobock

Ottobock Shape System 1 Cover Per 4 Years

False $230.85 EachReplacement coverPattern on client file must be sent to Ottobock

X454



Custom-Made

"Foam-in-Place" Back or Base 1 Back or Base Per 4 Years

True $2,029.33 EachCustom-made foam back or base.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 E-business.

X024

ACH - Custom Made Insert for Commercial Stroller 1 Seating System Per 4 Years

True $1,102.20 EachIncludes 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 catalogue number.

X036

Base 1 Cushion Per 3 Years

True $485.66 EachKid Kart X618

Commode Insert 1 Insert Per 4 Years

False Prior ApprovalIncludes: back, laterals, footstraps, chest straps - no seat.Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL.

X047


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APL X-28


14. Complete Seating Systems



Custom-Made

Glenrose Infant Seat 1 Seating System Per 4 Years

True $1,102.20 EachCustom 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#

X636

GRIP Seat 1 Floor Sitting Per 4 Years

False $172.00 EachFloor Sitter X474


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APL X-29


15. Service Fees



Commercial Tray Customization 1 Tray Customization Per 2 Years

False $67.85 EachTo accommodate a power wheelchair control box X587

Hand/Arm/Shoulder Supports as provided from

"V" APL

1 Service Fee Per 2 Years


Level I - Repairs/Modifications 50% of Replacement Cost Per 4 Years

True $67.85 Per Hour Invoiced in 1/4 hour

Increments

Repairs/modifications to an existing seating system; transferring seating system to another mobility base. Price includes labour and materials. Must be authorized on E-business. Benefit notes must document type of repairs and cost breakdown.

- Cost under $67.85 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)- Repairs MUST be assessed and authorized by an AADL Authorizer, E1 forms will no longer be accepted.

X964

Recycle Fee for Seating Benefits 1 Recycle Fee Per Seating System

False $67.85 Per HourPer Hour Invoiced in 1/4

hour Increments

List recycled components in Benefit Note

- Maximum 4 hours

X651

Shipping Fee 1 Fee Per Component

False Prior ApprovalCommercial Seating Components/System RepairsSubmit invoice to AADL

X357

False $57.00 Retrieval of Trial Seating Equipment Rural - One way X783

Wheelchair Cushions provided on "V" APL 1 Service Fee Per 3 Years




Level II - Repairs/Modifications 50% of Replacement Cost Per 4 Years

True $67.85 Per Hour Invoiced in 1/4 hour

Increments

Repairs/modifications to an existing seating system; transferring seating system to another mobility base. Price includes labour and materials. Must be authorized on E-business. Benefit notes must document type of repairs and cost breakdown.

- Cost under $67.85 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)

X172

Recycle Fee for Custom Seating Benefits 4 Hours Per Seating System

False $67.85 Per Hour Invoiced in 1/4 hour

Increments

List recycled components in Benefit Note

- Maximum 4 hours

X377


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APL X-30


15. Service Fees



Shipping Fee 1 Fee Per Component

False Prior ApprovalCustom-Made Seating Components/System RepairsSubmit invoice to AADL

X358


of 32



APL X-31

alberta aids to daily living manual x - seating approved ... › dataset ›...

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