Alberta Health
AADL Approved Product List - Prosthetic Benefits
Pricing effective April 1, 2015
© 2013 Government of Alberta April 1, 2014
Generic Pricing Procedure
Catalogue Number Information
General Information
Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number.
Procedure 1. Locate the catalogue number and enter the manufacturer invoice cost for the component into the calculator. Do not include shipping costs, exchange or any other cost. The cost used for generic catalogue number must be the manufacturer's invoice cost only. The calculator will automatically add mark-up, shipping and labour costs.2. Copy and paste the calculation into the Benefit Note on E-Business. Be sure to also indication the manufacturer and model number in the Benefit Note.3. Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade.
The AADL funding amount (AADL Price) for most orthotic and prosthetic benefit catalogue numbers is determined using the following formula:
(Material Cost + Markup) + (Shipping Cost) + (Labour Hours x Charge-Out Rate)
Definitions:
Material CostThe estimated, reasonable costs for the materials required to provide benefit. Where possible the cost will be based on the manufacturer's price list. Note: for Generic Catalogue Numbers the Specialty Supplier's actual invoice cost is used.
MarkupAn aditional amount added to the AADL Price intended to account for handling, rework and loss. For most benefits this is determined by taking a percentage of the Material Cost.
Shipping CostThe estimated, reasonable cost to ship the materials from the manufacturer to the Specialty Supplier.
Labour HoursThe estimated, reasonable number of hours required for a Certified Orthotist/Prosthetist and Technician to assess/fabricate/provide the the benefit.
Charge-Out RateAn hourly rate to account for the Specialty Supplier's costs related to providing the benefit. This includes the estimated, reasonable costs for: most overhead expenses (excluding materials and shipping cost); labour costs for certified and technical staff; administrative costs and profit margin.
Note: The above formula and definitions are provided for information purposes only. AADL reserves the right to set and adjust funding amounts as it deems appropriate.
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-1
Functional Levels
General Information
Lower Limb
Level 0 Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
Level 1 The ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed pace. This prosthesis is typical for the household ambulator.
Level 2 The ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. This prosthesis is typical for the limited community ambulator.
Level 3 The ability or potential for ambulation with variable pace. This prosthesis is typical of a community ambulator with the ability to traverse most environmental barriers while participating in activities of daily living that require prosthetic use beyond simple locomotion.
Level 4 The ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. This prosthesis is typical of the prosthetic demands of the child or active adult functioning in the community.
Upper Limb
Level 5 The ability to enhance a patient's body awareness to improve quality of life and or prepare for the patient's future functional ability.
Level 6 The ability to use the prostheses for basic hand skill activities. Generally, these activities are required for lifting, stabilizing or holding objects between two extremities.
Level 7 The ability to demonstrate a high level of function with the prosthesis that enables a client to perform sophisticated, hand skill patterns. Some typical activities would include grasping and releasing, positioning (pre-position) of the terminal device, or changing to alternate terminal devices.
Level 9 The ability to demonstrate a high level of function with a myoelectric prosthesis that enables a client to perform sophisticated, hand skill patterns.
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-2
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
#Stump Protectors
Physician Prescription Required
Stump Protector 1 Protector Per Limb Per 2 Years
False
For immediate post-operative use. A socket adaptor may be added in order to determine the client's eligibilty/suitabilty for a definitive prosthesis.
P9261 - 7, or 9 $838.35 Each(4/116/0)
##Shrinker Socks - Lower Limb
Shrinker Socks - Custom Made 6 Socks Per 12 Months
FalseP5411 - 4 Prior Approval
TF Shrinker Sock - After 12 Months 2 Socks Per 12 Months
FalseP5791 - 4 $63.87 Each(0.05/46/2)
TF Shrinker Sock - New Amp 3 Socks Per 12 Months
FalseP5201 - 42HPM9613 $63.87 Each(0.05/46/2)
TT Shrinker Sock - Non-Ambulatory 2 Socks Per 12 Months
FalseP5810 $52.39 Each(0.05/36/2)
TT Shrinker Sock - After 12 months 3 Socks Per 12 Months
FalseP5821 - 4 $52.39 Each(0.05/36/2)
TT Shrinker Sock - New Amp 6 SocksSocks Per 12 Months
FalseP4901 - 42HPHDW $52.39 Each(0.05/36/2)
##Lower Limb Socket Procedures
Physician Prescription Required
Check Socket 2 Check Socket Per 2 Years
FalseP1131 - 4Ankle Disarticulation/Chopart P-SK-301 $807.21 Each(3.75/111/18)
FalseP1201 - 4Hemipelvectomy $939.96 Each(4.5/111/18)
FalseP1191 - 4Hip Disarticulation P-SK-306 $939.96 Each(4.5/111/18)
FalseP1161 - 4Knee Disarticulation P-SK-303 $807.21 Each(3.75/111/18)
FalseP4981 - 4Proximal Femoral Focal Deficiency PFFD $797.88 Each(3.75/104/16)
FalseP1171 - 4Transfemoral P-SK-304 $807.21 Each(3.75/111/18)
FalseP1141 - 4Transtibial P-SK-302 $753.63 Each(3.5/104/16)
Definitive Socket 1 Procedure Per 2 Years
FalseP0121 - 4Ankle disarticulation (AD) P-AD-20 $3,348.30 Each(18/122/24)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-3
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
##Lower Limb Socket Procedures
Physician Prescription Required
Definitive Socket 1 Procedure Per 2 Years
FalseP9291 - 4Boyde/Chopart $3,569.55 Each(19.25/122/24)
FalseP0331 - 4Hip Disarticulation/Hemipelvectomy (HD/HP) HD-70 $4,928.39 Each(25.75/277/60)
FalseP0201 - 4Knee Disarticulation (KD) $4,174.88 Each(22.25/176/38)
False
Prior Approval - Fax the name of the client, PHN, description of the procedure, cost of materials and hours to fabricate the partial foot prosthesis. When approved by the AADL Manager, create the authorization on E-Business.
P0031 - 4Partial Foot Prior Approval
FalseP0311 - 4Proximal Femoral Focal Deficiency (PFFD) PD-60 $5,288.53 Each(28.5/182/39)
FalseP9281 - 4Rotation Plasty $3,932.73 Each(21.5/101/13)
FalseP0271 - 4Transfemoral (TF) P-TF-50 $4,359.28 Each(23.25/182/39)
FalseP0171 - 4Transtibial (TT) P-TT-30 $3,534.47 Each(19.25/94/20)
Socket Replacement - New Amputee 1 Early Replacement Per 2 Years
False
Replacement within 6 months
P0961 - 4Above Knee P-TF-51 $4,359.28 Each(23.25/182/39)
False
Replacement within 6 months
P0991 - 4Below Knee Socket P-TT-31 $3,534.47 Each(19.25/94/20)
False
Replacement within 6 months
P0951 - 4Knee Disarticulation Socket $4,174.88 Each(22.25/176/38)
Temporary Socket 3 Temporary Sockets Per 2 Years
False
For new amputee or client with complex issues with volume and/or shape.Criteria: Where multiple sockets will be required due to anticipated swelling and/or shape and/or volume change of the stump. If a check socket is required, only 2 temporary sockets will be funded. Ambulation with socket.
E7031 - 7, or 9 $1,295.63 Each(6.5/111/20)
##Additions to Lower/Upper Limb Procedures
Air Cushion - Transfemoral 1 Per 2 Years
FalseP1411 - 4 $544.97 Each(2.5/78/14)
Bariatric Option 1 Per 2 Years
False
Client is 100 lb. over normal weight or over 275 lb.
P9241 - 4 $466.00 Each(2/100/0)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-4
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
##Additions to Lower/Upper Limb Procedures
ISNY Socket Modifications 1 Per 2 Years
FalseP9311 - 7, or 9 $177.00 Each(1/0/0)
Suction Socket Procedure 1 Suction Socket Per 2 Years
False
To be billed with definitive prosthesis only
P1631 - 7 $177.01 Each(1/0/0)
Suprachondylar/Epichondylar
Modification
1 Per 2 Years
FalseP1561 - 7P-SA-301 $133.62 Each(0.75/0/0)
Syme's Posterior or Lateral Opening 1 Per 2 Years
FalseP1281 - 4P-SK-308 $509.02 Each(2.5/53/6)
Syme's PTB Design 1 Per 2 Years
FalseP1271 - 4P-SK-307 $44.26 Each(0.25/0/0)
Thermolyn Insert/ Thermo Plastic Lining 1 Per 2 Years
FalseP9341 - 7 $360.88 Each(1.25/124/0)
##Stubbies
Stubbies 2 Per 3 Years
False
Prior Approval to establish contributionSubmit hours and material costs to the AADL Manager
P7171 - 4Laminated or Non-Laminated Sockets with crepe bottom Prior Approval
##Suction- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $914.28 per year or a maximum quantity of 6 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 6 suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Contex Gel Sleeve 6 Per 12 Months
TrueP6491 - 43 mm Transtibial Gel Sleeve $146.83 Each(0.05/115/9)
Easy Sleeve - heavy duty 6 Suction Sleeves Per Limb Per 12 Months
TrueP1661 - 4SFR-24-6HP $103.49 Each(0.05/76/9)
Generic Suction Sleeve 6 Suction Sleeves Per 12 Months
False
See Generic Pricing Procedure
N1001 - 7 $247.59 Max. Each(0.05/205/9)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-5
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
##Suction- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $914.28 per year or a maximum quantity of 6 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 6 suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Ossur Iceflex Endurance sleeve 6 Suction Sleeves Per Limb Per 12 Months
TrueE5052 - 4F-0107XX $149.03 Each(0.05/117/9)
##Tension- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $1026.84 per year or a maximum quantity of 12 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 12 suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Generic Tension Sleeve 12 Tension Sleeves Per 12 Months
True
See Generic Pricing Procedure
N1101 - 7 $77.17 Max. Each(0.05/52/9)
Neoprene Sleeve 12 Per 12 Months
False
Heavy duty or equivalent (no Rx required)
P1581 - 4DKS316 $86.70 Each(0.05/61/9)
##Suspension Belts
Pelvic Belt 1 Per 12 Months
FalseP1731 - 4Light $375.07 Each(1.25/118/21)
FalseP1741 - 4Padded $595.11 Each(2/185/33)
PTB Cuff 1 Per 12 Months
FalseP2041 - 4 $315.80 Each(1.5/38/6)
Silesian Belt 1 Per 12 Months
TrueP1791 - 4 $304.46 Each(1.25/67/7)
TES Belt 2 Per 12 Months
TrueP1821 - 421B37 $186.96 Each(0.4/101/2)
Waist Belt 1 Per 12 Months
FalseP1711 - 4Padded $509.28 Each(2/119/21)
FalseP1701 - 4Standard $236.85 Each(1.25/12/2)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-6
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
##Additions to Suspension
Fork Strap 1 Per 12 Months
FalseP1671 - 4 $244.60 Each(1/52/9)
Ottobock Gator Sleeve Protector 6 Per 12 Months
True
Not required for P153, P155 - c/w sleeves.
P0411 - 4 $25.45 Each(0.05/12/2)
###Gel Cushion Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner 1 Custom Liner Per 12 Months
FalseP7252 - 4, 6 - 7, or 9Duplicate $652.38 Each(0.75/375/99)
FalseP7242 - 4, 6 - 7, or 9Initial $1,020.33 Each(1.5/585/99)
Generic Custom Gel Cushion Liner 1 Custom Liner Per 12 Months
False
See Generic Pricing Procedure
N1211 - 7, or 9 $1,497.45 Max. Each(1.5/1011/99)
Ottobock Custom Made TEC 1 Custom Liner Per 12 Months
FalseE7141 - 4 Partial Foot/Ankle Disarticulation $1,497.45 Each(1.5/1011/99)
FalseE7131 - 7, or 9Transfemoral/Syme's/Above Elbow $1,613.95 EachEach
(2/1036/99)
FalseE5041 - 4Transtibial $1,497.45 Each(1.5/1011/99)
###Gel Cushion Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Cushion Liner 2 Liners Per 12 Months
False
See Generic Pricing Procedure
N1201 - 4 $746.86 Max. Each(0.75/532/18)
Iceross TF Seal-in Liner 2 Per 12 Months
True
No pins, no locking systems or sleeves
P0561 - 4 $870.06 Each(0.75/642/18)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-7
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Gel Cushion Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Ohio Willow Wood Alpha Cushion Liner 2 Liners Per Limb Per 12 Months
TrueE7151 - 4 $473.71 Each(0.75/288/18)
Ottobock Simplicity Liner 2 Liners Per Limb Per 12 Months
TrueE5221 - 7, or 9With and without cover, no lock. $761.42 Each(0.75/545/18)
###Gel Locking Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner - Locking 1 Custom Liner Per 12 Months
FalseP7272 - 4Duplicate $722.38 Each(0.75/437/99)
FalseP7262 - 4Initial $1,058.41 Each(1.5/619/99)
Generic Custom Gel Locking Liner 1 Custom Liner Per 12 Months
False
See Generic Pricing Procedure
N1311 - 7 $1,058.41 Max. Each(1.5/619/99)
###Gel Locking Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Locking Liner 2 Liners Per 12 Months
True
See Generic Pricing Procedure
N1301 - 7 $817.42 Max. Each(0.75/595/18)
Iceross Dermo/Stabilo Liners 2 Liners Per 12 Months
TrueE5181 - 7 $651.66 Each(0.75/447/18)
Ohio Willow Wood Alpha Cushion Liner
With Lock
2 Liners Per 12 Months
TrueP6461 - 4, 6 or 7 $544.26 Each(0.75/351/18)
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© 2015 Government of Alberta Revised April 1, 2015
APL P-8
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Gel Locking Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.
Ossur Iceross Comfort Liner 2 Liners Per 12 Months
TrueE7161 - 71-5006XX $624.78 Each(0.75/423/18)
###Additions to Liners
Alpha Gel Cup 2 Per 12 Months
FalseP7201 - 4, 6 or 7 $103.23 Each(0.25/44/8)
Iceross Pads 2 Pads Per Limb Per 12 Months
FalseE5171 - 7, or 9 $111.13 Each(0.25/52/8)
Molded Distal Cushion 1 Per 12 Months
FalseP6941 - 7 $92.96 Each(0.5/3/0)
Ossur Iceross Silicone Distal Cap 2 Per 12 Months
TrueP7131 - 71-3000XX $299.98 Each(0.75/133/18)
Ottobock TEC Spots 2 TEC Spots per limb Per 12 Months
FalseE7041 - 7 $78.63 Each(0.25/22/8)
###Spacer Socks
Filler Cast Sock - 1 Ply 12 Socks Per 12 Months
TrueP2181 - 7, or 9 $20.52 Each(0.05/7/2)
###Socket Inserts- Lower and Upper
Kemblow Liner - Transtibial 1 Per 2 Years
FalseP1431 - 4 $589.57 Each(3/46/6)
Leather Socket Knee Disarticulation - KD 1 Per 2 Years
FalseP3561 - 4 $501.03 Each(2/113/20)
Liner - Transfemoral 1 Per 2 Years
FalseP1471 - 4P-SK-317 $421.78 Each(2.25/14/7)
Pelite Liner 1 Per 2 Years
FalseP4745 - 7, or 9TR, TH $270.34 Each(1.5/2/1)
FalseP1451 - 4Transtibial TFSK-316 $366.45 Each(2/7/3)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-9
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Socket Inserts- Lower and Upper
Silicone or Equivalent 1 Per 2 Years
FalseP1491 - 7, or 9 TT, TR, TH SK-318 $841.54 Each(4/109/10)
FalseP1511 - 4TF SK-319 $890.40 Each(4.25/106/19)
Symes/Knee Disarticulation Stovepipe
Liner
1 Per 2 Years
FalseP9351 - 7 $558.33 Each(3/24/0)
###Additions to Socket Inserts
Expandable Wall Socket 1 Per 2 Years
FalseP1251 - 7 $677.68 Each(3.5/45/7)
Full Leather Lining 1 Per 2 Years
FalseP9331 - 7 $215.84 Each(1/34/0)
Ischial Containment 1 Per 2 Years
FalseP9321 - 4 $177.00 Each(1/0/0)
Suprachondylar Liner Buildup 1 Per 2 Years
FalseP9301 - 4 $132.75 Each(0.75/0/0)
###Suction Valves
Generic Suction Valves 1 Suction Valve Per 2 Years
False
See Generic Pricing Procedure
N2201 - 7 $275.22 Max. Each(0.5/159/8)
Icelock Expulsion Valve 1 Per 2 Months
TrueP0591 - 4TF 542 $175.79 Each(0.25/110/8)
TrueP0581 - 4TT 541 $154.51 Each(0.25/91/8)
Ossur Valve 1 Per 2 Years
FalseP3111 - 7641 $174.42 Each(0.5/69/8)
Ottobock Thermal Valve 1 Per 2 Years
TrueP1751 - 421Y12 $285.30 (0.5/168/8)
TEC V5 Expulsion Valve Kit 1 Per 2 Years
FalseP1401 - 7 $165.86 Each(0.5/61/8)
Valve Parts 1 Valve Part Per 2 Years
True
See Generic Pricing Procedure
N1651 - 7 $131.29 Max. Each(0.25/70/8)
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-10
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Lock Systems
Fillauer Shuttle Lock 1 Shuttle Lock Per 2 Years
FalseE7351 - 7 125234 $269.29 Each(0.75/114/8)
Generic Lock Systems 1 Per 2 Years
True
See Generic Pricing Procedure
N2501 - 7 $538.99 Max. Each(0.75/355/8)
Icelock Clutch 1 Per 2 Years
FalseP1361 - 7211 $315.55 Each(0.75/155/8)
TrueP1371 - 7214 $368.75 Each(0.75/203/8)
Locking Lanyard 1 Per 2 Years
FalseP0791 - 7 $364.27 Each(0.75/199/8)
Ossur Ratchet 1 Per 2 Years
TrueP0941 - 7621 $301.55 Each(0.75/143/8)
Pro Advantage Locking Kit 1 Per 2 Years
FalseP8661 - 7 $265.22 Each(0.75/110/8)
###Additions to Lock Systems
Attachment Pin Icelock 1 Per 2 Years
FalseP1381 - 7, or 9211 & 214 $96.57 Each(0.25/39/8)
Fillauer Clutch Lock Pin 1 Clutch Lock Pin Per 2 Years
FalseE7361 - 7 $88.39 Each(0.25/31/8)
###Blocks and Laminate-in Adaptors
Generic Blocks and Laminate-in Adaptors 1 Per 2 Years
False
See generic pricing procedure
N2701 - 7, or 9 $540.09 Max. Each(0.25/435/8)
Ossur Alloy 4-hole 1 Per 2 Years
FalseP3161 - 4674 $111.13 Each(0.25/52/8)
Ossur Titanium 1 Per 2 Years
TrueP5461 - 44-Hole 675 $404.64 Each(1.25/132/35)
Ottobock Attachment Block 1 Per 2 Years
FalseP7111 - 45R1 $152.45 Each(0.5/49/8)
Ottobock Laminated Pyramid 1 Per 2 Years
FalseP8451 - 44R100 $262.90 Each(0.5/148/8)
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APL P-11
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Blocks and Laminate-in Adaptors
Ottobock Socket Adaptor 1 Per 2 Years
FalseP2111 - 7, or 94R41 $258.42 Each(0.5/144/8)
Ottobock Threaded Ring w/ Lamination
Anchor 4-Prong
1 Per 2 Years
FalseP4141 - 44R111 $249.46 Each(0.5/136/8)
###Distal Socket Adaptors
Generic Distal Socket Adaptors 1 Per 2 Years
False
See Generic Pricing Procedure
N2601 - 4 $517.69 Max. Each(0.25/415/8)
Ossur 4-hole Male Pyramid Adaptor 1 Per 2 Years
TrueP7311 - 4A233100 $107.77 Each(0.25/49/8)
Ottobock 4 Bolt Pyramid 1 Per 2 Years
FalseP6851 - 44R54 $143.34 Each(0.25/80/8)
Ottobock Rotatable Pyramid With Hole 1 Per 2 Years
FalseP6811 - 44R77 $241.05 Each(0.25/168/8)
Ottobock Rotator 1 Per 2 Years
FalseP6841 - 44R51 $200.73 Each(0.25/132/8)
###Knee Axial Rotators
Ottobock A/K Rotation Adaptor 1 Per 2 Years
FalseP6881 - 44R57 $752.89 Each(0.25/625/8)
###Proximal Knee Adaptors
Generic Proximal Knee Adaptors 1 Knee Adaptor Per 2 Years
False
See Generic Pricing Procedure - Max. $347.45
N2301 - 4 $347.45 Max. Each(0.25/263/8)
Ossur Total Knee Pyramid 1 Per 2 Years
FalseP6801 - 422 $279.14 Each(0.5/162/8)
Ottobock Pyramid Adaptor 1 Per 2 Years
FalseP6901 - 44R50 $301.53 Each(0.25/222/8)
###Proximal Knee Procedures
Thigh Lacer 1 Per 2 Years
FalseP1641 - 4 5-902A $571.24 Each(2.5/104/11)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-12
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Proximal Knee Procedures
Thigh Lacer 1 Per 2 Years
FalseP1651 - 4With gluteal/ischial moulding $927.04 Each(4.5/104/13)
###Knee Systems
Daw Teh-Lin Knee 1 Knee Per 2 Years
FalseP5603 - 4 4 Bar Pneumatic TGK-4P00 $3,400.35 Each(2.63/2588/35)
FalseP5613 - 4Graphlite Pneumatic TGK-4P10 $3,592.65 Each(2.63/2760/35)
Generic Knee 1 Knee Per 2 Years
False
See Generic Pricing Procedure
N1511 - 4Friction $3,269.35 Max. Each(2.05/2563/35)
False
See Generic Pricing Procedure
N1533 - 4Hydraulic $4,973.22 Max. Each(2.63/3993/35)
False
See Generic Pricing Procedure
N1542 - 4Hydraulic $3,827.46 Max. Each(2.63/2970/35)
False
See Generic Pricing Procedure
N1501 - 4Knee/Shin $1,436.81 Max. Each(3.5/698/35)
False
See Generic Pricing Procedure
N1521 - 4Locking $1,612.59 Max. Each(2/1092/35)
False
See Generic Pricing Procedure
N1562 - 4Multifunctional $5,694.77 Max. Each(3.22/4544/35)
Hosmer Durathane Knee Shin for Mauch
SNS
1 Per 2 Years
FalseP0462 - 434932 $1,160.45 Each(3.5/451/35)
Medial Lateral Support With BK Suction
Socket
1 Per 2 Years
FalseP7232 - 4 $1,855.22 Each(9/193/45)
Ossur Mauch Graphite Frame With
Hydraulic SNS
1 Per 2 Years
FalseP2473 - 4FRM01804U $4,141.06 Each(2.63/3250/35)
Ossur Gaitmaster Knee With Mauch SNS
(250-350 lbs.)
1 Per 2 Years
FalseP8762 - 4MKN0136 $4,475.94 Each(2.63/3549/35)
Ossur Total Knee 1 Knee Per 2 Years
TrueP9522 - 4Hydraulic 2000 $3,571.25 Each(3.22/2648/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-13
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Knee Systems
Ossur Total Knee 1 Knee Per 2 Years
False
High impact, multi speed, heavy duty weight up to 275 lb, knee disarticulate, with heavy use.Note criteria on client benefit note.
P9794Hydraulic 2100 $6,530.29 Each(3.22/5290/35)
FalseP9732 - 4Pediatric 1100 $2,134.40 Each(2.05/1550/35)
Ottobock Knee 1 Knee Per 2 Years
FalseP9603 - 4EBS 3R60 $5,694.77 Each(3.22/4544/35)
FalseP9673 - 4Hydraulic 3R45 $3,839.78 Each(2.63/2981/35)
TrueP9763 - 4Hydraulic Knee Disarticulation Titanium 3R46 - to 275 lbs. $3,671.78 Each(2.63/2831/35)
TrueP0443 - 4Pneumatic 3R106=1 $2,512.58 Each(2.63/1796/35)
TrueP5661 - 4Polycentric 4 Bar 3R36 $1,838.72 Each(2.05/1286/35)
FalseP9502 - 4Polycentric Child's Knee 3R66 $1,718.88 Each(2.05/1179/35)
FalseP9683 - 4Single Axis Hydraulic 3R80 $5,408.05 Each(3.22/4288/35)
TrueP5651 - 4Single Axis Locking 3R33 $1,385.23 Each(2/889/35)
###Knee Side Joint
Generic Knee Side Joint 1 Knee Side Joint Per 2 Years
False
See Generic Pricing Procedure
N1591 - 4 $1,137.74 Max. Each(3.5/455/8)
Ottobock Side Joints 1 Knee Side Joint Per 2 Years
TrueP9361 - 47U26 $954.06 Each(3.5/291/8)
###Microprocessor Knees
AADL provides a grant to those clients who are at least a Functional Level 3 and want to upgrade to a microprocessor knee. The grant will be paid directly to the Specialty Supplier once the microprocessor knee has been provided to the client (service date). The individual will own the microprocessor knee. AADL will not pay for repairs or maintenance of a microprocessor knee. The quantity/frequency limit of one microprocessor knee grant per five years will be strictly enforced. A client declaration for the microprocessor knee must be completed and signed prior to the authorization being submitted. A copy of this declaration must be kept on the client file in addition to the AADL client declaration form. AADL will not replace any prosthetic knee provided within 2 years due to client preference.
Microprocessor Knee 1 Microprocessor Knee Per 5 Years
FalseP9253 - 4 $6,000.00 Grant(0/0/6000)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-14
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Knee Caps
Ossur Knee Cap 1 Cap Per 2 Years
FalseP1261 - 4Large $206.90 Each(0.5/98/8)
FalseP1241 - 4Small $167.70 Each(0.5/63/8)
###Knee Extension Assists
Total Knee Extension Assist 1 Per 2 Years
FalseP1292 - 4 $203.54 Each(0.5/95/8)
###Shin Ferrules
Ossur Shin Ferrule 1 Per 2 Years
FalseP1231 - 4 $141.10 Each(0.5/39/8)
###Additions to External Knee Joints
Back Check 1 Per 12 Months
FalseP1681 - 4 $192.60 Each(1/12/2)
Joint Covers 1 Pair Per 12 Months
FalseP1621 - 4 $102.15 Pair(0.5/11/0)
###Hydraulic Cylinders
Catech SNS Hydraulic Cylinder -
Replacement Only
1 Per 2 Years
FalseP9653 - 4500R $1,855.26 Each(0.5/1569/8)
Ossur Mauch 1 Per 2 Years
FalseP7153 - 4SNS00100U - Cylinder SNS69571 - Black Replacement only $2,096.34 Each(0.5/1785/8)
###Modular Adaptors/connectors - Adjustable
Generic Adaptor/Connectors - Fixed 1 Per 2 Years
False
See Generic Pricing Procedure
N2901 - 4 $1,309.53 Max. Each(0.25/1122/8)
Generic Components 1 Per 2 Years
False
See Generic Pricing Procedure
N2401 - 4 $476.82 Max. Each(0.5/339/8)
Ottobock Slide Adaptor 1 Per 2 Years
FalseP8151 - 44R103 $396.18 Each(0.5/267/8)
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APL P-15
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Modular Adaptors/connectors - Fixed
Ottobock 4R72 Double Tube Adaptor -
female
1 Per 2 Years
FalseP8031 - 4 $244.41 Each(0.25/171/8)
Ottobock Double Pyramid Adaptor 1 Per 2 Years
FalseP8331 - 44R84 $236.57 Each(0.25/164/8)
###Tube Clamps
Generic Tube Clamps 1 Tube Clamp Per 2 Years
False
See Generic Pricing Procedure
N2101 - 4 $347.45 Max. Each(0.25/263/8)
Ottobock Tube Clamp 1 Tube Clamp Per 2 Years
FalseP8021 - 434 mm 4R82 $211.93 Each(0.25/142/8)
FalseP1101 - 7, or 94R52 P-LC-336 $211.93 Each(0.25/142/8)
FalseP8221 - 4Sliding Tube Clamp - 34 mm 4R88 $391.70 Each(0.5/263/8)
###Tubes
Generic Tubes 1 Tube Per 2 Years
False
See Generic Pricing Procedure
N2001 - 7, or 9 $477.37 Max. Each(0.25/379/8)
Ottobock 2R37 Pipe 1 Tube Per 2 Years
FalseP1081 - 7, or 9Long P-LC-338 $205.21 Each(0.25/136/8)
FalseP1071 - 7, or 9Short P-LC337 $185.05 Each(0.25/118/8)
###Torque and Shock Absorbers
Century Total Shock 1 Per 2 Years
FalseP8513 - 422 4400/4410 $1,272.05 Each(0.5/1025/35)
Generic Shock Absorber 1 Shock Absorber Per 2 Years
False
See Generic Pricing Procedure - Max. $1765.97
N1223 - 4 $1,765.97 Max. Each(0.5/1466/35)
Ottobock 4R40 Torsion Plate 1 Per 2 Years
FalseP9712 - 4 $747.89 Each(0.5/557/35)
Ottobock Torsion Tube 1 Per 2 Years
FalseP2032 - 44R39 $747.89 Each(0.5/557/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-16
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Torque and Shock Absorbers
Ottobock Torsion Tube Clamp 1 Per 2 Years
FalseP8272 - 44R85 $671.73 Each(0.5/489/35)
###Vacuum Suspension Systems and Replacement Components
Criteria
Must be a non-neuropathic client with full cognitive ability.
Must have reasonable volume management and stump shaping.
Socket Replacement Crriteria
Shrinkage of 3-5 ply as per Otto Bock.
Generic Vacuum System 1 Electric Vacuum System Per 2 Years
False
See Generic Pricing Procedure
N1603 - 4Electric $2,875.92 Max. Each(4.05/1896/35)
False
See Generic Pricing Procedure
N1613 - 4Standard $3,739.82 Max. Each(3.47/2759/35)
Ottobock Barbed Elbow Connector 1 Per 2 Years
True
Connects suction supension socket to vacuum hose at 90 degrees
P7193 - 44Y350 $145.31 Each(0.25/58/35)
Ottobock Expulsion Valve With Filter 1 Per 2 Years
FalseP6483 - 44Y345 $139.16 Each(0.25/53/35)
Ottobock Harmony System 1 Electric Vacuum System Per 2 Years
False
(1 year warranty) includes cost of V5 valve kit & shock absorbers
P9203 - 4Heavy Duty 4R150 $3,589.74 Each(3.47/2625/35)
True
(1 year warranty) includes cost of V5 valve kit & shock absorbers
P9213 - 4P2 (with pyramid and tube clamp) 4R144 $3,678.22 Each(3.47/2704/35)
###Ankles
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Endolite Attachment Plate/Bolt 1 Ankle Per 2 Years
FalseP8712 - 4 $190.61 Each(0.25/115/17)
Endolite Snubber 1 Ankle Per 2 Years
FalseP2122 - 4Heavy Duty $388.30 Each(0.5/252/17)
FalseP2052 - 4Standard $388.30 Each(0.5/252/17)
Ohio Willow Wood Impulse Ankle 1 Ankle Per 2 Years
FalseP0872 - 4 $394.18 Each(0.5/257/17)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-17
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Ankles
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Ottobock Child SACH Adaptor With
Pyramid
1 Ankle Per 2 Years
FalseP8742 - 42R40 $148.88 Each(0.25/77/17)
Ottobock SACH 1 Ankle Per 2 Years
TrueP5561 - 4Adaptor With Pyramid Titanium 2R31 $174.65 Each(0.25/101/17)
FalseP1901 - 4Shaped Wood Ankle Block 2K35 $267.63 Each(0.75/105/17)
Ottobock Single Axis Ankle 1 Ankle Per 2 Years
FalseP8671 - 4Aluminium 2R51 $390.26 Each(0.5/254/17)
TrueP5551 - 4Titanium 2R33 $505.62 Each(0.5/357/17)
Trulife Ankle 1 Ankle Per 2 Years
FalseP5762 - 4Child's Ankle Block SAB313/312/311 $199.09 Each(0.75/43/17)
Truper Ankle 1 Ankle Per 2 Years
FalseP5922 - 4Endoskeletal Ankle $441.78 Each(0.5/300/17)
False
Growth in height/length, expect 3 yr. if start at size 16
P5931 - 4Exoskeletal Ankle $486.03 Each(0.75/300/17)
###Feet
College Park Trustep 1 Foot Per 2 Years
FalseP8902 - 4 $1,755.44 Each(2.13/1199/35)
Elation (aka Total Concept) 1 Foot Per 2 Years
FalseP9143 - 4 $2,277.36 Each(2.13/1665/35)
Flex Foot 1 Foot Per 2 Years
False
Shock/Torque Absorber Not Required
P3893 - 4Ceterus Foot $4,607.51 Each(3/3608/35)
FalseP0653 - 4LP Vari-Flex Foot $2,047.19 Each(1.88/1499/35)
TrueP0663 - 4LP Vari-Flex Pyramid $2,706.87 Each(1.88/2088/35)
False
Please note repair criteria at end of schedule. When repair involves removal of costmetic skin, AADL will pay for only 1 hour to remove and replace cosmetic skin without prior approval
P9093 - 4Modular III $3,055.19 Each(1.88/2399/35)
False
Please note repair criteria at end of schedule
P8854Reflex V.S.P. S/T $4,981.59 Each(3/3942/35)
FalseP9011 - 4Sure Flex With Pyramid $780.43 Each(0.88/526/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-18
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Feet
Flex Foot 1 Foot Per 2 Years
FalseP9003 - 4Variflex with split toe $2,047.19 Each(1.88/1499/35)
Freedom Innovations Renegade 1 Foot Per 2 Years
FalseP4753 - 4 $3,498.71 Each(1.88/2795/35)
Generic Foot 1 Foot Per 2 Years
False
See Generic Pricing Procedure
N1713 - 4Adjustable $3,726.07 Max. Each(1.88/2998/35)
False
See Generic Pricing Procedure
N1722 - 4Articulated $2,091.44 Max. Each(2.13/1499/35)
False
See Generic Pricing Procedure
N1742 - 4Complex $4,981.59 Max. Each(3/3942/35)
False
See Generic Pricing Procedure
N1701 - 4Permanent $3,039.37 Max. Each(6.22/1699/35)
False
See generic pricing procedure
N1731 - 4Simple $1,207.15 Max. Each(0.88/907/35)
Magnum Heavy Duty System 1 Foot Per 2 Years
FalseP8752 - 4250-350 lbs. $1,811.15 Each(3/1111/35)
Ottobock Foot 1 Foot Per 2 Years
TrueP0111 - 41C20 Pro Symes $3,100.97 Each(6.22/1754/35)
FalseP0263 - 41E50 Advantage DP2 $2,630.71 Each(1.88/2020/35)
TrueP5212 - 4Axtion 1E56 $2,213.52 Each(2.13/1608/35)
TrueP8912 - 4Child Dynamic 1K10 $433.23 Each(0.88/216/35)
FalseP9043 - 4C-Walk Carbon 1C40 $3,314.48 Each(2.13/2591/35)
TrueP5592 - 4Dynamic Foot With Toes 1D10 $521.71 Each(0.88/295/35)
FalseP5492 - 4Trias 1C30 $1,268.79 Each(1.88/804/35)
Springlite Chopart/Syme's 1 Foot Per 2 Years
FalseP9152 - 4 $2,259.85 Each(6.22/1003/35)
Trulife 1 Foot Per 2 Years
FalseP8932 - 4Lifecast SFH110 $504.57 Each(0.88/279/35)
Trulife Foot 1 Foot Per 2 Years
FalseP9052 - 4Carbon Lightfoot SCF185 $503.29 Each(0.88/278/35)
FalseP8942 - 4Child's Play SLF132 $478.31 Each(0.88/256/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-19
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Feet
Trulife Foot 1 Foot Per 2 Years
FalseP5502 - 4Lightfoot SLF160 $503.29 Each(0.88/278/35)
###Additions to Feet
Spectra sock can be provided in addition to other catalogue items in this group
College Park Trustep Foot Shell 2 Per 12 Months
FalseP2172 - 4 $162.65 Each(0.25/98/8)
Flex Foot Spectra Sock 3 Per 12 Months
FalseP2461 - 4 $70.81 Each(0.25/16/8)
Junior Foot Shell 2 Per 12 Months
FalseP0432 - 4 $198.59 Each(0.25/130/8)
Ossur Flex Foot Foot Shell 2 Per 12 Months
TrueP2652 - 4 $219.77 Each(0.25/149/8)
Ottobock Syme's Kit 1 Per 2 Years
TrueP1981 - 41P5 - 1P9 $634.28 Each(2.25/179/35)
Springlite Foot Shell 2 Per 12 Months
FalseP2152 - 4 $272.41 Each(0.25/196/8)
###Foot Plates
Silipos Comfortzone Double Socket Gel
Liner
6 Per 12 Months
FalseP6781 - 4 $107.88 Each(0.05/85/2)
Springlite Inserts 2 Per 12 Months
FalseP6751 - 4Foot Plate $264.45 Each(0.75/85/35)
###Hip Joints
Any comparable quality system to below listed items may be substituted with AADL prior approval
External Pelvic Joint 1 Hip Joint Per 2 Years
FalseP3921 - 4 $749.66 Each(3.5/108/8)
Hip Joint 1 Hip Joint Per 2 Years
FalseP8501 - 4TGH-01 $3,522.02 Each(3.25/2599/35)
Ottobock Hip Joint 1 Hip Joint Per 2 Years
FalseP8481 - 47E4 $1,314.16 Each(3.25/628/35)
FalseP8491 - 47E5 $1,423.92 Each(3.25/726/35)
FalseP8471 - 47E7 $2,466.64 Each(3.25/1657/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-20
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Hip Joints
Any comparable quality system to below listed items may be substituted with AADL prior approval
Trulife Littig Hip Disarticulation System 1 Hip Joint Per 2 Years
FalseP7161 - 4Adult $2,110.14 Each(3.25/1338/35)
FalseP7141 - 4Pediatric - P28455 to P28464 $1,883.01 Each(3.25/1135/35)
###Additions to Hip Joints
Stainless Steel Pelvic Band 1 Per 2 Years
FalseP1771 - 4 $80.83 Each(0.25/24/8)
###Finishing
Endoskeletal Finish 1 Finish Per 2 Years
FalseP0821 - 4Hip Disarticulation (HD) P-CF-72 $1,673.99 Each(8/213/19)
FalseP0621 - 4Knee Disarticulation (KD) CF-42 $1,098.74 Each(4.75/213/19)
FalseP0341 - 4Proximal Femoral Focal Deficiency (PFFD) $1,054.14 Each(5/133/19)
FalseP5751 - 4Transfemoral (TF) $1,142.99 Each(5/213/19)
FalseP0521 - 4Transtibial (TT) $733.40 Each(3.5/88/14)
Exoskeletal Finish 1 Finish Per 2 Years
FalseP0131 - 4Ankle Disarticulation (AD) P-CF-21 $557.73 Each(3/20/3)
FalseP0251 - 4Knee Disarticulation (KD) P-CF-41 $1,514.28 Each(8/74/15)
FalseP0321 - 4Proximal Femoral Focal Deficiency (PFFD) P-CF-61 $1,514.28 Each(8/74/15)
FalseP0281 - 4Transfemoral (TF) $1,514.28 Each(8/74/15)
FalseP0191 - 4Transtibial (TT) $994.89 Each(5.25/47/12)
###Additions to Finishing
"Upgrade" indicates a product whose cost exceeds the AADL maximum contribution. Any additional cost is a client's choice and responsibility
Generic Cosmetic Skin - Silicone or
Equivalent
4 Cosmetic Skins Per 12 Months
False
Upgrade
N1831 - 4 AK $410.19 Max. Each(0.75/240/8)
False
Upgrade
N1821 - 4BK $342.99 Max. Each(0.75/180/8)
Ottobock Prosthetic Underhose 4 Per 12 Months
TrueP4951 - 499B14 TF $80.61 Each(0.25/24/8)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-21
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Lower Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Additions to Finishing
"Upgrade" indicates a product whose cost exceeds the AADL maximum contribution. Any additional cost is a client's choice and responsibility
Ottobock Prosthetic Underhose 4 Per 12 Months
TrueP4881 - 499B16 TT $74.54 Each(0.25/19/8)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-22
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
##Additions to Lower/Upper Limb Procedures
Leather Socket 1 Per 2 Years
FalseP2845 - 7 $348.52 Each(1.75/30/4)
Split Socket Design 1 Per 2 Years
FalseP2815 - 7 $934.25 Each(4.75/74/9)
###Shrinker Socks - Upper Limb
Shrinker Sock - Upper Limb 3 Socks Per 12 Months
FalseP5345 - 7 $165.95 Each(0.05/137/2)
###Upper Limb Socket Procedures
Please refer to Lower Limb Prosthetic Benefits Section for the following:
Additions to Upper Limb Procedures
Suspension Sleeves and Additions to Suspensions
Gel Cushion Liners
Gel Locking Liners
Additions to Liners
Spacer Socks
Socket Inserts
Suction Valves
Lock Systems and Additions to Lock Systems
Blocks and Laminate-in AdaptorsPhysician Prescription Required (except P122).
Check Socket 2 Check Sockets Per 2 Years
FalseP1225 - 7, or 9Upper Extremity $652.74 Each(3.5/27/2)
Definitive Socket 1 Procedure Per 2 Years
FalseP2855 - 7Elbow Disarticulation (ED) $2,764.71 Each(15/87/11)
FalseP2945 - 7Fore Quarter $4,461.14 Each(24/170/21)
False
See generic pricing procedure
P2785 - 7Plastic Hand Socket With Wrist and 4 Fingers $3,440.02 Max. Each(18/216/11)
FalseP2905 - 7Shoulder Disarticulation (SD) $3,288.43 Each(17.75/118/13)
FalseP2875 - 7, or 9Transhumeral (TH) $2,548.57 Each(14/52/11)
FalseP2825 - 7Transradial (TR) $2,013.60 Each(11/50/10)
FalseP2805 - 7, or 9Wrist Disarticulation (WD) $2,273.37 Each(12.5/46/9)
© 2013 Government of Alberta April 1, 2014
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APL P-23
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Terminal Devices
Becker Imperial 2 Terminal Devices Per 2 Years
FalseP3516 - 750316 $961.40 Each(0.5/763/17)
Generic Terminal Device 2 Terminal Devices Per 2 Years
False
See Generic Pricing Procedure
N1815 - 7Passive $718.42 Max. Each(0.5/547/17)
False
See Generic Pricing Procedure
N1806 - 7Standard $1,798.38 Max. Each(0.5/1511/17)
Hosmer Terminal Device 2 Terminal Devices Per 2 Years
TrueP3156 - 7Hook - 55009 Model 5X $601.53 Each(0.5/442/17)
FalseP3346 - 7Hook 55059 Model 555 $610.40 Each(0.5/450/17)
FalseP3585 - 7Passive Hand $354.25 Each(0.5/221/17)
Ottobock Terminal Device 2 Terminal Devices Per 2 Years
FalseP3595 - 7Passive Hand 8K18 $718.42 Each(0.5/547/17)
FalseP7216 - 7Physolivo Baby Hand - Hand, glove and wrist unit 8K14=1 $1,512.56 Each(2/1019/17)
TrueP3616 - 7Voluntary Opening 8K23 $681.46 Each(0.5/514/17)
TRS Terminal Device 2 Terminal Devices Per 2 Years
FalseP3676 - 7Grip Adult $1,883.89 Each(0.5/1587/17)
FalseP5266 - 7Infant Hand-Passive $583.83 Each(0.5/426/17)
###Gloves for Hands
Generic Multi-Articulating Glove for
Myoelectric Hand
2 Gloves Per 12 Months
False
See Generic Pricing Procedure
N1869 $1,132.81 Max. Each(0.75/885/8)
Hosmer Glove 2 Gloves Per 12 Months
FalseP3685 - 7, or 957586 $414.05 Each(0.75/243/8)
Leather Glove 2 Gloves Per 12 Months
FalseP3665 - 7NGL006-PR $420.55 Each(0.75/249/8)
Ottobock Glove 2 Gloves Per 12 Months
TrueP3645 - 7, or 98S5 $331.79 Each(0.75/170/8)
© 2013 Government of Alberta April 1, 2014
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APL P-24
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Gloves for Hands
Regal Passive Glove 2 Gloves Per 12 Months
FalseP8825 - 7 $656.59 Each(0.75/460/8)
###Hand Restoration
Partial Hand 1 Procedure Per 2 Years
FalseP3695 - 7Glove for Thumb or Finger $1,328.12 Each(4/464/99)
FalseP3705 - 7Multiple Fingers $1,339.09 Each(4/474/99)
Regal Custom Glove 1 Procedure Per 2 Years
False
See generic pricing procedure
N1855 - 7 $1,057.82 Max. Each(0.75/817/9)
###Wrist Units
Any comparable quality system to below listed items may be substituted with AADL prior approval
Generic Wrist Unit 1 Wrist Per 2 Years
False
Requires flexion/extension capability combined with rotation/quick disconnect. Cannot be combined with P377.See Generic Pricing Procedure
N1407 $1,137.98 Max. Each(0.75/882/17)
Hosmer Wrist 1 Wrist Per 2 Years
FalseP3765 - 7CAPP Nylon Body 1-1/2" 55108 $197.90 Each(0.5/82/17)
FalseP3755 - 7CAPP Nylon Body 1-3/4" 55109 $197.90 Each(0.5/82/17)
FalseP3745 - 7CAPP Nylon Body 2" 55110 $197.90 Each(0.5/82/17)
FalseP8687Child Quick Disconnect Wrist 58151 $472.31 Each(0.75/287/17)
FalseP4006 - 7Flexion Friction Wrist 51100 FW 500 (2") $375.53 Each(0.5/240/17)
FalseP3885 - 7Nylon Friction Wrist - 52156 WE 200N (1-1/2") or 300N (1-3/4")
$199.97 Each
(0.5/84/17)
FalseP3875 - 7Nylon Friction Wrist - 52160 WE 500N $199.97 Each(0.5/84/17)
FalseP3837Quick Disconnect 52127 WD 400 $281.13 Each(0.75/117/17)
TrueP3807Quick Disconnect Wrist 51043 FM 100 $361.18 Each(0.75/188/17)
FalseP3867Quick Disconnect Wrist All Stainless 53896 WD 400SS $665.73 Each(0.75/460/17)
FalseP3827Quick Disconnect Wrist Stainless Steel 51044 FM 100S $642.05 Each(0.75/439/17)
FalseP3847Quick Disconnect Wrist Stainless Steel 52128 WD 400S $397.33 Each(0.75/220/17)
FalseP3955 - 7WE 100N Infant $185.24 Each(0.5/70/17)
© 2013 Government of Alberta April 1, 2014
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© 2015 Government of Alberta Revised April 1, 2015
APL P-25
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Wrist Units
Any comparable quality system to below listed items may be substituted with AADL prior approval
Hosmer Wrist 1 Wrist Per 2 Years
FalseP3905 - 7WE 200N 1-1/2" Nylon Friction 52147 $199.97 Each(0.5/84/17)
N-Abler Wrist Unit 1 Wrist Per 2 Years
False
Bi-lateral upper limb, used for dominant hand
P5277 $3,127.28 Each(0.5/2697/17)
TRS Wrist 1 Wrist Per 2 Years
FalseP5286 - 7Infant Wrist $174.08 Each(0.5/60/17)
###Additions to Wrist Units
Sierra Wrist Flexion - Friction Wrist 1 Per 2 Years
FalseP3776 - 752371 $495.43 Each(0.5/347/17)
Wrist Unit Inserts 1 Per 2 Years
FalseP4085 - 7Aluminum - 50527 $86.56 Each(0.25/22/17)
FalseP4095 - 7Stainless Steel - 50528 $139.20 Each(0.25/69/17)
###Elbows
Generic Elbow Hinge 1 Elbow Per 2 Years
False
See Generic Pricing Procedure
N1906 - 7Single Axis Below Elbow $827.00 Max. Each(3.5/177/8)
Hosmer Elbow 1 Elbow Per 2 Years
FalseP4126 - 750606 E-200 $831.35 Each(1/552/35)
FalseP4116 - 750650 E-400 $912.55 Each(1/625/35)
FalseP4235 - 7External Locking Elbow Hinges 53885 $1,327.58 Each(3.5/624/8)
FalseP5076 - 7HD 50613 E-200 $893.06 Each(1/607/35)
FalseP5066 - 7HD 50653 E-400 $912.55 Each(1/625/35)
FalseP4205 - 7Outside Locking Hinge - Heavy Duty 50950 $1,669.52 Each(3.5/929/8)
FalseP4165 - 7Outside Locking Hinge 50776 $1,277.80 Each(3.5/580/8)
FalseP7376 - 7Power Bow 60665 E 400 $1,703.77 Each(1/1331/35)
FalseP4355 - 7Single Axis Below Elbow Hinge - Long 51856 $831.48 Each(3.5/181/8)
Ottobock Elbow 1 Elbow Per 2 Years
FalseE5086 - 7ErgoArm Elbow with Forearm - 12K42 $4,377.83 Each(1/3719/35)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-26
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Elbows
Ottobock Elbow 1 Elbow Per 2 Years
FalseP3326 - 7ErgoArm Elbow With Forearm 12K44 $4,638.79 Each(1/3952/35)
FalseE5125 - 7Modular 12R1 $557.49 Each(0.5/387/35)
###Shoulder Joint
Generic Shoulder Joint 1 Shoulder Joint Per 2 Years
False
See Generic Pricing Procedure
N1915 - 7Abduction $672.78 Max. Each(1.5/331/35)
False
See Generic Pricing Procedure
N1925 - 7Flexion - Abduction $666.51 Max. Each(1.5/326/35)
Hosmer Shoulder Joint 1 Per 2 Years
FalseP4445 - 7Abduction - Adult 51836 $683.59 Each(1.5/341/35)
FalseP4475 - 7Flexion Abduction - Adult 51010 $663.65 Each(1.5/323/35)
FalseP4495 - 7Universal - 52028 USJ-100 $647.58 Each(1.5/309/35)
###Universal Shoulder Joint
Generic Shoulder Joint 1 Shoulder Joint Per 2 Years
False
See Generic Pricing Procedure
N1935 - 7Universal $666.51 Max. Each(1.5/326/35)
###Control Cables
Hosmer Cable Control 2 Per 2 Years
TrueP4556 - 755683 $349.78 Each(1.25/102/13)
Hosmer Elbow Cable 2 Per 2 Years
FalseP1695 - 750724 $242.68 Each(1.25/17/2)
Hosmer Hook To Cable Adaptor 2 Per 2 Years
FalseP4566 - 750444 $120.78 Each(0.5/26/2)
Teflon Lining 2 Per 2 Years
FalseP4546 - 7 $99.22 Each(0.5/7/2)
###Upper Limb Suspension/Gel Liners
Any comparable quality system to below listed items may be substituted with AADL prior approval
Iceross Upper Limb 2 Per 12 Months
TrueP5335 - 7, or 9 $829.74 Each(0.75/606/18)
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
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APL P-27
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Upper Limb Suspension/Gel Liners
Any comparable quality system to below listed items may be substituted with AADL prior approval
Ottobock 14Y1 Silicone Arm Liner 2 Per 12 Months
TrueP5295 - 7 $762.54 Each(0.75/546/18)
###Upper Prosthetic Suspension
Auxila Loop 2 Per 12 Months
TrueP5095 - 7, or 950115 $122.44 Each(0.5/27/2)
Elbow Hinge - Flexible Using Leather Or
Dacron
1 Per 2 Years
FalseP4765 - 7LH100 $92.02 Each(0.5/2/0)
Epicondylar Suspension 1 Per 2 Years
FalseP1155 - 7, or 9 $320.10 Each(1.5/42/7)
Expandable Wall Design 1 Per 2 Years
FalseP4835 - 7, or 9 $713.84 Each(3.5/75/9)
Flexible Elbow - Metal 1 Per 2 Years
FalseP4775 - 7HFH-6 $792.65 Each(3.5/146/8)
Harness 2 Per 12 Months
FalseP4685 - 7Chest $162.32 Each(0.5/56/10)
FalseP4625 - 7Figure 8 $351.56 Each(1.75/30/7)
FalseP4645 - 7Figure 8 With Olecrannon $395.81 Each(2/30/7)
FalseP4635 - 7Figure 9 $301.62 Each(1.5/26/6)
Hosmer 50752 Forearm Lift Assist 1 Per 2 Years
FalseP4786 - 7E46O R&L $306.02 Each(0.5/186/8)
Icelock Ratchet 1 Per 2 Years
FalseP5307 or 9721 $344.66 Each(0.5/221/8)
North Western Ring Harness 2 Per 12 Months
FalseP4605 - 7NRH-100 $415.01 Each(1.75/80/15)
Nudge Control 1 Per 2 Years
FalseP4806 - 752521 $423.79 Each(0.5/291/8)
Ottobock Lock Pin 1 Per 2 Years
FalseP532714A107 $126.26 Each(0.5/26/8)
Ottobock Lock Set 1 Per 2 Years
FalseP531714A1 $418.58 Each(0.5/287/8)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-28
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Upper Prosthetic Suspension
Shoulder Saddle 1 Per 12 Months
FalseP4665 - 7, or 9HD100L $778.73 Each(4/54/9)
Suction Housing 1 Per 2 Years
FalseP4795 - 720004 $120.75 Each(0.5/21/8)
Suction Procedure - Upper Limb 1 Per 2 Years
FalseP2495 - 7, or 9 $177.01 Each(1/0/0)
Tricep Cuff - Full 1 Per 12 Months
FalseP4705 - 7BEC 360 $273.39 Each(1.25/39/7)
Tricep Cuff - Half 1 Per 12 Months
FalseP4725 - 7BICEPS 320 $260.38 Each(1.25/29/6)
Tricep Cuff Laminated 1 Per 2 Years
FalseP4585 - 7BEC160 $329.33 Each(1.5/49/8)
###Upper Limb Finishing
Endoskeletal Finish 1 Per 2 Years
FalseP3045 - 7Fore Quarter (FQ) $1,283.04 Each(6.75/69/10)
FalseP3015 - 7Shoulder Disarticulation (SD) $1,283.04 Each(6.75/69/10)
FalseP2985 - 7Transhumeral (TH) $973.29 Each(5/69/10)
FalseP2795 - 7Transradial (TR) $629.03 Each(3.5/7/1)
FalseP2925 - 7With Forearm - Elbow Disarticulation (ED) $929.04 Each(4.75/69/10)
Exoskeletal Finish 1 Per 2 Years
FalseP2895 - 7Elbow Disarticulation (ED) $1,658.97 Each(9/52/6)
FalseP2775 - 7Transradial (TR) $859.53 Each(4.5/50/6)
FalseP3025 - 7With Arm Sections - Fore Quarter (FQ) $2,446.36 Each(13.25/81/9)
FalseP2995 - 7With Arm Sections - Shoulder Disarticulation (SD) $2,446.36 Each(13.25/81/9)
FalseP2935 - 7With Forearm - Transhumeral (TH) $1,703.97 Each(9.25/52/7)
FalseP2525 - 7Wrist Disarticulation (WD) $764.43 Each(4/46/4)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-29
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Myoelectric Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Upper Limb Myoelectric Prosthesis
Criteria - Adults
Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be discussed with AADL.Criteria - Children
Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.
Must be at least 2 years old.
1. Clients are eligible for a conventional OR Myoelectric prosthesis.2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by AADL. 4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception: Electrodes).5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for approval. AADL will provide the maximum contributions and client upgrade costs.6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement prosthetic device.7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.8. Repairs over $800 contact AADL for prior approval.
4 Channel Processor 1 Per 3 Years
FalseP8529Allows switching of operation modes for control with the wrist rotator or locking/unlocking the elbow
Prior Approval
Batteries 2 Per 2 Years
FalseP8139 Prior Approval
Battery Chargers 1 Per 4 Years
FalseP8189 Prior Approval
Battery Mounting Set 1 Per 3 Years
FalseP8659 Prior Approval
Connection Cables 3 Per 3 Years
FalseP8259 Prior Approval
Custom Upper Extremity Liner 1 Per 12 Months
True
For use with myeoelectric electrodes
P7229- Diagnostic liner (88L3=P)- TR Silicone liner with Ottobock fixation (88L1=BA) - TH Silicone liner with OB fixation (88L1=OA)
$1,800.12 Each
(2/1236/61)
Elbow 1 Per 3 Years
FalseP8369 Prior Approval
Electric Hands & Hooks 1 Per 3 Years
FalseP8379 Prior Approval
Electric Wrist Rotators 1 Per 3 Years
FalseP8639 Prior Approval
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-30
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Upper Limb Myoelectric Prosthetic Benefits
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Upper Limb Myoelectric Prosthesis
Criteria - Adults
Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be discussed with AADL.Criteria - Children
Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.
Must be at least 2 years old.
1. Clients are eligible for a conventional OR Myoelectric prosthesis.2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by AADL. 4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception: Electrodes).5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for approval. AADL will provide the maximum contributions and client upgrade costs.6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement prosthetic device.7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.8. Repairs over $800 contact AADL for prior approval.
Electrodes 2 Per 3 Years
FalseP8389 Prior Approval
MyoWrist Flexion Unit 1 Per 3 Years
FalseP940910V40 Prior Approval
Recycle of Myoelectric Component 1 Per 12 Months
FalseP8649Cost of rebuilt component by manufacturer, shipping, plus labour hours to disassemble and install into new prosthesis
Prior Approval
Socket costs above conventional socket 1 Per 3 Years
FalseP8609ED finishing included $3,097.50 Each(17.5/0/0)
FalseP8629SH finishing included $4,779.00 Each(27/0/0)
FalseP8619TH finishing included $2,964.75 Each(16.75/0/0)
FalseP8599TR finishing included $1,991.25 Each(11.25/0/0)
FalseP8589WD Finishing Included $2,124.00 Each(12/0/0)
Switch Control 1 Per 2 Years
FalseP8399 Prior Approval
Wrist Units 1 Per 3 Years
FalseP8539Includes: Lamination Ring, Coupling Ring, Coaxial Plug Prior Approval
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-31
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Prosthetic Soft Supplies and Fees
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Socks
Prosthetic Socks 12 Per 12 Months
False
See generic pricing procedure
P7831 - 7Custom-made $113.49 Max. Each(0.05/90/2)
False
See generic pricing procedure
P5831 - 7In Catalogue $40.01 Max. Each(0.05/25/2)
###Donning Aids
Easy Proth 2 Per 12 Months
FalseP4101 - 4 $73.22 Each(0.05/54/2)
###Sheaths
Daw Prosthetic Sheath 12 Per 12 Months
TrueP4891 - 7 $46.85 Each(0.05/31/2)
Prosthetic Sheath 12 Per 12 Months
TrueP4861 - 7, or 9 $26.29 Each(0.05/13/2)
Prosthetic Sheath In Catalogue 12 Per 12 Months
False
Dealer cost plus $11.73
P5801 - 7 $52.63 Max. Each(0.05/36/2)
Silo Sheaths 8 Sheaths Per Limb Per 12 Months
FalseE7002 - 7SA332 - Regular $49.70 Each(0.05/33/2)
FalseE7012 - 7SA333 - Active $71.03 Each(0.05/52/2)
###Other Fees
Consult with Client and Multidisciplinary
Team
4 Per 12 Months
False
One hour per client at $177.00Available to private prosthetic facilities only
P9371 - 7, or 9 $177.00 Per Hour(1/0/0)
Off-Site Facility Fee 1 Per 12 Months
False
One hour per client at $177.00Invoice for only one off site fee /per client/ per device. Available to all prosthetic facilitiesDocument on the benefit note: the name of off-site facility, device, and reason for off-site fee
P9381 - 7, or 9 $177.00 Per Hour(1/0/0)
© 2013 Government of Alberta April 1, 2014
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APL P-32
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Prosthetic Soft Supplies and Fees
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Prosthetic Repairs
1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement prosthetic device.2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.3. Repairs over $800 contact AADL for prior approval4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be deducted from the initial procedure on the cost of the new device.5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and replace cosmetic skin. 6. Activities not considered a repair benefit:
trialling new components.
trimming/mods to NEW gel liners.
gait training.7. Shipping and Brokerage Fees where a device or component is:
under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials", and no "shipping or brokerage fees".
under warranty and being replaced, it must be provided under the appropriate AADL catalogue number (shipping and brokerage fees are already included).
not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included under P693/P857.
Labour 12 Hours Per 12 Months
False
Indicate on invoice # of hrs. & total $ of hrs. onlyDocumentation required:- Describe repair/mods.- # of hrs. and cost- Total cost of repair (hrs.+ materials)- % of total repair cost of device/component
P4921 - 7 $177.00 Per Hour(1/0/0)
Materials 6 Repairs Materials Per 12 Months
False
Invoice quantity = 1 per repair/modifications- Quantity of 1 is up to a maximum of $300Documentation required: - List of materials and cost
P6931 - 7 $300.00 Max. Each(0/267/0)
Myoelectric Labour 12 Hours Per 12 Months
False
Indicate on invoice # of hrs. & total $ of hrs.Documentation required:- Describe repair/mods.- # of hrs. and cost- Cost of materials- Total cost of repair (hrs.+ materials)- % of total repair cost of device/component
P8559 $177.00 Per Hour(1/0/0)
© 2013 Government of Alberta April 1, 2014
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Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
© 2015 Government of Alberta Revised April 1, 2015
APL P-33
Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###Prosthetic Soft Supplies and Fees
Functional
LevelCat. No. AADL PriceQty. / Freq.
(#hrs/material/ship)
###Prosthetic Repairs
1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement prosthetic device.2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.3. Repairs over $800 contact AADL for prior approval4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be deducted from the initial procedure on the cost of the new device.5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and replace cosmetic skin. 6. Activities not considered a repair benefit:
trialling new components.
trimming/mods to NEW gel liners.
gait training.7. Shipping and Brokerage Fees where a device or component is:
under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials", and no "shipping or brokerage fees".
under warranty and being replaced, it must be provided under the appropriate AADL catalogue number (shipping and brokerage fees are already included).
not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included under P693/P857.
Myoelectric Materials 6 Repair Materials Per 12 Months
False
Invoice quantity = 1 per repair/modifications- Quantity of 1 is up to a maximum of $300Documentation required:- List of materials and cost
P8579 $300.00 Each(0/267/0)
© 2013 Government of Alberta April 1, 2014
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© 2015 Government of Alberta Revised April 1, 2015
APL P-34