Alberta Health
AADL Approved Product List - Prosthetic Benefits
Pricing effective April 1, 2015
© 2013 Government of
Alberta April 1, 2014
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
General Information
Catalogue Number Information
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 Cost
The 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.
Markup
An 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 Cost
The estimated, reasonable cost to ship the materials from the manufacturer to the Specialty
Supplier.
Labour Hours
The estimated, reasonable number of hours required for a Certified Orthotist/Prosthetist and
Technician to assess/fabricate/provide the the benefit.
Charge-Out Rate
An 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.
Generic Pricing Procedure
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.
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
APL P-1
Page 2 of 35
Alberta Health - Professional Services and Health Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
General Information
Functional Levels
Lower Limb
Level 0
Does not have the ability or potential to ambulate or transfer safely with or without
assistance and a prosthesis does not enhance their quality of life or mobility.
Level 1
The ability or potential to use a prosthesis for transfers or ambulation on level
surfaces at fixed pace. This prosthesis is typical for the household ambulator.
Level 2
The ability or potential for ambulation with the ability to traverse low-level
environmental barriers such as curbs, stairs, or uneven surfaces. This prosthesis is
typical for the limited community ambulator.
Level 3
The ability or potential for ambulation with variable pace. This prosthesis is typical of
a community ambulator with the ability to traverse most environmental barriers while
participating in activities of daily living that require prosthetic use beyond simple
locomotion.
Level 4
The ability or potential for prosthetic ambulation that exceeds basic ambulation skills,
exhibiting high impact, stress, or energy levels. This prosthesis is typical of the
prosthetic demands of the child or active adult functioning in the community.
Upper Limb
Level 5
The ability to enhance a patient's body awareness to improve quality of life and or
prepare for the patient's future functional ability.
Level 6
The ability to use the prostheses for basic hand skill activities. Generally, these
activities are required for lifting, stabilizing or holding objects between two extremities.
Level 7
The ability to demonstrate a high level of function with the prosthesis that enables a
client to perform sophisticated, hand skill patterns. Some typical activities would
include grasping and releasing, positioning (pre-position) of the terminal device, or
changing to alternate terminal devices.
Level 9
The ability to demonstrate a high level of function with a myoelectric prosthesis that
enables a client to perform sophisticated, hand skill patterns.
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
APL P-2
Page 3 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
#
Stump Protectors
Physician Prescription Required
Stump Protector
1 Protector Per Limb
Per 2 Years
1 - 7, or 9
False
P926
For immediate post-operative use. A socket adaptor may be added in order
to determine the client's eligibilty/suitabilty for a definitive prosthesis.
$838.35 Each
(4/116/0)
##
Shrinker Socks - Lower Limb
Shrinker Socks - Custom Made
TF Shrinker Sock - After 12 Months
6 Socks Per 12 Months
1-4
False
P541
Prior Approval
1-4
False
P579
$63.87 Each
False
P520
$63.87 Each
False
P581
$52.39 Each
False
P582
$52.39 Each
False
P490
$52.39 Each
2 Socks Per 12 Months
TF Shrinker Sock - New Amp
2HPM9613
3 Socks Per 12 Months
TT Shrinker Sock - Non-Ambulatory
2 Socks Per 12 Months
1-4
0
TT Shrinker Sock - After 12 months
(0.05/46/2)
(0.05/36/2)
3 Socks Per 12 Months
1-4
TT Shrinker Sock - New Amp
(0.05/46/2)
(0.05/36/2)
6 Socks
Socks Per 12 Months
2HPHDW
1-4
(0.05/36/2)
##
Lower Limb Socket Procedures
Physician Prescription Required
Check Socket
2 Check Socket Per 2
Years
Ankle Disarticulation/Chopart P-SK-301
1-4
False
P113
$807.21 Each
Hemipelvectomy
1-4
False
P120
$939.96 Each
False
P119
$939.96 Each
(3.75/111/18)
(4.5/111/18)
Hip Disarticulation P-SK-306
1-4
Knee Disarticulation P-SK-303
1-4
False
P116
$807.21 Each
Proximal Femoral Focal Deficiency PFFD
1-4
False
P498
$797.88 Each
Transfemoral P-SK-304
1-4
False
P117
$807.21 Each
Transtibial P-SK-302
1-4
False
P114
$753.63 Each
False
P012
$3,348.30 Each
Definitive Socket
Ankle disarticulation (AD) P-AD-20
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(4.5/111/18)
(3.75/111/18)
(3.75/104/16)
(3.75/111/18)
(3.5/104/16)
1 Procedure Per 2 Years
1-4
(18/122/24)
APL P-3
Page 4 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
##
Lower Limb Socket Procedures
Physician Prescription Required
Definitive Socket
Boyde/Chopart
1 Procedure Per 2 Years
1-4
False
P929
$3,569.55 Each
(19.25/122/24)
Hip Disarticulation/Hemipelvectomy (HD/HP) HD-70
1-4
False
P033
$4,928.39 Each
Knee Disarticulation (KD)
1-4
False
P020
$4,174.88 Each
Partial Foot
1-4
False
P003
Prior Approval
False
P031
$5,288.53 Each
(25.75/277/60)
(22.25/176/38)
Prior Approval - Fax the name of the client, PHN, description of the
procedure, cost of materials and hours to fabricate the partial foot prosthesis.
When approved by the AADL Manager, create the authorization on EBusiness.
Proximal Femoral Focal Deficiency (PFFD) PD-60
1-4
Rotation Plasty
1-4
False
P928
$3,932.73 Each
Transfemoral (TF) P-TF-50
1-4
False
P027
$4,359.28 Each
Transtibial (TT) P-TT-30
1-4
False
P017
$3,534.47 Each
False
P096
$4,359.28 Each
False
P099
$3,534.47 Each
False
P095
$4,174.88 Each
False
E703
$1,295.63 Each
Socket Replacement - New Amputee
(21.5/101/13)
(23.25/182/39)
(19.25/94/20)
1 Early Replacement
Per 2 Years
Above Knee P-TF-51
1-4
Replacement within 6 months
Below Knee Socket P-TT-31
1-4
Replacement within 6 months
Knee Disarticulation Socket
1-4
Replacement within 6 months
Temporary Socket
(28.5/182/39)
(23.25/182/39)
(19.25/94/20)
(22.25/176/38)
3 Temporary Sockets
Per 2 Years
1 - 7, or 9
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.
(6.5/111/20)
##
Additions to Lower/Upper Limb Procedures
Air Cushion - Transfemoral
1 Per 2 Years
1-4
Bariatric Option
Client is 100 lb. over normal weight or over 275 lb.
Revised April 1, 2015
$544.97 Each
False
P924
$466.00 Each
(2.5/78/14)
1 Per 2 Years
1-4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
False
P141
(2/100/0)
APL P-4
Page 5 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
##
Additions to Lower/Upper Limb Procedures
ISNY Socket Modifications
1 Per 2 Years
1 - 7, or 9
Suction Socket Procedure
False
P931
$177.00 Each
False
P163
$177.01 Each
1-7
False
P156
$133.62 Each
False
P128
$509.02 Each
False
P127
$44.26 Each
False
P934
$360.88 Each
To be billed with definitive prosthesis only
Suprachondylar/Epichondylar
Modification
P-SA-301
(1/0/0)
1 Suction Socket Per 2
Years
(1/0/0)
1 Per 2 Years
1-7
Syme's Posterior or Lateral Opening
P-SK-308
1 Per 2 Years
Syme's PTB Design
P-SK-307
1 Per 2 Years
Thermolyn Insert/ Thermo Plastic Lining
1 Per 2 Years
1-4
1-4
1-7
(0.75/0/0)
(2.5/53/6)
(0.25/0/0)
(1.25/124/0)
##
Stubbies
2 Per 3 Years
Stubbies
Laminated or Non-Laminated Sockets with crepe bottom
1-4
False
P717
Prior Approval
Prior Approval to establish contribution
Submit hours and material costs to the AADL Manager
##
Suction- Suspension Sleeves
A combination of any suction suspension sleeves can be provided to a maximum of $914.28 per year or a maximum
quantity of 6 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing
a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 6
suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely
monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different
types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar
maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.
Contex Gel Sleeve
3 mm Transtibial Gel Sleeve
Easy Sleeve - heavy duty
6 Per 12 Months
1-4
1-4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
True
P166
$103.49 Each
False
N100
$247.59 Max. Each
(0.05/115/9)
(0.05/76/9)
6 Suction Sleeves Per
12 Months
1-7
See Generic Pricing Procedure
$146.83 Each
6 Suction Sleeves Per
Limb Per 12 Months
SFR-24-6HP
Generic Suction Sleeve
True
P649
(0.05/205/9)
APL P-5
Page 6 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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.
6 Suction Sleeves Per
Limb Per 12 Months
Ossur Iceflex Endurance sleeve
F-0107XX
2- 4
True
E505
$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
1-7
True
N110
$77.17 Max. Each
False
P158
$86.70 Each
See Generic Pricing Procedure
Neoprene Sleeve
DKS316
(0.05/52/9)
12 Per 12 Months
1-4
Heavy duty or equivalent (no Rx required)
(0.05/61/9)
##
Suspension Belts
Pelvic Belt
Light
1 Per 12 Months
Padded
PTB Cuff
1-4
False
P173
$375.07 Each
1-4
False
P174
$595.11 Each
False
P204
$315.80 Each
True
P179
$304.46 Each
True
P182
$186.96 Each
Waist Belt
Padded
1-4
False
P171
$509.28 Each
Standard
1-4
False
P170
$236.85 Each
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(1.5/38/6)
1 Per 12 Months
1-4
TES Belt
21B37
(2/185/33)
1 Per 12 Months
1-4
Silesian Belt
(1.25/118/21)
(1.25/67/7)
2 Per 12 Months
1-4
(0.4/101/2)
1 Per 12 Months
(2/119/21)
(1.25/12/2)
APL P-6
Page 7 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Functional
Level
Qty. / Freq.
Cat. No.
AADL Price
(#hrs/material/ship)
##
Additions to Suspension
Fork Strap
1 Per 12 Months
1-4
Ottobock Gator Sleeve Protector
False
P167
$244.60 Each
True
P041
$25.45 Each
(1/52/9)
6 Per 12 Months
1-4
Not required for P153, P155 - c/w sleeves.
(0.05/12/2)
###
Gel Cushion Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner
1 Custom Liner Per 12
Months
Duplicate
2 - 4, 6 - 7, or 9
Initial
Generic Custom Gel Cushion Liner
2 - 4, 6 - 7, or 9
False
P725
$652.38 Each
False
P724
$1,020.33 Each
(1.5/585/99)
1 Custom Liner Per 12
Months
1 - 7, or 9
False $1,497.45 Max. Each
N121
(1.5/1011/99)
See Generic Pricing Procedure
Ottobock Custom Made TEC
(0.75/375/99)
1 Custom Liner Per 12
Months
Partial Foot/Ankle Disarticulation
1-4
False
E714
$1,497.45 Each
Transfemoral/Syme's/Above Elbow
1 - 7, or 9
False
E713
$1,613.95 Each
Each
False
E504
$1,497.45 Each
(1.5/1011/99)
(2/1036/99)
Transtibial
1-4
(1.5/1011/99)
###
Gel Cushion Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Cushion Liner
2 Liners Per 12 Months
1-4
False
N120
$746.86 Max. Each
True
P056
$870.06 Each
See Generic Pricing Procedure
Iceross TF Seal-in Liner
2 Per 12 Months
1-4
No pins, no locking systems or sleeves
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.75/532/18)
(0.75/642/18)
APL P-7
Page 8 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Gel Cushion Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Ohio Willow Wood Alpha Cushion Liner
2 Liners Per Limb Per
12 Months
1-4
Ottobock Simplicity Liner
True
E715
$473.71 Each
True
E522
$761.42 Each
(0.75/288/18)
2 Liners Per Limb Per
12 Months
With and without cover, no lock.
1 - 7, or 9
(0.75/545/18)
###
Gel Locking Liners - Custom
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Alpha Design Cushion Liner - Locking
1 Custom Liner Per 12
Months
Duplicate
2- 4
False
P727
$722.38 Each
Initial
2- 4
False
P726
$1,058.41 Each
Generic Custom Gel Locking Liner
(0.75/437/99)
(1.5/619/99)
1 Custom Liner Per 12
Months
1-7
False $1,058.41 Max. Each
N131
(1.5/619/99)
See Generic Pricing Procedure
###
Gel Locking Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Generic Standard Gel Locking Liner
2 Liners Per 12 Months
1-7
True
N130
$817.42 Max. Each
True
E518
$651.66 Each
True
P646
$544.26 Each
See Generic Pricing Procedure
Iceross Dermo/Stabilo Liners
2 Liners Per 12 Months
1-7
Ohio Willow Wood Alpha Cushion Liner
With Lock
Revised April 1, 2015
(0.75/447/18)
2 Liners Per 12 Months
1 - 4, 6 or 7
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
(0.75/595/18)
(0.75/351/18)
APL P-8
Page 9 of 35
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Gel Locking Liners - Standard
Clients are eligible for either a Gel Cushion Liner OR a Gel Locking Liner
Replacement Criteria
- Standard size: minimum at 2 cm distal shrinkage
- Custom made: document distal circumferences by CAD printout indicating shape and volume changes
All liners have a 6 month minimum manufacturer's warranty coverage.
Ossur Iceross Comfort Liner
1-5006XX
2 Liners Per 12 Months
1-7
True
E716
$624.78 Each
(0.75/423/18)
###
Additions to Liners
Alpha Gel Cup
2 Per 12 Months
1 - 4, 6 or 7
Iceross Pads
Ottobock TEC Spots
False
E517
$111.13 Each
False
P694
$92.96 Each
True
P713
$299.98 Each
False
E704
$78.63 Each
(0.25/44/8)
(0.25/52/8)
1 Per 12 Months
1-7
Ossur Iceross Silicone Distal Cap
1-3000XX
$103.23 Each
2 Pads Per Limb Per 12
Months
1 - 7, or 9
Molded Distal Cushion
False
P720
(0.5/3/0)
2 Per 12 Months
1-7
(0.75/133/18)
2 TEC Spots per limb
Per 12 Months
1-7
(0.25/22/8)
###
Spacer Socks
Filler Cast Sock - 1 Ply
12 Socks Per 12 Months
1 - 7, or 9
True
P218
$20.52 Each
(0.05/7/2)
###
Socket Inserts- Lower and Upper
Kemblow Liner - Transtibial
1 Per 2 Years
1-4
Leather Socket Knee Disarticulation - KD
False
P143
$589.57 Each
False
P356
$501.03 Each
False
P147
$421.78 Each
5 - 7, or 9
False
P474
$270.34 Each
1-4
False
P145
$366.45 Each
1-4
Liner - Transfemoral
P-SK-317
Pelite Liner
TR, TH
Transtibial TFSK-316
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(3/46/6)
1 Per 2 Years
(2/113/20)
1 Per 2 Years
1-4
(2.25/14/7)
1 Per 2 Years
(1.5/2/1)
(2/7/3)
Page 10 of 35
APL P-9
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Socket Inserts- Lower and Upper
Silicone or Equivalent
TT, TR, TH SK-318
1 Per 2 Years
TF SK-319
Symes/Knee Disarticulation Stovepipe
Liner
1 - 7, or 9
False
P149
$841.54 Each
1-4
False
P151
$890.40 Each
False
P935
$558.33 Each
(4/109/10)
(4.25/106/19)
1 Per 2 Years
1-7
(3/24/0)
###
Additions to Socket Inserts
Expandable Wall Socket
1 Per 2 Years
1-7
Full Leather Lining
False
P933
$215.84 Each
False
P932
$177.00 Each
False
P930
$132.75 Each
(3.5/45/7)
(1/34/0)
1 Per 2 Years
1-4
Suprachondylar Liner Buildup
$677.68 Each
1 Per 2 Years
1-7
Ischial Containment
False
P125
(1/0/0)
1 Per 2 Years
1-4
(0.75/0/0)
###
Suction Valves
Generic Suction Valves
1 Suction Valve Per 2
Years
1-7
False
N220
$275.22 Max. Each
True
P059
$175.79 Each
True
P058
$154.51 Each
False
P311
$174.42 Each
See Generic Pricing Procedure
Icelock Expulsion Valve
TF 542
1 Per 2 Months
1-4
TT 541
Ossur Valve
641
Ottobock Thermal Valve
21Y12
TEC V5 Expulsion Valve Kit
1-4
1-7
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.25/91/8)
(0.5/69/8)
1 Per 2 Years
1-4
True
P175
$285.30
(0.5/168/8)
1 Per 2 Years
False
P140
$165.86 Each
True
N165
$131.29 Max. Each
(0.5/61/8)
1 Valve Part Per 2 Years
1-7
See Generic Pricing Procedure
(0.25/110/8)
1 Per 2 Years
1-7
Valve Parts
(0.5/159/8)
(0.25/70/8)
Page 11 of 35
APL P-10
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Lock Systems
Fillauer Shuttle Lock
1 Shuttle Lock Per 2
Years
125234
Generic Lock Systems
1-7
False
E735
$269.29 Each
True
N250
$538.99 Max. Each
1-7
False
P136
$315.55 Each
True
P137
$368.75 Each
False
P079
$364.27 Each
True
P094
$301.55 Each
False
P866
$265.22 Each
See Generic Pricing Procedure
Icelock Clutch
211
(0.75/355/8)
1 Per 2 Years
1-7
214
Locking Lanyard
(0.75/114/8)
1 Per 2 Years
1-7
(0.75/155/8)
(0.75/203/8)
1 Per 2 Years
1-7
Ossur Ratchet
621
1 Per 2 Years
Pro Advantage Locking Kit
1 Per 2 Years
1-7
1-7
(0.75/199/8)
(0.75/143/8)
(0.75/110/8)
###
Additions to Lock Systems
Attachment Pin Icelock
211 & 214
1 Per 2 Years
Fillauer Clutch Lock Pin
1 Clutch Lock Pin Per 2
Years
1 - 7, or 9
1-7
False
P138
$96.57 Each
False
E736
$88.39 Each
(0.25/39/8)
(0.25/31/8)
###
Blocks and Laminate-in Adaptors
Generic Blocks and Laminate-in Adaptors
1 Per 2 Years
1 - 7, or 9
False
N270
$540.09 Max. Each
False
P316
$111.13 Each
True
P546
$404.64 Each
False
P711
$152.45 Each
False
P845
$262.90 Each
See generic pricing procedure
Ossur Alloy 4-hole
674
1 Per 2 Years
Ossur Titanium
4-Hole 675
1 Per 2 Years
Ottobock Attachment Block
5R1
1 Per 2 Years
Ottobock Laminated Pyramid
4R100
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
1-4
1-4
1-4
(0.25/435/8)
(0.25/52/8)
(1.25/132/35)
(0.5/49/8)
1 Per 2 Years
1-4
(0.5/148/8)
Page 12 of 35
APL P-11
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Blocks and Laminate-in Adaptors
Ottobock Socket Adaptor
4R41
1 Per 2 Years
Ottobock Threaded Ring w/ Lamination
Anchor 4-Prong
4R111
1 Per 2 Years
1 - 7, or 9
1-4
False
P211
$258.42 Each
False
P414
$249.46 Each
(0.5/144/8)
(0.5/136/8)
Distal Socket Adaptors
1 Per 2 Years
Generic Distal Socket Adaptors
1-4
False
N260
$517.69 Max. Each
True
P731
$107.77 Each
False
P685
$143.34 Each
False
P681
$241.05 Each
False
P684
$200.73 Each
See Generic Pricing Procedure
(0.25/415/8)
1 Per 2 Years
Ossur 4-hole Male Pyramid Adaptor
A233100
1-4
Ottobock 4 Bolt Pyramid
4R54
1 Per 2 Years
Ottobock Rotatable Pyramid With Hole
4R77
1 Per 2 Years
Ottobock Rotator
4R51
1 Per 2 Years
1-4
1-4
1-4
(0.25/49/8)
(0.25/80/8)
(0.25/168/8)
(0.25/132/8)
###
Knee Axial Rotators
1 Per 2 Years
Ottobock A/K Rotation Adaptor
4R57
1-4
False
P688
$752.89 Each
(0.25/625/8)
###
Proximal Knee Adaptors
Generic Proximal Knee Adaptors
1 Knee Adaptor Per 2
Years
1-4
False
N230
$347.45 Max. Each
False
P680
$279.14 Each
False
P690
$301.53 Each
See Generic Pricing Procedure - Max. $347.45
Ossur Total Knee Pyramid
22
1 Per 2 Years
Ottobock Pyramid Adaptor
4R50
1 Per 2 Years
1-4
1-4
(0.25/263/8)
(0.5/162/8)
(0.25/222/8)
###
Proximal Knee Procedures
Thigh Lacer
5-902A
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
###
1 Per 2 Years
1-4
False
P164
$571.24 Each
(2.5/104/11)
Page 13 of 35
APL P-12
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Proximal Knee Procedures
Thigh Lacer
With gluteal/ischial moulding
1 Per 2 Years
1-4
False
P165
$927.04 Each
(4.5/104/13)
###
Knee Systems
Daw Teh-Lin Knee
4 Bar Pneumatic TGK-4P00
1 Knee Per 2 Years
Graphlite Pneumatic TGK-4P10
Generic Knee
Friction
3-4
False
P560
$3,400.35 Each
3-4
False
P561
$3,592.65 Each
1-4
False $3,269.35 Max. Each
N151
(2.05/2563/35)
Hydraulic
3-4
False $4,973.22 Max. Each
N153
(2.63/3993/35)
See Generic Pricing Procedure
Hydraulic
2- 4
False $3,827.46 Max. Each
N154
(2.63/2970/35)
See Generic Pricing Procedure
Knee/Shin
1-4
False $1,436.81 Max. Each
N150
(3.5/698/35)
See Generic Pricing Procedure
Locking
1-4
False $1,612.59 Max. Each
N152
(2/1092/35)
See Generic Pricing Procedure
Multifunctional
2- 4
False $5,694.77 Max. Each
N156
(3.22/4544/35)
See Generic Pricing Procedure
Hosmer Durathane Knee Shin for Mauch
SNS
34932
1 Per 2 Years
Medial Lateral Support With BK Suction
Socket
1 Per 2 Years
2- 4
2- 4
Ossur Mauch Graphite Frame With
Hydraulic SNS
FRM01804U
1 Per 2 Years
Ossur Gaitmaster Knee With Mauch SNS
(250-350 lbs.)
MKN0136
1 Per 2 Years
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(2.63/2760/35)
1 Knee Per 2 Years
See Generic Pricing Procedure
Ossur Total Knee
Hydraulic 2000
(2.63/2588/35)
3-4
2- 4
False
P046
$1,160.45 Each
False
P723
$1,855.22 Each
False
P247
$4,141.06 Each
False
P876
$4,475.94 Each
True
P952
$3,571.25 Each
(3.5/451/35)
(9/193/45)
(2.63/3250/35)
(2.63/3549/35)
1 Knee Per 2 Years
2- 4
(3.22/2648/35)
Page 14 of 35
APL P-13
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Knee Systems
Ossur Total Knee
Hydraulic 2100
1 Knee Per 2 Years
4
False
P979
$6,530.29 Each
False
P973
$2,134.40 Each
3-4
False
P960
$5,694.77 Each
Hydraulic 3R45
3-4
False
P967
$3,839.78 Each
Hydraulic Knee Disarticulation Titanium 3R46 - to 275 lbs.
3-4
True
P976
$3,671.78 Each
Pneumatic 3R106=1
3-4
True
P044
$2,512.58 Each
Polycentric 4 Bar 3R36
1-4
True
P566
$1,838.72 Each
Polycentric Child's Knee 3R66
2- 4
False
P950
$1,718.88 Each
Single Axis Hydraulic 3R80
3-4
False
P968
$5,408.05 Each
Single Axis Locking 3R33
1-4
True
P565
$1,385.23 Each
High impact, multi speed, heavy duty weight up to 275 lb, knee disarticulate,
with heavy use.
Note criteria on client benefit note.
Pediatric 1100
Ottobock Knee
EBS 3R60
2- 4
(3.22/5290/35)
(2.05/1550/35)
1 Knee Per 2 Years
(3.22/4544/35)
(2.63/2981/35)
(2.63/2831/35)
(2.63/1796/35)
(2.05/1286/35)
(2.05/1179/35)
(3.22/4288/35)
(2/889/35)
###
Knee Side Joint
Generic Knee Side Joint
1 Knee Side Joint Per 2
Years
1-4
False $1,137.74 Max. Each
N159
(3.5/455/8)
See Generic Pricing Procedure
Ottobock Side Joints
1 Knee Side Joint Per 2
Years
7U26
1-4
True
P936
$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
3-4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
False
P925
$6,000.00 Grant
(0/0/6000)
Page 15 of 35
APL P-14
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Knee Caps
Ossur Knee Cap
Large
1 Cap Per 2 Years
Small
1-4
False
P126
$206.90 Each
1-4
False
P124
$167.70 Each
(0.5/98/8)
(0.5/63/8)
###
Knee Extension Assists
Total Knee Extension Assist
1 Per 2 Years
2- 4
False
P129
$203.54 Each
(0.5/95/8)
###
Shin Ferrules
Ossur Shin Ferrule
1 Per 2 Years
1-4
False
P123
$141.10 Each
(0.5/39/8)
###
Additions to External Knee Joints
Back Check
1 Per 12 Months
1-4
Joint Covers
False
P168
$192.60 Each
False
P162
$102.15 Pair
(1/12/2)
1 Pair Per 12 Months
1-4
(0.5/11/0)
###
Hydraulic Cylinders
Catech SNS Hydraulic Cylinder Replacement Only
500R
1 Per 2 Years
3-4
1 Per 2 Years
Ossur Mauch
SNS00100U - Cylinder SNS69571 - Black Replacement only
3-4
False
P965
$1,855.26 Each
False
P715
$2,096.34 Each
(0.5/1569/8)
(0.5/1785/8)
###
Modular Adaptors/connectors - Adjustable
Generic Adaptor/Connectors - Fixed
1 Per 2 Years
1-4
False $1,309.53 Max. Each
N290
(0.25/1122/8)
See Generic Pricing Procedure
Generic Components
1 Per 2 Years
1-4
False
N240
$476.82 Max. Each
False
P815
$396.18 Each
See Generic Pricing Procedure
Ottobock Slide Adaptor
4R103
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.5/339/8)
1 Per 2 Years
1-4
(0.5/267/8)
Page 16 of 35
APL P-15
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Modular Adaptors/connectors - Fixed
Ottobock 4R72 Double Tube Adaptor female
1 Per 2 Years
1-4
Ottobock Double Pyramid Adaptor
4R84
False
P803
$244.41 Each
False
P833
$236.57 Each
(0.25/171/8)
1 Per 2 Years
1-4
(0.25/164/8)
Tube Clamps
Generic Tube Clamps
1 Tube Clamp Per 2
Years
1-4
False
N210
$347.45 Max. Each
1-4
False
P802
$211.93 Each
1 - 7, or 9
False
P110
$211.93 Each
1-4
False
P822
$391.70 Each
See Generic Pricing Procedure
Ottobock Tube Clamp
(0.25/263/8)
1 Tube Clamp Per 2
Years
34 mm 4R82
4R52 P-LC-336
Sliding Tube Clamp - 34 mm 4R88
(0.25/142/8)
(0.25/142/8)
(0.5/263/8)
###
Tubes
Generic Tubes
1 Tube Per 2 Years
1 - 7, or 9
False
N200
$477.37 Max. Each
1 - 7, or 9
False
P108
$205.21 Each
1 - 7, or 9
False
P107
$185.05 Each
See Generic Pricing Procedure
Ottobock 2R37 Pipe
Long P-LC-338
(0.25/379/8)
1 Tube Per 2 Years
Short P-LC337
(0.25/136/8)
(0.25/118/8)
###
Torque and Shock Absorbers
Century Total Shock
22 4400/4410
Generic Shock Absorber
1 Per 2 Years
3-4
False
P851
(0.5/1466/35)
1 Per 2 Years
2- 4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.5/1025/35)
False $1,765.97 Max. Each
N122
See Generic Pricing Procedure - Max. $1765.97
Ottobock Torsion Tube
4R39
$1,272.05 Each
1 Shock Absorber Per 2
Years
3-4
Ottobock 4R40 Torsion Plate
###
False
P971
$747.89 Each
False
P203
$747.89 Each
(0.5/557/35)
1 Per 2 Years
2- 4
(0.5/557/35)
Page 17 of 35
APL P-16
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Torque and Shock Absorbers
Ottobock Torsion Tube Clamp
4R85
1 Per 2 Years
2- 4
$671.73 Each
False
P827
(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
Electric
3-4
False $2,875.92 Max. Each
N160
(4.05/1896/35)
See Generic Pricing Procedure
Standard
3-4
False $3,739.82 Max. Each
N161
(3.47/2759/35)
See Generic Pricing Procedure
Ottobock Barbed Elbow Connector
4Y350
1 Per 2 Years
3-4
True
P719
$145.31 Each
False
P648
$139.16 Each
False
P920
$3,589.74 Each
True
P921
$3,678.22 Each
(0.25/58/35)
Connects suction supension socket to vacuum hose at 90 degrees
Ottobock Expulsion Valve With Filter
4Y345
Ottobock Harmony System
1 Per 2 Years
3-4
(0.25/53/35)
1 Electric Vacuum
System Per 2 Years
Heavy Duty 4R150
3-4
(3.47/2625/35)
(1 year warranty) includes cost of V5 valve kit & shock absorbers
P2 (with pyramid and tube clamp) 4R144
3-4
(1 year warranty) includes cost of V5 valve kit & shock absorbers
(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
2- 4
Endolite Snubber
Heavy Duty
$190.61 Each
2- 4
False
P212
$388.30 Each
2- 4
False
P205
$388.30 Each
False
P087
$394.18 Each
Revised April 1, 2015
(0.5/252/17)
(0.5/252/17)
1 Ankle Per 2 Years
2- 4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
(0.25/115/17)
1 Ankle Per 2 Years
Standard
Ohio Willow Wood Impulse Ankle
False
P871
(0.5/257/17)
Page 18 of 35
APL P-17
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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
2R40
1 Ankle Per 2 Years
Ottobock SACH
Adaptor With Pyramid Titanium 2R31
1 Ankle Per 2 Years
2- 4
Truper Ankle
Endoskeletal Ankle
True
P556
$174.65 Each
False
P190
$267.63 Each
False
P867
$390.26 Each
True
P555
$505.62 Each
False
P576
$199.09 Each
2- 4
False
P592
$441.78 Each
1-4
False
P593
$486.03 Each
1-4
(0.25/77/17)
(0.25/101/17)
(0.75/105/17)
1 Ankle Per 2 Years
1-4
Titanium 2R33
Trulife Ankle
Child's Ankle Block SAB313/312/311
$148.88 Each
1-4
Shaped Wood Ankle Block 2K35
Ottobock Single Axis Ankle
Aluminium 2R51
False
P874
1-4
(0.5/254/17)
(0.5/357/17)
1 Ankle Per 2 Years
2- 4
(0.75/43/17)
1 Ankle Per 2 Years
Exoskeletal Ankle
Growth in height/length, expect 3 yr. if start at size 16
(0.5/300/17)
(0.75/300/17)
###
Feet
College Park Trustep
1 Foot Per 2 Years
2- 4
Elation (aka Total Concept)
$1,755.44 Each
False
P914
$2,277.36 Each
False
P389
$4,607.51 Each
False
P065
$2,047.19 Each
(2.13/1199/35)
1 Foot Per 2 Years
3-4
Flex Foot
Ceterus Foot
False
P890
(2.13/1665/35)
1 Foot Per 2 Years
3-4
Shock/Torque Absorber Not Required
(3/3608/35)
LP Vari-Flex Foot
3-4
LP Vari-Flex Pyramid
3-4
True
P066
$2,706.87 Each
Modular III
3-4
False
P909
$3,055.19 Each
False
P885
$4,981.59 Each
False
P901
$780.43 Each
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
Reflex V.S.P. S/T
4
Please note repair criteria at end of schedule
Sure Flex With Pyramid
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
1-4
(1.88/1499/35)
(1.88/2088/35)
(1.88/2399/35)
(3/3942/35)
(0.88/526/35)
Page 19 of 35
APL P-18
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Feet
Flex Foot
Variflex with split toe
1 Foot Per 2 Years
Freedom Innovations Renegade
1 Foot Per 2 Years
3-4
3-4
Generic Foot
Adjustable
False
P900
$2,047.19 Each
False
P475
$3,498.71 Each
(1.88/1499/35)
(1.88/2795/35)
1 Foot Per 2 Years
3-4
False $3,726.07 Max. Each
N171
(1.88/2998/35)
See Generic Pricing Procedure
Articulated
2- 4
False $2,091.44 Max. Each
N172
(2.13/1499/35)
See Generic Pricing Procedure
Complex
2- 4
False $4,981.59 Max. Each
N174
(3/3942/35)
See Generic Pricing Procedure
Permanent
1-4
False $3,039.37 Max. Each
N170
(6.22/1699/35)
See Generic Pricing Procedure
Simple
1-4
False $1,207.15 Max. Each
N173
(0.88/907/35)
See generic pricing procedure
Magnum Heavy Duty System
250-350 lbs.
1 Foot Per 2 Years
Ottobock Foot
1C20 Pro Symes
1 Foot Per 2 Years
False
P875
$1,811.15 Each
1-4
True
P011
$3,100.97 Each
1E50 Advantage DP2
3-4
False
P026
$2,630.71 Each
Axtion 1E56
2- 4
True
P521
$2,213.52 Each
Child Dynamic 1K10
2- 4
True
P891
$433.23 Each
C-Walk Carbon 1C40
3-4
False
P904
$3,314.48 Each
Dynamic Foot With Toes 1D10
2- 4
True
P559
$521.71 Each
Trias 1C30
2- 4
False
P549
$1,268.79 Each
False
P915
$2,259.85 Each
False
P893
$504.57 Each
False
P905
$503.29 Each
False
P894
$478.31 Each
Springlite Chopart/Syme's
2- 4
Trulife
Lifecast SFH110
1 Foot Per 2 Years
Trulife Foot
Carbon Lightfoot SCF185
1 Foot Per 2 Years
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(6.22/1754/35)
(1.88/2020/35)
(2.13/1608/35)
(0.88/216/35)
(2.13/2591/35)
(0.88/295/35)
(1.88/804/35)
1 Foot Per 2 Years
2- 4
Child's Play SLF132
(3/1111/35)
2- 4
2- 4
2- 4
(6.22/1003/35)
(0.88/279/35)
(0.88/278/35)
(0.88/256/35)
Page 20 of 35
APL P-19
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Feet
Trulife Foot
Lightfoot SLF160
1 Foot Per 2 Years
2- 4
False
P550
$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
2- 4
Flex Foot Spectra Sock
False
P246
$70.81 Each
False
P043
$198.59 Each
True
P265
$219.77 Each
True
P198
$634.28 Each
False
P215
$272.41 Each
(0.25/98/8)
(0.25/16/8)
2 Per 12 Months
2- 4
Ossur Flex Foot Foot Shell
$162.65 Each
3 Per 12 Months
1-4
Junior Foot Shell
False
P217
(0.25/130/8)
2 Per 12 Months
2- 4
Ottobock Syme's Kit
1P5 - 1P9
1 Per 2 Years
Springlite Foot Shell
2 Per 12 Months
1-4
2- 4
(0.25/149/8)
(2.25/179/35)
(0.25/196/8)
###
Foot Plates
Silipos Comfortzone Double Socket Gel
Liner
6 Per 12 Months
1-4
Springlite Inserts
Foot Plate
False
P678
$107.88 Each
False
P675
$264.45 Each
(0.05/85/2)
2 Per 12 Months
1-4
(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
1-4
Hip Joint
TGH-01
1 Hip Joint Per 2 Years
Ottobock Hip Joint
7E4
1 Hip Joint Per 2 Years
1-4
1-4
7E5
1-4
7E7
1-4
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
False
P392
$749.66 Each
False
P850
$3,522.02 Each
False
P848
$1,314.16 Each
False
P849
$1,423.92 Each
False
P847
$2,466.64 Each
(3.5/108/8)
(3.25/2599/35)
(3.25/628/35)
(3.25/726/35)
(3.25/1657/35)
Page 21 of 35
APL P-20
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
AADL Price
Cat. No.
(#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
Adult
1 Hip Joint Per 2 Years
1-4
Pediatric - P28455 to P28464
1-4
False
P716
$2,110.14 Each
False
P714
$1,883.01 Each
(3.25/1338/35)
(3.25/1135/35)
###
Additions to Hip Joints
Stainless Steel Pelvic Band
1 Per 2 Years
1-4
False
P177
$80.83 Each
(0.25/24/8)
###
Finishing
Endoskeletal Finish
Hip Disarticulation (HD) P-CF-72
1 Finish Per 2 Years
1-4
False
P082
$1,673.99 Each
False
P062
$1,098.74 Each
(8/213/19)
Knee Disarticulation (KD) CF-42
1-4
Proximal Femoral Focal Deficiency (PFFD)
1-4
False
P034
$1,054.14 Each
Transfemoral (TF)
1-4
False
P575
$1,142.99 Each
Transtibial (TT)
1-4
False
P052
$733.40 Each
1-4
False
P013
$557.73 Each
1-4
False
P025
$1,514.28 Each
False
P032
$1,514.28 Each
Exoskeletal Finish
Ankle Disarticulation (AD) P-CF-21
(4.75/213/19)
(5/133/19)
(5/213/19)
(3.5/88/14)
1 Finish Per 2 Years
Knee Disarticulation (KD) P-CF-41
(3/20/3)
(8/74/15)
Proximal Femoral Focal Deficiency (PFFD) P-CF-61
1-4
Transfemoral (TF)
1-4
False
P028
$1,514.28 Each
Transtibial (TT)
1-4
False
P019
$994.89 Each
(8/74/15)
(8/74/15)
(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
AK
4 Cosmetic Skins Per
12 Months
1-4
False
N183
$410.19 Max. Each
False
N182
$342.99 Max. Each
True
P495
$80.61 Each
Upgrade
BK
1-4
Upgrade
Ottobock Prosthetic Underhose
99B14 TF
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.75/240/8)
(0.75/180/8)
4 Per 12 Months
1-4
(0.25/24/8)
Page 22 of 35
APL P-21
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Lower Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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
99B16 TT
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
4 Per 12 Months
1-4
True
P488
$74.54 Each
(0.25/19/8)
Page 23 of 35
APL P-22
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
##
Additions to Lower/Upper Limb Procedures
1 Per 2 Years
Leather Socket
5-7
False
P284
$348.52 Each
False
P281
$934.25 Each
(1.75/30/4)
1 Per 2 Years
Split Socket Design
5-7
(4.75/74/9)
###
Shrinker Socks - Upper Limb
Shrinker Sock - Upper Limb
3 Socks Per 12 Months
5-7
False
P534
$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 Adaptors
Physician Prescription Required (except P122).
Check Socket
2 Check Sockets Per 2
Years
Upper Extremity
Definitive Socket
Elbow Disarticulation (ED)
5 - 7, or 9
False
P122
$652.74 Each
False
P285
$2,764.71 Each
$4,461.14 Each
(3.5/27/2)
1 Procedure Per 2 Years
5-7
(15/87/11)
Fore Quarter
5-7
False
P294
Plastic Hand Socket With Wrist and 4 Fingers
5-7
False $3,440.02 Max. Each
P278
(18/216/11)
See generic pricing procedure
Shoulder Disarticulation (SD)
Transhumeral (TH)
Transradial (TR)
Wrist Disarticulation (WD)
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(24/170/21)
5-7
False
P290
$3,288.43 Each
5 - 7, or 9
False
P287
$2,548.57 Each
5-7
False
P282
$2,013.60 Each
False
P280
$2,273.37 Each
5 - 7, or 9
(17.75/118/13)
(14/52/11)
(11/50/10)
(12.5/46/9)
Page 24 of 35
APL P-23
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Terminal Devices
Becker Imperial
2 Terminal Devices Per
2 Years
50316
Generic Terminal Device
6-7
False
P351
$961.40 Each
False
N181
$718.42 Max. Each
Passive
5-7
See Generic Pricing Procedure
Standard
6-7
(0.5/1511/17)
2 Terminal Devices Per
2 Years
Hook - 55009 Model 5X
6-7
Hook 55059 Model 555
Passive Hand
Ottobock Terminal Device
(0.5/547/17)
False $1,798.38 Max. Each
N180
See Generic Pricing Procedure
Hosmer Terminal Device
(0.5/763/17)
2 Terminal Devices Per
2 Years
True
P315
$601.53 Each
6-7
False
P334
$610.40 Each
5-7
False
P358
$354.25 Each
(0.5/442/17)
(0.5/450/17)
(0.5/221/17)
2 Terminal Devices Per
2 Years
Passive Hand 8K18
5-7
False
P359
$718.42 Each
Physolivo Baby Hand - Hand, glove and wrist unit 8K14=1
6-7
False
P721
$1,512.56 Each
Voluntary Opening 8K23
6-7
True
P361
$681.46 Each
False
P367
$1,883.89 Each
False
P526
$583.83 Each
TRS Terminal Device
(0.5/547/17)
(2/1019/17)
(0.5/514/17)
2 Terminal Devices Per
2 Years
Grip Adult
6-7
Infant Hand-Passive
6-7
(0.5/1587/17)
(0.5/426/17)
###
Gloves for Hands
Generic Multi-Articulating Glove for
Myoelectric Hand
2 Gloves Per 12 Months
9
False $1,132.81 Max. Each
N186
(0.75/885/8)
See Generic Pricing Procedure
Hosmer Glove
57586
2 Gloves Per 12 Months
5 - 7, or 9
Leather Glove
NGL006-PR
2 Gloves Per 12 Months
Ottobock Glove
8S5
2 Gloves Per 12 Months
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
5-7
5 - 7, or 9
False
P368
$414.05 Each
False
P366
$420.55 Each
True
P364
$331.79 Each
(0.75/243/8)
(0.75/249/8)
(0.75/170/8)
Page 25 of 35
APL P-24
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Gloves for Hands
Regal Passive Glove
2 Gloves Per 12 Months
5-7
False
P882
$656.59 Each
(0.75/460/8)
###
Hand Restoration
Partial Hand
Glove for Thumb or Finger
1 Procedure Per 2 Years
Multiple Fingers
Regal Custom Glove
5-7
False
P369
$1,328.12 Each
5-7
False
P370
$1,339.09 Each
(4/464/99)
(4/474/99)
1 Procedure Per 2 Years
5-7
False $1,057.82 Max. Each
N185
(0.75/817/9)
See generic pricing procedure
###
Wrist Units
Any comparable quality system to below listed items may be substituted with AADL prior approval
Generic Wrist Unit
1 Wrist Per 2 Years
7
False $1,137.98 Max. Each
N140
(0.75/882/17)
Requires flexion/extension capability combined with rotation/quick
disconnect. Cannot be combined with P377.
See Generic Pricing Procedure
Hosmer Wrist
CAPP Nylon Body 1-1/2" 55108
1 Wrist Per 2 Years
5-7
False
P376
$197.90 Each
False
P375
$197.90 Each
(0.5/82/17)
CAPP Nylon Body 1-3/4" 55109
5-7
CAPP Nylon Body 2" 55110
5-7
False
P374
$197.90 Each
7
False
P868
$472.31 Each
6-7
False
P400
$375.53 Each
Child Quick Disconnect Wrist 58151
Flexion Friction Wrist 51100 FW 500 (2")
(0.5/82/17)
(0.5/82/17)
(0.75/287/17)
(0.5/240/17)
Nylon Friction Wrist - 52156 WE 200N (1-1/2") or 300N (13/4")
5-7
False
P388
$199.97 Each
Nylon Friction Wrist - 52160 WE 500N
5-7
False
P387
$199.97 Each
Quick Disconnect 52127 WD 400
7
False
P383
$281.13 Each
Quick Disconnect Wrist 51043 FM 100
7
True
P380
$361.18 Each
Quick Disconnect Wrist All Stainless 53896 WD 400SS
7
False
P386
$665.73 Each
Quick Disconnect Wrist Stainless Steel 51044 FM 100S
7
False
P382
$642.05 Each
Quick Disconnect Wrist Stainless Steel 52128 WD 400S
7
False
P384
$397.33 Each
5-7
False
P395
$185.24 Each
(0.5/84/17)
WE 100N Infant
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(0.5/84/17)
(0.75/117/17)
(0.75/188/17)
(0.75/460/17)
(0.75/439/17)
(0.75/220/17)
(0.5/70/17)
Page 26 of 35
APL P-25
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
AADL Price
Cat. No.
(#hrs/material/ship)
###
Wrist Units
Any comparable quality system to below listed items may be substituted with AADL prior approval
Hosmer Wrist
WE 200N 1-1/2" Nylon Friction 52147
1 Wrist Per 2 Years
N-Abler Wrist Unit
1 Wrist Per 2 Years
5-7
7
False
P390
$199.97 Each
False
P527
$3,127.28 Each
False
P528
$174.08 Each
Bi-lateral upper limb, used for dominant hand
TRS Wrist
Infant Wrist
(0.5/84/17)
(0.5/2697/17)
1 Wrist Per 2 Years
6-7
(0.5/60/17)
###
Additions to Wrist Units
Sierra Wrist Flexion - Friction Wrist
52371
1 Per 2 Years
Wrist Unit Inserts
Aluminum - 50527
1 Per 2 Years
6-7
Stainless Steel - 50528
False
P377
$495.43 Each
5-7
False
P408
$86.56 Each
5-7
False
P409
$139.20 Each
(0.5/347/17)
(0.25/22/17)
(0.25/69/17)
###
Elbows
Generic Elbow Hinge
Single Axis Below Elbow
1 Elbow Per 2 Years
6-7
False
N190
$827.00 Max. Each
6-7
False
P412
$831.35 Each
50650 E-400
6-7
False
P411
$912.55 Each
External Locking Elbow Hinges 53885
5-7
False
P423
$1,327.58 Each
HD 50613 E-200
6-7
False
P507
$893.06 Each
False
P506
$912.55 Each
See Generic Pricing Procedure
Hosmer Elbow
50606 E-200
(3.5/177/8)
1 Elbow Per 2 Years
(1/552/35)
(1/625/35)
(3.5/624/8)
(1/607/35)
HD 50653 E-400
6-7
Outside Locking Hinge - Heavy Duty 50950
5-7
False
P420
$1,669.52 Each
Outside Locking Hinge 50776
5-7
False
P416
$1,277.80 Each
Power Bow 60665 E 400
6-7
False
P737
$1,703.77 Each
False
P435
$831.48 Each
False
E508
$4,377.83 Each
Single Axis Below Elbow Hinge - Long 51856
Ottobock Elbow
ErgoArm Elbow with Forearm - 12K42
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
5-7
(1/625/35)
(3.5/929/8)
(3.5/580/8)
(1/1331/35)
(3.5/181/8)
1 Elbow Per 2 Years
6-7
(1/3719/35)
Page 27 of 35
APL P-26
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
AADL Price
Cat. No.
(#hrs/material/ship)
###
Elbows
Ottobock Elbow
ErgoArm Elbow With Forearm 12K44
1 Elbow Per 2 Years
Modular 12R1
6-7
False
P332
$4,638.79 Each
5-7
False
E512
$557.49 Each
(1/3952/35)
(0.5/387/35)
###
Shoulder Joint
Generic Shoulder Joint
1 Shoulder Joint Per 2
Years
Abduction
5-7
False
N191
$672.78 Max. Each
False
N192
$666.51 Max. Each
5-7
False
P444
$683.59 Each
Flexion Abduction - Adult 51010
5-7
False
P447
$663.65 Each
Universal - 52028 USJ-100
5-7
False
P449
$647.58 Each
(1.5/331/35)
See Generic Pricing Procedure
Flexion - Abduction
5-7
(1.5/326/35)
See Generic Pricing Procedure
Hosmer Shoulder Joint
Abduction - Adult 51836
1 Per 2 Years
(1.5/341/35)
(1.5/323/35)
(1.5/309/35)
###
Universal Shoulder Joint
Generic Shoulder Joint
1 Shoulder Joint Per 2
Years
Universal
5-7
False
N193
$666.51 Max. Each
See Generic Pricing Procedure
(1.5/326/35)
###
Control Cables
Hosmer Cable Control
55683
2 Per 2 Years
Hosmer Elbow Cable
50724
2 Per 2 Years
Hosmer Hook To Cable Adaptor
50444
2 Per 2 Years
Teflon Lining
6-7
5-7
6-7
True
P455
$349.78 Each
False
P169
$242.68 Each
False
P456
$120.78 Each
False
P454
$99.22 Each
(1.25/102/13)
(1.25/17/2)
(0.5/26/2)
2 Per 2 Years
6-7
(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
5 - 7, or 9
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
True
P533
$829.74 Each
(0.75/606/18)
Page 28 of 35
APL P-27
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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
5-7
True
P529
$762.54 Each
(0.75/546/18)
###
Upper Prosthetic Suspension
Auxila Loop
50115
2 Per 12 Months
5 - 7, or 9
True
P509
$122.44 Each
False
P476
$92.02 Each
False
P115
$320.10 Each
False
P483
$713.84 Each
False
P477
$792.65 Each
5-7
False
P468
$162.32 Each
Figure 8
5-7
False
P462
$351.56 Each
Figure 8 With Olecrannon
5-7
False
P464
$395.81 Each
Figure 9
5-7
False
P463
$301.62 Each
False
P478
$306.02 Each
False
P530
$344.66 Each
False
P460
$415.01 Each
False
P480
$423.79 Each
False
P532
$126.26 Each
False
P531
$418.58 Each
Elbow Hinge - Flexible Using Leather Or
Dacron
LH100
1 Per 2 Years
Epicondylar Suspension
1 Per 2 Years
5-7
5 - 7, or 9
Expandable Wall Design
Harness
Chest
5-7
Icelock Ratchet
721
1 Per 2 Years
6-7
7 or 9
5-7
1 Per 2 Years
Ottobock Lock Pin
14A107
1 Per 2 Years
Revised April 1, 2015
(3.5/146/8)
(0.5/56/10)
(1.75/30/7)
(2/30/7)
(1.5/26/6)
(0.5/186/8)
(0.5/221/8)
2 Per 12 Months
Nudge Control
52521
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
(3.5/75/9)
2 Per 12 Months
Hosmer 50752 Forearm Lift Assist
E46O R&L
Ottobock Lock Set
14A1
(1.5/42/7)
1 Per 2 Years
1 Per 2 Years
North Western Ring Harness
NRH-100
(0.5/2/0)
1 Per 2 Years
5 - 7, or 9
Flexible Elbow - Metal
HFH-6
(0.5/27/2)
6-7
7
(1.75/80/15)
(0.5/291/8)
(0.5/26/8)
1 Per 2 Years
7
(0.5/287/8)
Page 29 of 35
APL P-28
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Upper Prosthetic Suspension
Shoulder Saddle
HD100L
1 Per 12 Months
Suction Housing
20004
1 Per 2 Years
Suction Procedure - Upper Limb
1 Per 2 Years
5 - 7, or 9
5-7
5 - 7, or 9
Tricep Cuff - Full
BEC 360
1 Per 12 Months
Tricep Cuff - Half
BICEPS 320
1 Per 12 Months
Tricep Cuff Laminated
BEC160
5-7
5-7
False
P466
$778.73 Each
False
P479
$120.75 Each
False
P249
$177.01 Each
False
P470
$273.39 Each
False
P472
$260.38 Each
False
P458
$329.33 Each
(4/54/9)
(0.5/21/8)
(1/0/0)
(1.25/39/7)
(1.25/29/6)
1 Per 2 Years
5-7
(1.5/49/8)
###
Upper Limb Finishing
Endoskeletal Finish
Fore Quarter (FQ)
1 Per 2 Years
5-7
False
P304
$1,283.04 Each
Shoulder Disarticulation (SD)
5-7
False
P301
$1,283.04 Each
Transhumeral (TH)
5-7
False
P298
$973.29 Each
Transradial (TR)
5-7
False
P279
$629.03 Each
With Forearm - Elbow Disarticulation (ED)
5-7
False
P292
$929.04 Each
False
P289
$1,658.97 Each
Exoskeletal Finish
Elbow Disarticulation (ED)
(6.75/69/10)
(6.75/69/10)
(5/69/10)
(3.5/7/1)
(4.75/69/10)
1 Per 2 Years
5-7
(9/52/6)
Transradial (TR)
5-7
False
P277
$859.53 Each
With Arm Sections - Fore Quarter (FQ)
5-7
False
P302
$2,446.36 Each
With Arm Sections - Shoulder Disarticulation (SD)
5-7
False
P299
$2,446.36 Each
False
P293
$1,703.97 Each
False
P252
$764.43 Each
With Forearm - Transhumeral (TH)
5-7
Wrist Disarticulation (WD)
5-7
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(4.5/50/6)
(13.25/81/9)
(13.25/81/9)
(9.25/52/7)
(4/46/4)
Page 30 of 35
APL P-29
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Myoelectric Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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.
1 Per 3 Years
4 Channel Processor
Allows switching of operation modes for control with the wrist
rotator or locking/unlocking the elbow
Batteries
Battery Chargers
Battery Mounting Set
Connection Cables
9
False
P852
Prior Approval
9
False
P813
Prior Approval
9
False
P818
Prior Approval
9
False
P865
Prior Approval
9
False
P825
Prior Approval
9
True
P722
$1,800.12 Each
2 Per 2 Years
1 Per 4 Years
1 Per 3 Years
3 Per 3 Years
1 Per 12 Months
Custom Upper Extremity Liner
- Diagnostic liner (88L3=P)
- TR Silicone liner with Ottobock fixation (88L1=BA)
- TH Silicone liner with OB fixation (88L1=OA)
(2/1236/61)
For use with myeoelectric electrodes
Elbow
Electric Hands & Hooks
Electric Wrist Rotators
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
1 Per 3 Years
9
False
P836
Prior Approval
9
False
P837
Prior Approval
9
False
P863
Prior Approval
1 Per 3 Years
1 Per 3 Years
Page 31 of 35
APL P-30
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Upper Limb Myoelectric Prosthetic Benefits
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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
9
False
P838
Prior Approval
9
False
P940
Prior Approval
9
False
P864
Prior Approval
9
False
P860
$3,097.50 Each
SH finishing included
9
False
P862
$4,779.00 Each
TH finishing included
9
False
P861
$2,964.75 Each
TR finishing included
9
False
P859
$1,991.25 Each
WD Finishing Included
9
False
P858
$2,124.00 Each
9
False
P839
Prior Approval
9
False
P853
Prior Approval
MyoWrist Flexion Unit
10V40
1 Per 3 Years
1 Per 12 Months
Recycle of Myoelectric Component
Cost of rebuilt component by manufacturer, shipping, plus
labour hours to disassemble and install into new prosthesis
Socket costs above conventional socket
ED finishing included
Switch Control
1 Per 3 Years
Revised April 1, 2015
(27/0/0)
(16.75/0/0)
(11.25/0/0)
(12/0/0)
1 Per 2 Years
1 Per 3 Years
Wrist Units
Includes: Lamination Ring, Coupling Ring, Coaxial Plug
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
(17.5/0/0)
Page 32 of 35
APL P-31
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Prosthetic Soft Supplies and Fees
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#hrs/material/ship)
###
Socks
12 Per 12 Months
Prosthetic Socks
Custom-made
1-7
False
P783
$113.49 Max. Each
False
P583
$40.01 Max. Each
See generic pricing procedure
In Catalogue
1-7
See generic pricing procedure
(0.05/90/2)
(0.05/25/2)
###
Donning Aids
2 Per 12 Months
Easy Proth
1-4
False
P410
$73.22 Each
(0.05/54/2)
###
Sheaths
12 Per 12 Months
Daw Prosthetic Sheath
1-7
True
P489
$46.85 Each
True
P486
$26.29 Each
False
P580
$52.63 Max. Each
1 - 7, or 9
(0.05/13/2)
12 Per 12 Months
Prosthetic Sheath In Catalogue
1-7
Dealer cost plus $11.73
Silo Sheaths
(0.05/31/2)
12 Per 12 Months
Prosthetic Sheath
(0.05/36/2)
8 Sheaths Per Limb Per
12 Months
SA332 - Regular
2-7
False
E700
$49.70 Each
SA333 - Active
2-7
False
E701
$71.03 Each
(0.05/33/2)
(0.05/52/2)
###
Other Fees
Consult with Client and Multidisciplinary
Team
4 Per 12 Months
1 - 7, or 9
False
P937
$177.00 Per Hour
False
P938
$177.00 Per Hour
One hour per client at $177.00
Available to private prosthetic facilities only
Off-Site Facility Fee
1 Per 12 Months
1 - 7, or 9
One hour per client at $177.00
Invoice for only one off site fee /per client/ per device. Available to all
prosthetic facilities
Document on the benefit note: the name of off-site facility, device, and reason
for off-site fee
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
(1/0/0)
(1/0/0)
Page 33 of 35
APL P-32
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Prosthetic Soft Supplies and Fees
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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 approval
4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be
deducted from the initial procedure on the cost of the new device.
5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and
replace cosmetic skin.
6. Activities not considered a repair benefit:
trialling new components.
trimming/mods to NEW gel liners.
gait training.
7. Shipping and Brokerage Fees where a device or component is:
under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials",
and no "shipping or brokerage fees".
under warranty and being replaced, it must be provided under the appropriate AADL catalogue number
(shipping and brokerage fees are already included).
not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included
under P693/P857.
Labour
12 Hours Per 12 Months
1-7
False
P492
$177.00 Per Hour
False
P693
$300.00 Max. Each
False
P855
$177.00 Per Hour
Indicate on invoice # of hrs. & total $ of hrs. only
Documentation required:
- Describe repair/mods.
- # of hrs. and cost
- Total cost of repair (hrs.+ materials)
- % of total repair cost of device/component
Materials
6 Repairs Materials Per
12 Months
1-7
Invoice quantity = 1 per repair/modifications
- Quantity of 1 is up to a maximum of $300
Documentation required:
- List of materials and cost
Myoelectric Labour
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
Revised April 1, 2015
(0/267/0)
12 Hours Per 12 Months
9
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
(1/0/0)
(1/0/0)
Page 34 of 35
APL P-33
Alberta- Health
- Professional
Services
andHealth
Health Benefits
Alberta Health
Professional
Services
and
Benefits
Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List
Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits
###
Prosthetic Soft Supplies and Fees
Qty. / Freq.
Functional
Level
Cat. No.
AADL Price
(#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 approval
4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be
deducted from the initial procedure on the cost of the new device.
5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and
replace cosmetic skin.
6. Activities not considered a repair benefit:
trialling new components.
trimming/mods to NEW gel liners.
gait training.
7. Shipping and Brokerage Fees where a device or component is:
under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials",
and no "shipping or brokerage fees".
under warranty and being replaced, it must be provided under the appropriate AADL catalogue number
(shipping and brokerage fees are already included).
not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included
under P693/P857.
Myoelectric Materials
6 Repair Materials Per
12 Months
9
Invoice quantity = 1 per repair/modifications
- Quantity of 1 is up to a maximum of $300
Documentation required:
- List of materials and cost
© 2013 Government of
© 2015
Government of Alberta
Alberta April
1, 2014
Revised April 1, 2015
False
P857
$300.00 Each
(0/267/0)
Page 35 of 35
APL P-34