alberta health superseded · custom made from cast o215false $1,825.04 each tlso 1 spinal orthosis...
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Alberta Health
AADL Approved Product List - Orthotic Benefits
Pricing effective October 16, 2017
© 2013 Government of Alberta April 1, 2014
Supers
eded
Functional Outcomes
Generic Pricing Procedure
General Information
100 Restrict range of motion of a joint to reduce/prevent the need for surgical or medical treatment101 Restrict range of motion of a joint to reduce/control tone or spasticity102 Control spinal deformity (e.g., scoliosis)103 Protection of a body part (e.g., helmet)104 Improve function by providing stability of the joint105 Improve function by positioning body part for activities of daily living106 Improve function by assisting muscle weakness107 Improve function by enabling lying, sitting, and standing (likely the more disabled client)108 Improve function by enabling walking and/or increased walking efficiency/endurance109 Facilitate healing of a body part110 Reduce pain (e.g., arthritis-related)111 Support soft tissue (e.g., hernia)112 Repairs
Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number. Generic catalogue numbers can be indentified as they have their price is indicated as a "Max". Most generic catalogue numbers start with an "N". All generic catalogue numbers are considered to be "Upgrades". Refer to the General Policies and Procedure Manual for more information about upgrade costs.
Procedure
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.
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
Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade.
© 2013 Government of Alberta April 1, 2014
Page 2 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-1
Supers
eded
Orthotic Types
AFO ANKLE FOOT ORTHOSISCF CLUBFOOT ORTHOSISCO CERVICAL ORTHOSIS
CTLSO CERVICAL THORACIC LUMBAR SACRAL ORTHOSISEO ELBOW ORTHOSIS
HELMET HELMETHERNIA CUSTOM MADE HERNIA
HIPO HIP ORTHOSISHKAFO HIP KNEE ANKLE FOOT ORTHOSISKAFO KNEE ANKLE FOOT ORTHOSIS
KO KNEE BRACELSO LUMBAR-SACRAL ORTHOSISNRS NON-RIGID SPINAL ORTHOSISPR PARTIAL FOOT PROSTHESIS/ORTHOSIS
RGO RECIPROCATING GAIT ORTHOSISSO SHOULDER ORTHOSIS
THKAFO THORACIC KNEE ANKLE FOOT ORTHOSISTLSO THORACIC LUMBAR SACRAL ORTHOSISWHO WRIST HAND ORTHOSIS
© 2013 Government of Alberta April 1, 2014
Page 3 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-2
Supers
eded
Qty. / Freq.
###Spinal Orthoses
Cat. No. AADL PriceOrth. Type
###Cervical Orthoses
Prescription Required
C.O.
FalseO166Custom Made - Molded to patient model, cervical and thoracic control (Minerva type)
$2,653.84 Each
CO
1 Spinal Orthosis Per 2 Years
FalseO168Custom Made - molded to patient model, cervical and thoracic control (Minerva type) plus interface
$2,671.59 Each
CO
1 Spinal Orthosis Per 2 Years
FalseO088Molded to patient model $897.57 EachCO
1 Spinal Orthosis Per 2 Years
FalseO084Prefabricated C.O. which requires custom fitting (e.g. Philadelphia or thermoplastic designs or equivalent)
$206.42 Each
CO
1 Spinal Orthosis Per 2 Years
FalseO090With occipital/mandibular supports with thoracic extensions for increased cervical control, custom-fitted (e.g. S.O.M.I., Fi-way, La-cal, Guilford or equivalent)
$510.79 Each
CO, CTLSO
1 Spinal Orthosis Per 2 Years
Hensinger Head Support
FalseO300 $441.17 EachCO
1 Head Support Per 2 Years
###Thoracic Orthoses
Prescription Required
Pectus Brace
FalseO342 $1,131.59 EachTLSO
1 Thoracic Brace Per 2 Years
###Rigid Spinal Orthoses
Prescription Required
Rigid Spinal Orthosis
FalseO135Custom Made $1,404.14 EachLSO
1 Spinal Orthosis Per 2 Years
FalseN117Generic Custom Fitted $721.54 Max. EachLSO, TLSO
1 Spinal Orthosis Per 2 Years
###Additions to Rigid Spinal Orthoses
Bariatric Option
False
Client is 100 lb. over normal weight or over 275 lb. Must indicated criteria in E-Business Benefit Note.
O497 $233.00 EachCTLSO, LSO, TLSO
1 Rigid Spinal Addition Per 2 Years
Corset front
FalseO150As opposed to apron front $178.98 EachLSO
1 Rigid Spinal Addition Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 4 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-3
Supers
eded
Qty. / Freq.
###Spinal Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Rigid Spinal Orthoses
Full corset
FalseO152As opposed to apron front $134.73 EachLSO
1 Rigid Spinal Addition Per 2 Years
Sub-Clavicular Extensions
FalseO148For rotary control $167.11 EachLSO, TLSO
1 Rigid Spinal Addition Per 2 Years
###Total Contact T.L.S.O. (Body Jacket)
Prescription Required
May be provided to a client who has had a spinal fracture or surgical intervention, when the orthotic is required for discharge from a general hospital. Vendor must clearly document clinical assessment and discharge plan.
Must indicate clinical rationale in E-Business Benefit Note.
Boston Jacket
FalseO215Custom made from cast $1,825.04 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO506Custom made from measurement $1,348.27 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO505Soft - Stock $1,287.23 EachTLSO
1 Spinal Orthosis Per 2 Years
Boston Orthosis
FalseO213Custom from cast $1,851.39 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO211Custom from measurement $1,755.17 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO218Stock custom fitted $1,766.37 EachTLSO
1 Spinal Orthosis Per 2 Years
Boston Overlap Orthosis or Equivalent
FalseO219Molded to patient $1,379.33 EachTLSO
1 Spinal Orthosis Per 2 Years
T.L.S.O.
FalseO123Molded antero-posterior design $2,468.27 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO125Molded antero-posterior design with interface $2,613.62 EachCTLSO, TLSO
1 Spinal Orthosis Per 2 Years
FalseO122Molded to patient model $2,334.70 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO124Molded to patient model with interface $2,480.23 EachTLSO
1 Spinal Orthosis Per 2 Years
FalseO127Posterior, Anterior shell only with corset or equivalent front
$1,878.40 Each
TLSO
1 Spinal Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 5 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-4
Supers
eded
Qty. / Freq.
###Spinal Orthoses
Cat. No. AADL PriceOrth. Type
###Total Contact T.L.S.O. (Body Jacket)
Prescription Required
May be provided to a client who has had a spinal fracture or surgical intervention, when the orthotic is required for discharge from a general hospital. Vendor must clearly document clinical assessment and discharge plan.
Must indicate clinical rationale in E-Business Benefit Note.
T.L.S.O.
FalseO220Scoliosis procedure - Molded to patient model with interface
$2,571.68 Each
TLSO
1 Spinal Orthosis Per 2 Years
###C.T.L.S.O. - Milwaukee
Prescription Required
Complete Milwaukee Orthosis
False
No additions
O188Initial $3,284.44 EachCTLSO
1 Spinal Orthosis Per 2 Years
###Protective Helmet
Prescription Required
CriteriaMust be required for daily use for protection in cases of self-abusive behaviour, seizure disorder, and protect/facilitate healing of chronic wounds or cranial defects.
Must indicate criteria in E-Business Benefit Note.
Custom Fitted Helmet
False
Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate.
O051A modular helmet system requiring measurement, modification of modular parts and assembly, based on DANMAR helmet.
$1,103.07 Each
HELMET
1 Helmet Per 2 Years
Helmet Molded to Patient Model.
False
Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate.
O053Helmet made with high temperature thermoplastic with liner.
$1,494.39 Each
HELMET
1 Helmet Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 6 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-5
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Hip Abduction Control
Prescription Required
Dennis Brown Plate
FalseO306 $224.17 EachAFO, HIPO
1 L/E Orthosis Per 2 Years
Dynamic Brace
FalseO241Pelvic control, adjustable hip motion control, thigh cuffs (Rancho Hip Action Design)
$2,134.39 Each
HIPO
1 L/E Orthosis Per 2 Years
Static Adjustable
FalseO235Custom Fitted $1,059.13 EachHIPO
1 L/E Orthosis Per 2 Years
Static Foam or Thermoplastic Design
FalseO237Custom Fitted (Von Rosen or equivalent) $366.24 EachHIPO
1 L/E Orthosis Per 2 Years
FalseO238Custom Made (Von Rosen or equivalent) $748.10 EachHIPO
1 L/E Orthosis Per 2 Years
Static Pelvic Band or Spreader Bar
FalseO233Custom Fitted - with thigh cuffs $545.85 EachHIPO
1 L/E Orthosis Per 2 Years
###Torsion Control
Prescription Required
Pelvic Band/Belt
FalseO294With bilateral rotation straps $519.99 EachHIPO
1 Pelvic Band/Belt Per 2 Years
FalseO298With torsion cables and ball bearing hip joints, bilateral cable usage
$1,261.84 Each
HIPO
1 Pelvic Band/Belt Per 2 Years
FalseO297With torsion cables and ball bearing hip joints, unilateral cable usage hip joints, unilateral cable usage
$868.79 Each
HIPO
1 Pelvic Band/Belt Per 2 Years
###Abduction and Rotation Control
Prescription Required
Atlanta or Scottish-Rite Trilateral Orthosis
FalseO305 $2,107.68 EachHIPO
1 L/E Orthosis Per 2 Years
SWASH
FalseO242 $2,039.66 EachHIPO, RGO
1 L/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 7 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-6
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Knee Orthosis to Prevent Knee Flexion
Prescription RequiredCriteria
Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time isdefined as a minimum of 6 hours per day, every day. Not eligible for post-operative care or short-term need.
Prescriber must be one of the following specialist physicians: orthopedics, physiatry, rheumatology, geriatrics.
Must indicate clinical condition in E-Business Benefit Notes (example: failed knee replacement or knee fusion).
Total Contact Cylinder Orthosis
FalseO257High temp. thermoplastics, molded to patient model $1,024.40 EachKO
1 L/E Orthosis Per 4 Years
FalseO256Low temp. thermoplastics, molded directly to patient $559.70 EachKO
1 L/E Orthosis Per 4 Years
###Knee Hyperextension Orthoses
Prescription RequiredCriteria
Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time isdefined as a minimum of 6 hours per day, every day.
Must indicate clinicial condition in E-Business Benefit Note.
Generic Hyperextension Control Knee Orthosis
FalseN317Custom Fitted $800.40 Max. EachKO
1 L/E Orthosis Per 4 Years
###Dynamic Knee Extension Assist Orthoses
Prescription Required
Criteria
Must be used for maintaining or increasing range of motion at the knee for clients with chronic flexion contractures.
Clients are typically diagnosed with neuromuscular conditions (CP, Stroke) and are must not be candidates forserial casting due to practical limitations of this option (swelling, access to service).
The benefit cannot be provided to clients that require post-op ROM braces for short-term.
Must indicate criteria in E-Business Benefit Note.
Dynamic Knee Extension Assist Orthoses
FalseO550 $761.40 EachKO
1 L/E Orthosis Per 4 Years
© 2013 Government of Alberta April 1, 2014
Page 8 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-7
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Unloading Knee Orthoses
Criteria
Must be required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work.Full-time activity is defined as a minimum of 6 hours per day, every day.
Must have severe valgus or varus deformity and joint space narrowing.
Prescriber
Must be one of the following specialist physicians: orthopedics, physiatry, rheumatology, geriatrics, neurology,pediatrics.
Prescriptions from other physicians will only be accepted if accompanied by an x-ray report indicating moderate orsevere osteoarthritis.
AADL will provide funding for "minor or mild" OA or degenerative changes, if the Orthotist documents that unloading or realignment of the joint resulted in a functional pain relief (improved ambulation). Realignment can be demonstrated by an off-the-shelf bracing trial or taping techniques. The outcome must be documentd in the E-Business Benefit Note.
Clients must be offered a choice of unloading knee braces to address their assessed medical need at or below AADL's maximum contribution. "Upgrade" indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client's choice and responsibility.
Unloading Knee Orthosis
False
Procedure to be added, not other additions.
N730Generic CFAB (Custom) $1,141.45 Max. Each
KO
1 L/E Orthosis Per 4 Years
False
Procedure to be added, not other additions.
N712Generic Custom Fit (OTS) $782.12 Max. EachKO
1 L/E Orthosis Per 4 Years
False
Procedure and joints to be added
O537In-House (Custom) - Laminate $1,214.77 EachKO
1 L/E Orthosis Per 4 Years
False
Procedure and joints to be added
O259In-House (Custom) - Plastic $851.40 EachKO
1 L/E Orthosis Per 4 Year
Unloading Knee Orthosis Procedure
FalseO551CFAB (Custom) $563.69 EachKO
1 KO Procedure Per 4 Years
FalseO501In-House Custom Procedure $652.19 EachKO
1 KO Procedure Per 4 Years
FalseO565Presized OA $354.00 EachKO
1 KO Procedure Per 4 Years
© 2013 Government of Alberta April 1, 2014
Page 9 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-8
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Stabilizing Knee Orthoses
Criteria
Must be required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work.Full-time activity is defined as a minimum of 6 hours per day, every day.
Must meet either the "Orthopedic Criteria" or "Neurological Criteria" listed below.
Criteria must be indicated in E-Business Benefit Note.
Orthopedic CriteriaMust meet one of the following four criteria:1. Gross knee instability resulting from partial/total knee replacement. Prescriber: Physician.2. A single ligament tear with a meniscus removed or two ligaments with 2nd or 3rd degree tears. A prescription oran MRI or an arthroscopic report documenting the orthopedic condition will be accepted.*3. Ligament instability and client has a vocation that is physically demanding and requires bracing. Examples:construction worker, healthcare worker, police, oilfield worker, farmer. The vocation must be indicated on the authorization.*4. Ligament instability and client is not a surgical candidate. Examples: skeletal immaturity, medical condition, age,failed surgical repair.*5. MRI demonstrates complete tear of two ligaments and surgery not scheduled for six months.**Prescriber for Criteria 2, 3, 4 and 5: One of the following specialist physicians: orthopedics, physiatry,rheumatology, geriatrics, neurosurgery, neurology, pediatrics or a physician with a diploma in Sports Medicine from the Canadian Academy of Sport and Exercise Medicine.
Neurological CriteriaA progressive or chronic neurological condition that results or will result in severe knee instability due to weakening of quadriceps or spasticity at the knee (diagnosis of condition must be indicated on prescription). Brace must be used for ambulation. Prescriber: Physician.
Clients must be offered a choice of stabilizing knee braces that are available to address their identified medical need at or below AADL’s maximum contribution.“Upgrade” indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client’s choice and responsibility.
Stabilizing Knee Orthosis
False
Procedure to be added, not other additions.
N700Generic CFAB (Custom) $1,170.60 Max. Each
KO
1 L/E Orthosis Per 4 Years
False
Procedure to be added, not other additions.
N722Generic Custom Fit (OTS) $785.05 Max. EachKO
1 L/E Orthosis Per 4 Years
False
Procedure and joints to be added
O545In-House Custom - Plastic $851.40 EachKO
1 L/E Orthosis Per 4 Years
False
Procedure and Joints to be added
O546In-House Custom - Laminate $1,214.77 EachKO
1 L/E Orthosis Per 4 Years
Stabilizing Knee Orthosis Procedure
FalseO570CFAB Custom $563.69 EachKO
1 KO Procedure Per 4 Years
FalseO571Custom Fit (OTS) $354.00 EachKO
1 KO Procedure Per 4 Years
FalseO507In-House Custom $652.19 EachKO
1 KO Procedure Per 4 Years
© 2013 Government of Alberta April 1, 2014
Page 10 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-9
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Ankle Foot Orthoses (AFO)
Prescription Required
AFO
FalseO288Anterior Floor Reaction $1,343.48 EachAFO
1 L/E Orthosis Per 2 Years
False
Check socket should be used. Criteria - Severe deformity and greater than or equal to 200 lbs. and rotational stability required. Must indicate criteria in E-Business Benefit Note.
O265Composite plastic molded to patient model layered lamination/carbon fibre
$2,217.38 Each
AFO
1 L/E Orthosis Per 2 Years
FalseO280Conventional with double uprights, calf band and free ankle
$771.27 Each
AFO
1 L/E Orthosis Per 2 Years
FalseO278Conventional with single upright, calf band and free ankle
$638.52 Each
AFO
1 L/E Orthosis Per 2 Years
False
Criteria: Charcot Ankle Joint. Criteria must be inticated in E-Busniess Benefit Note.Clients cannot have custom made footwear and a CROW.
O602CROW (Bivalved AFO lined with Rocker Sole) $2,372.98 EachAFO
1 L/E Orthosis Per 2 Years
FalseO272Custom-made to paitent model - Single form $1,249.68 EachAFO
1 L/E Orthosis Per 2 Years
FalseO369Custom-made to patient model - Double form $1,654.66 EachAFO
1 L/E Orthosis Per 2 Years
False
Active community ambulator, plantar flexion weakness, quads good. Must indicate criteria in E-Business Benefit Note.
O578Energy Storing/Return Ankle Foot Orthosis $1,703.93 EachAFO
1 L/E Orthosis Per 2 Years
FalseN280Generic Pre-Fab $881.58 Max. EachAFO
1 L/E Orthosis Per 2 Years
False
Client not eligible for day and night AFO. Definitive brace policy confirmed with Physician. If KAFO required within 1 year, cost of AFO deducted.
E601Night Splints for Neuromuscular Peds $297.90 EachAFO
1 L/E Orthosis Per 2 Years
FalseO275PTB Prosthetic BK type socket molded to patient model with double uprights and free ankles
$1,962.98 Each
AFO
1 L/E Orthosis Per 2 Years
FalseO277PTB, plastic molded to patient model ant/post shell $1,962.98 EachAFO
1 L/E Orthosis Per 2 Years
False
Combined midfoot and hindfoot instability causing severe valgus or varus deformity at the ankle as a result of neuromuscular conditions such as CP, Spina Bifida, Down's Syndrome or orthopedic conditions such as post tibial dysfunction. Client's with soft tissue inflammatory conditions are not eligible. Must indicate criteria in E-Business Benefit Note.
O155Supra malleolar - High temperature thermoplastic molded to patient model.
$1,010.84 Each
AFO
1 L/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 11 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-10
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Ankle Foot Orthoses (AFO)
Prescription Required
Check for AFO
False
Skinny & boney prominent patients, Valgus / Varus greater than 10 – 15 degrees, severe sagital deformity, rotational deformity, high body weight, unstable midfoot, scarring or adhesions greater than 8 square cm.Criteria MUST be indicated in E-Business Benefit Note.
N309 $424.28 EachAFO
1 Check AFO Per 2 Years
###Knee Ankle Foot Orthoses (KAFO)
Prescription RequiredJoint to be added.
Check for KAFO
False
Skinny & boney prominent patients, Valgus / Varus greater than 10 – 15 degrees, severe sagital deformity, rotational deformity, high body weight, unstable midfoot, scarring or adhesions greater than 8 square cm.Criteria MUST be indicated in E-Business Benefit Note.
N310 $626.73 EachKAFO
1 Check KAFO Per 2 Years
KAFO
FalseO287Conventional - double upright $1,909.63 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO283Conventional - single upright $1,510.16 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO285Conventional - single upright without knee joint $1,510.16 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO299Graphite - double upright $3,710.78 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO293Hybrid - double upright $2,566.32 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO292Hybrid - single upright $2,273.83 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO291Plastic - double upright $2,566.32 EachKAFO
1 L/E Orthosis Per 2 Years
FalseO290Plastic - single upright $2,063.31 EachKAFO
1 L/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 12 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-11
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Stance Phase KAFO
Prescription Required
Criteria
weak quadriceps mechanism
adequate hip flexion and extension power
no spasticity
no knee flexion contracture > 10 degrees
no hip flexion contracture > 220 lbs.
good balance
good cognition
Criteria must be indicated in E-Business Benefit Note.
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Stance Phase KAFO
FalseO232Free Walk Ottobock170K1=L-120-OBA-7
$3,888.96 Each
KAFO
1 L/E Orthosis Per 2 Years
###Additions to Lower Extremity Othoses
Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized seperately, such as joints which are listed as "per side"
Ankle Joints
FalseN308Generic Ankle Joints $240.32 Max. Per Side
AFO, HKAFO, KAFO, THKAFO
5 L/E Additions Per 2 Years
Bail Locks Bar or Equivalent
False
To be added if the bail lock is activated by an extension assist, cable release, or other remote method, or in the case of bi-lateral joint uprights, the bail is contoured and attached to both joints. If only a single hinge/lock claim for 1/2 of price max.
O343 $330.07 Per PairKAFO, KO
5 L/E Additions Per 2 Years
Bariatric Option
False
Client is 100 lb. over normal weight or over 275 lb. Must indicate criteria in E-Business Benefit Note.
O498Lower Extremity Orthosis $349.50 EachAFO, HKAFO,
KAFO, THKAFO
5 L/E Additions Per 2 Years
Becker Cable Control for Trigger Lock
FalseO184MX003-HS/R $396.69 EachAFO, KAFO, KO
5 L/E Additions Per 2 Years
Calf Band
FalseO349Custom molded to patient model $399.36 EachAFO, KAFO
5 L/E Additions Per 2 Years
Calf Lacer
FalseO334Full, molded to patient model $525.28 EachKAFO
5 L/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 13 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-12
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Lower Extremity Othoses
Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized seperately, such as joints which are listed as "per side"
Calf Lacer
FalseO330Half, non-molded $239.99 EachKAFO
5 L/E Additions Per 2 Years
Custom Fabricated Flexible Interface
False
Criteria: For unstable, high tone, or severe foot deformity. Criteria must be indicated in E-Busniess Benefit Note.
O579 $289.05 EachAFO, KAFO
5 L/E Additions Per 2 Years
Dorsi Flexion Stop
FalseO351Custom $293.50 EachAFO, KAFO
5 L/E Additions Per 2 Years
Drop Lock or Equivalent
False
To be added if the addition of magnets or corking screws are incorporated into the fabrication procedure. If only a single hinge/lock claim for 1/2 of price maximum
O341 $184.08 Per PairHKAFO, KAFO,
THKAFO
5 L/E Additions Per 2 Years
Extension for Lineal Adjustment for Growth for Side
Bars
FalseO388 $200.04 EachKAFO, THKAFO,
RGO
5 L/E Additions Per 2 Years
Hip Joints
FalseO381Clevis type or thrust bearing, free $665.29 EachHKAFO, KAFO
5 L/E Additions Per 2 Years
Ischial Ring
FalseO366 $618.59 EachKAFO
5 L/E Additions Per 2 Years
Joint Covers
FalseO363 $135.90 Per PairKAFO
5 L/E Additions Per 2 Years
Knee Cage
FalseO359Pull Over $510.59 EachKAFO
5 L/E Additions Per 2 Years
FalseO357Standard $420.09 EachKAFO
5 L/E Additions Per 2 Years
Knee Joints
FalseO391Adjustible Extension Ring Lock - Becker 1006 $302.24 EachKAFO, KO
5 L/E Additions Per 2 Years
FalseO379Automatic Spring Lever - Becker 1003 $347.34 EachKAFO, KO
5 L/E Additions Per 2 Years
False
If only a single hinge/lock claim for 1/2 of price maximum
O345Disc or Dial Lock Joints for Adjustable Knee or Equivalent
$426.26 Per Pair
KAFO, KO
5 L/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 14 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-13
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Lower Extremity Othoses
Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized separately, such as joints which are listed as "per side"
Knee Joints
FalseO375Free Motion/Ring Lock - Becker - 1002/1005/1008 $248.84 EachKAFO, KO
5 L/E Additions Per 2 Years
FalseO373Free Motion/Ring Lock - Ottobock 17B43=16 $210.24 EachKAFO
5 L/E Additions Per 2 Years
FalseN699Generic $448.20 Max. EachNone
5 L/E Additions Per 2 Years
FalseO352Offset Bail Locks 17B33 or Equivalent $533.88 EachKAFO
5 L/E Additions Per 2 Years
FalseO350Offset Drop Locks 17B20 or Equivalent $242.85 EachKAFO
5 L/E Additions Per 2 Years
FalseO371Polycentric - Ottobock 17B46 $439.90 EachKAFO
5 L/E Additions Per 2 Years
FalseO377Polycentric Knee Joint - Becker $358.14 EachKAFO, KO
5 L/E Additions Per 2 Years
FalseO399Ratchet Lock - Becker $347.79 EachKAFO, KO
5 L/E Additions Per 2 Years
FalseO401Step Loc - OTS Corp $389.42 EachKAFO, KO
5 L/E Additions Per 2 Years
FalseO380Swiss Lock - Ottobock 17B36/17B48 $361.00 EachKAFO, KO
5 L/E Additions Per 2 Years
Locking Knee Hinge(s) or Equivalent
FalseO477For custom-made stabilizing knee orthosis $285.56 EachKO
5 L/E Additions Per 4 Years
FalseO479For custom-made unloading knee orthosis $285.56 EachKO
5 L/E Additions Per 4 Years
Molded Foot Section Attached to Stirrup
FalseO353 $743.68 EachAFO, KAFO
5 L/E Additions Per 2 Years
Pad
FalseO386Gluteal $148.93 EachHKAFO, KAFO,
THKAFO
5 L/E Additions Per 2 Years
FalseO358Sub Patellar $51.16 EachKAFO
5 L/E Additions Per 2 Years
Pelvic Band, Belt and Hip Joint
FalseO384Bilateral $1,696.74 EachHKAFO, KAFO
5 L/E Additions Per 2 Years
FalseO382Unilateral $1,094.03 EachHKAFO, KAFO
5 L/E Additions Per 2 Years
Plantar Flexion Stop
FalseO354Custom $161.75 EachAFO, KAFO
5 L/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 15 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-14
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Lower Extremity Othoses
Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized separately, such as joints which are listed as "per side"
Pre-Tibial or Femoral Shell
FalseO336Molded to patient model $434.85 EachAFO, HKAFO,
KAFO, THKAFO
5 L/E Additions Per 2 Years
Quadrilateral Brim
FalseO368Molded to patient model $867.99 EachKAFO
5 L/E Additions Per 2 Years
RGO (Reciprocating Gait Orthosis)
False
Contact AADL for prior approval of price.
O387Pelvic assembly and jacket only, does not include KAFO's.
Prior Approval
KAFO, RGO
5 L/E Additions Per 2 Years
Round Caliper Plate
FalseO362 $288.32 EachAFO, KAFO
5 L/E Additions Per 2 Years
Specialized Strap
False
High extensor tone requires additional strap. Must indicate criteria in E-Business Benefit Note.
O413Dorsal Ankle Strap (retention) $47.40 EachAFO
5 L/E Additions Per 2 Years
False
Quantity Limit: 1 per 2 years, except 2/2 years with O314, O316
O415Valgus or Varus "T" Straps $119.96 EachAFO, KAFO
5 L/E Additions Per 2 Years
Stirrup
FalseO367Spilt stirrup and flat caliper plate or solid sturrip $290.83 EachAFO, KAFO
5 L/E Additions Per 2 Years
Thigh Lacer
FalseO374Full, molded to patient model $620.28 EachKAFO
5 L/E Additions Per 2 Years
FalseO372Full, non-molded $422.36 EachKAFO
5 L/E Additions Per 2 Years
FalseO376Half, custom made $365.09 EachKAFO
5 L/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 16 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-15
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Stance Phase Knee Joint
Prescription Required
Criteria
weak quadriceps mechanism
adequate hip flexion and extension power
no spasticity
no knee flexion contracture > 10 degrees
no hip flexion contracture > 220 lbs.
good balance
good cognition
Criteria must be indicated in E-Business Benefit Note.
Any comparable quality system to below listed items may be substituted with AADL prior approval.
Becker Load Response
FalseO240 $1,219.36 EachKAFO
1 Joint Per 2 Years
Horton Stance Phase
FalseO243 $1,585.88 EachKAFO
2 Joints Per 2 Years
Stance Phase Knee Joint - Fillauer Swing Phase Lock
FalseO263 $3,825.60 EachKAFO
1 Joint Per 2 Years
###Thoracic-Hip-Knee-Ankle Orthoses
Prescription RequiredAny comparable quality system to below listed items may be substituted with AADL prior approval.
Parapodium
FalseO224Small/large (Variety Village style) $2,600.25 EachTHKAFO
1 L/E Orthosis Per 2 Years
Recycle fee
False
25% of list of: O224, O226, O227, O222, O302, O242
O517THKAFO
1 Recycle Fee Per Limb Per 4 Years
Standing Frame
FalseO226Custom fitted (Variety Village style) $1,695.23 EachTHKAFO
1 L/E Orthosis Per 2 Years
FalseO227Custom Made $2,344.47 EachTHKAFO
1 L/E Orthosis Per 2 Years
Winnipeg Standing Frame
FalseO222 $2,273.70 EachTHKAFO
1 L/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 17 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-16
Supers
eded
Qty. / Freq.
###Lower Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Footwear
Transfer Of Caliper Plate From Shoe To Shoe
FalseO442 $355.90 EachAFO
2 Transfers Per 2 Years
Transfer of Dennis Brown Foot Plates To New Shoes
FalseO446 $181.22 EachAFO, HIPO
2 Transfers Per 2 Years
Transfer Of Solid Stirrup From Shoe To Shoe
FalseO444 $444.40 EachAFO, KAFO
2 Transfers Per 2 Years
###Partial Foot Prostheses
Prescription Required
Partial Foot Prosthesis
False
No additions
O207AFO Style Partial Foot Prosthesis $2,331.50 EachPF
1 L/E Orthosis Per 2 Years
False
No additions
O087Custom Foot Orthosis Style with Toe Filler $504.54 EachPF
1 L/E Orthosis Per 2 Years
False
No additions
O157Custom Foot Orthosis Style with Toe Filler and Sole Stiffener
$742.49 Each
PF
1 L/E Orthosis Per 2 Years
False
UPGRADE, No additions
O247Custom Silicone Prosthesis $2,682.00 EachPF
1 L/E Orthosis Per 2 Years
False
No additions
O197Enclosed Socket Style Prosthesis $1,609.00 EachPF
1 L/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 18 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-17
Supers
eded
Qty. / Freq.
###Upper Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Shoulder and Shoulder-Elbow-Wrist-Hand Orthoses
Prescription Required
Functional Arm Orthosis With Shoulder Cap
False
No Additions
O453 $2,109.73 EachSO
1 U/E Orthosis Per 2 Years
Highlander Shoulder Sling
FalseO447 $656.36 EachSO
1 U/E Orthosis Per 2 Years
Humeral Orthosis
FalseO449Custom Fitted $295.72 EachSO
1 U/E Orthosis Per 2 Years
FalseO451Molded to patient model $961.96 EachSO
1 U/E Orthosis Per 2 Years
###Elbow Orthoses
Prescription Required
Elbow Orthosis
FalseO454Molded to patient - low temp thermoplastics $426.71 EachEO
1 U/E Orthosis Per 2 Years
FalseO456Molded to patient model $838.69 EachEO
1 U/E Orthosis Per 2 Years
Hinged Elbow Orthosis
FalseO455Molded to patient model $1,230.04 EachEO
1 U/E Orthosis Per 2 Years
###Wrist-Hand Orthoses - Dynamic
Prescription Required
CTI2 Wrist Brace
FalseO140Custom - made from cast $1,512.42 EachWHO
1 U/E Orthosis Per 2 Years
FalseO153OTS Fit according to measurements $544.31 EachWHO
1 U/E Orthosis Per 2 Years
WHO
FalseO463Molded to patient model with joints $1,098.57 EachWHO
1 U/E Orthosis Per 2 Years
FalseO465Rancho, Engen or equivalent $1,663.01 EachWHO
1 U/E Orthosis Per 2 Years
###Wrist-Hand Orthoses - Static
Prescription Required
WHO
FalseO466Custom Fitted, long opponens kit type $298.47 EachWHO
1 U/E Orthosis Per 2 Years
FalseO492Custom made, soft leather $983.73 EachWHO
1 U/E Orthosis Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 19 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-18
Supers
eded
Qty. / Freq.
###Upper Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Wrist-Hand Orthoses - Static
Prescription Required
WHO
FalseO462Molded to patient model, high temperature thermoplastics
$918.81 Each
WHO
1 U/E Orthosis Per 2 Years
FalseO490Static Molded to the patient model, working splint (wrist gauntlet)
$807.79 Each
WHO
1 U/E Orthosis Per 2 Years
###Hand Orthoses - cannot be added to WHO
Prescription Required
Short Opponens
FalseO469Molded to patient model $564.34 EachWHO
1 U/E Orthosis Per 2 Years
Short Opponens Kit
FalseO464Custom Fitted - Rancho, Engen or equivalent $243.75 EachWHO
1 U/E Orthosis Per 2 Years
###Finger Orthoses
Generic Finger Orthosis
False
To control finger deformities. No Additions.
N305Functional Ring Splints $293.63 Max. EachWHO
1 Per Digit Per 2 Years
###Additions to Upper Extremity Othoses
Total limit of 10 additions per orthoses. No duplicate additions for the same digits or joint.
1st Dorsal Interosseous Assist
FalseO470 $154.22 EachWHO
10 U/E Additions Per 2 Years
Adjustable MP Flexion Control
FalseO486 $302.85 EachWHO
10 U/E Additions Per 2 Years
Adjustable MP Flexion Control and IP Flexion Control
FalseO488 $347.10 EachWHO
10 U/E Additions Per 2 Years
Adjustable Position Lock
FalseO460Contracture reduction $349.83 EachEO
10 U/E Additions Per 2 Years
FalseO461With Active Control $1,130.49 EachEO
10 U/E Additions Per 2 Years
Dynamic Elbow Extension Assist
False
To maintain/increase ROM chronic non-fixed flexion contractures. Must indicate criteria in E-Business Benefit Note.
O365 $761.40 EachEO
10 U/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 20 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-19
Supers
eded
Qty. / Freq.
###Upper Extremity Orthoses
Cat. No. AADL PriceOrth. Type
###Additions to Upper Extremity Othoses
Total limit of 10 additions per orthoses. No duplicate additions for the same digits or joint.
Figure 8 Harness and Bowden Cable
FalseO485 $259.00 EachEO
10 U/E Additions Per 2 Years
Flexion or Extension Assist
FalseO484 $161.44 EachWHO
10 U/E Additions Per 2 Years
Flexion/Extension Assist
FalseO458 $237.25 EachEO
10 U/E Additions Per 2 Years
IP Ext. Assist
FalseO472 $65.77 EachWHO
10 U/E Additions Per 2 Years
Lumbrical Bar
FalseO473 $182.65 EachWHO
10 U/E Additions Per 2 Years
Metal Uniaxial Hinge with Adjustable Postion Lock
FalseO360Beckers 4001C/4001B $377.03 EachWHO
10 U/E Additions Per 2 Years
FalseO356Beckers Flexion or Extension Assist 4001C/4001B $377.03 EachWHO
10 U/E Additions Per 2 Years
MP Ext. Assist
FalseO476 $65.77 EachWHO
10 U/E Additions Per 2 Years
MP Ext. Stop
FalseO474 $94.15 EachWHO
10 U/E Additions Per 2 Years
Spring Swivel Thumb
FalseO480 $214.52 EachWHO
10 U/E Additions Per 2 Years
Tamarack Hinge for Elbow
FalseO158Dorsiflexion assist or non-dorsiflexion assist $235.20 Per PairEO
10 U/E Additions Per 2 Years
Tamarack Hinge for Wrist
FalseO160Dorsiflexion assist or non-dorsiflexion assist $235.20 Per PairWHO
10 U/E Additions Per 2 Years
Thumb MP Stop With Thumb IP Ext. Assist
FalseO482 $211.68 EachWHO
10 U/E Additions Per 2 Years
Thumb Post
FalseO471 $101.42 EachWHO
10 U/E Additions Per 2 Years
© 2013 Government of Alberta April 1, 2014
Page 21 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-20
Supers
eded
Qty. / Freq.
###Non-Rigid Musculoskeletal Supports
Cat. No. AADL PriceOrth. Type
###Spinal Orthoses - Non-Rigid
Prescription Required
Generic Dorso-Lumbar Support
FalseN7411st Fitting $338.68 Max. EachNRS
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
FalseN3012nd Support - No Fitting Fee $161.68 Max. EachNRS
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
Generic Lumbo-Sacral Support
FalseN7441st Fitting $350.62 Max. EachNRS
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
FalseN3022nd Support - No Fitting Fee $173.62 Max. EachNRS
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
Lumbosacral Support
FalseO128Custom Made $362.84 EachNRS
1 Custom Made Support Per 12 Months
Sacroiliac Support
FalseO156Custom Made $567.28 EachNRS
1 Support Per 12 Months
Thoraco-Lumbo-Sacral support
FalseO097Custom Made $554.81 EachNRS
1 Custom Made Support Per 12 Months
###Soft Support Additions
Bariatric Option for Soft Supports
FalseN746 $177.00 EachHERNIA, NRS
2 Additions Per 12 Months
###Hernia Supports
Prescription Required
Generic Abdominal Hernia Support
FalseN7401st Fitting $281.56 Max. EachHERNIA
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
FalseN3062nd support - No Fitting Fee $104.56 Max. EachHERNIA
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
Generic Inguinal Hernia Support
FalseN7421st Fitting $237.70 Max. EachHERNIA
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
FalseN3072nd support - No Fitting Fee $60.70 Max. EachHERNIA
1 "1st Fitting" & 1 "2nd Support" Per 12 Months
© 2013 Government of Alberta April 1, 2014
Page 22 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-21
Supers
eded
Qty. / Freq.
###Non-Rigid Musculoskeletal Supports
Cat. No. AADL PriceOrth. Type
###Hernia Supports
Prescription Required
Hernia Support Cloth/elastic Type
FalseO179Custom Made $597.55 EachHERNIA
1 Custom Made Support Per 12 Months
© 2013 Government of Alberta April 1, 2014
Page 23 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-22
Supers
eded
Qty. / Freq.
###Orthotic Benefits for Clubfoot
Cat. No. AADL PriceOrth. Type
###Orthotic Benefits for Clubfoot
Clubfoot benefits are part of AADL Orthotic Benefits, but are administered differently.
Eligibility Criteria:
Clients must meet all AADL general eligibility criteria.
Clients must be diagnosed with clubfoot and have an orthosis recommended by an orthopedic surgeon orspecialized clubfoot team.
In lieu of a prescription, Specialty Suppliers may obtain an "AADL Clubfoot Benefits Referral" form prior toassessing or providing benefits.
Clients are not eligible to be provided AADL Clubfoot Benefits and other lower extremity Orthotic Benefits at thesame time. For example, a client may not have a clubfoot brace and another AFO at the same time.
Clubfoot benefits are not eligible for repairs or modifications. The cost for any repairs or maintenance outside ofthe manufacturer's warranty are the client's responsibility.
Authorizations:
Clubfoot benefits are provided using an ongoing authorization which is active for five years from the initialassessment date.
Specialty Suppliers must select authorization type "CF" when creating the authorization on E-business.
Clients or Specialty Suppliers may contact AADL directly to request a vendor change for a clubfoot authorization.
Specialty Suppliers must contact AADL directly for clients who require benefits for longer than five years.
Assessment
False
Includes the assessment, measurement, and fitting of clubfoot AFOs and abduction bar.Only available to non-AHS vendors.
O750Complete Orthotic Assessment $132.75 Per Assessment
CF
3 Complete Assessments Per 5 Years
False
Includes the assessment, measurment and fitting of replacement components (AFOs or abduction bar).Only available to non-AHS vendors, if new measurements are taken by the vendor.
O753Follow-Up Assessment $70.80 Per Assessment
CF
10 Follow-Ups Per 5 Years
Generic Abduction Bar
FalseN751All sizes $111.32 Max. EachCF
3 Abduction Bars Per 5 Years
Generic AFOs/Boots
False
If only one boot required, maximum price is $170.86
N753All sizes $341.72 Max. Per Pair
CF
8 Pairs of AFOs/Boots Per 5 Years
© 2013 Government of Alberta April 1, 2014
Page 24 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-23
Supers
eded
Qty. / Freq.
###Orthotic Service Fees
Cat. No. AADL PriceOrth. Type
###Orthotic Modifications and Repairs
AADL will not fund any modifications or repairs to an orthotic device within ninety (90) days of provision of the device. Specialty Suppliers are required to provide all necessary follow-up to ensure the device is able to be used for the purpose intended without additional cost to AADL or the client.
Replacement of components (joints, retention straps, etc.) must be authorized using the respective catalogue numbers listed in the approved product list. Do not use moditication or repair catalogue numbers for replacement.
Basic maintenance of an orthosis, for example cleaning of the device is the client's responsibility.
Specialty Supplier must document the nature of the work completed and the clinical justification in the E-business benefit notes for all authorized modications or repairs.
Adjustments
False
For adjustments due to a documented area of pressure or significant irritation.
O605Adjustment for Pressure Area $59.70 All except CF, HERNIA, NRS
3 Adjustsments Per 12 Months
False
For adjustments due to a change in the size or shape of the client's body.
O603Sizing/Fit Adjustment $59.70 All except CF, HERNIA, NRS
3 Adjustsments Per 12 Months
Orthotic Modification and Repairs
False
Eligible only if component will not be replaced for at least 6 months.
Fax the following information to AADL for prior approval:- Client information- Detailed description of the work to be done- Clinical justification- Cost breakdown, including all labour and materials
O609Major Modification or Repair Prior ApprovalAll except CF, HERNIA, NRS
3 Modifications/Repairs Per 12 Months
False
To maintain structural integrity and/or function orthosis.
O607Minor Modification or Repair $139.35 All except CF, HERNIA, NRS
3 Modifications/Repairs Per 12 Months
False
Eligible only if component will not be replaced for at least 6 months.
Fax the following information to AADL for prior approval:- Client information- Detailed description of the work to be done- Clinical justification- Cost breakdown, including all labour and materials
O627Non-Warranty Repair by Manufacturer Prior ApprovalAll except CF, HERNIA, NRS
3 Modifications/Repairs Per 12 Months
False
For commercial components only. Cannot be authorized for fit adjustments. Eligible only if component will not be replaced for at least 6 months. Includes: Removal and re-installation of the component.
O625Warranty Repair by Manufacturer $221.25 All except CF, HERNIA, NRS
3 Modifications/Repairs Per 12 Months
© 2013 Government of Alberta April 1, 2014
Page 25 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-24
Supers
eded
Qty. / Freq.
###Orthotic Service Fees
Cat. No. AADL PriceOrth. Type
###Orthotic Replacement Components
AADL will not fund any replacement components for an orthotic device for a minimum of ninety (90) days of provision of the device. Specialty Suppliers are required to provide all necessary follow-up to ensure the device is able to be used for the purpose intended without additional cost to AADL or the client.
The catalogue numbers listed below must only be used to replace a component on the client's most current orthosis. They cannot be used as part of an authorization for a new device, nor can they be used to authorize a duplicate or back-up components.
If the component to be replacement was origianlly authorized upsing a specific catalogue number (joints, retention straps, etc.), it must be authorized using that same original catalogue number.
Specialty Supplier must documents the nature of the work completed and the clinical justification in the E-business benefit notes for all authorized replacement components.
Replacement Liner
False
After 6 months
O495Cervical Orthosis $36.25 EachCO
1 Liner Per 12 Months
False
After 6 months
N708Generic Knee Orthosis Liner Kit $119.91 Max. EachKO
1 Set of Liners Per 12 Months
Replacement Parts for Milwaukee Orthosis
FalseO192Kyphosis pad $163.28 EachCTLSO
3 Replacement Parts Per 2 Years
FalseO194Lumbar pad $82.86 EachCTLSO
3 Replacement Parts Per 2 Years
FalseO214Skirt $1,776.12 EachCTLSO
3 Replacement Parts Per 2 Years
FalseO198Sternal pad $120.54 EachCTLSO
3 Replacement Parts Per 2 Years
Replacement Straps
FalseO526Lower Extremity Strap - Lower Leg $33.15 EachAFO, HKAFO,
KAFO, KO, THKAFO
4 Lower Leg Straps Per 12 Months
False
Primarily used as part of a CFAB KO
N714Lower Extremity Strap - Specialized Knee Strap - Generic
$57.55 Max. Each
HKAFO, KAFO, KO, THKAFO
1 Knee Strap Per 12 Months
FalseO519Lower Extremity Strap - Upper Leg $33.15 EachHKAFO, KAFO, KO,
THKAFO
4 Upper Leg Straps Per 12 Months
FalseO529Spinal Orthosis Strap $33.15 EachCO, CTLSO, LSO,
TLSO
4 Spinal Straps Per 12 Months
FalseO528Upper Extremity Strap $33.15 EachEO, SO, WHO
8 U/E Straps Per 12 Months
© 2013 Government of Alberta April 1, 2014
Page 26 of 26
Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List
© 2017 Government of AlbertaRevised October 16, 2017
APL O-25
Supers
eded
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