Alberta Health. AADL Approved Product List - Seating Benefits. Pricing effective May 1, Revision History

Transcription

1 Health AADL Approved Product List - Seating Benefits Pricing effective May Revision History X964: Update to process. See description inside. Updates to Catalogue Numbers (highlighted in yellow) Updated: Approved Seating Manufacturers Updated: APL Format 5/1/ 5/1/ 5/1/ 4/1/

2 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List General Information for Seating Benefits AADL clients are eligible for one seating system. If clients have more than one mobility base and the components cannot be transferred, the client is responsible for the costs of the duplicate components. Benefits listed on the AADL Seating Approved Product List can only be authorized by designated AADL Seating Authorizers. Two levels of Seating Clinics: Level I Seating Clinics Provide commercially available seating components in conjunction with an AADL Seating Vendor who has a Commercial Seating Technician. Level II Seating Clinics Provide custom-fabricated seating components in conjunction with AADL Seating Vendors who has a Adaptive Seating Technician. The prices listed in the AADL Seating Approved Product List are as follows: Level I The price is the manufacturer retail price less a 5% discount. Level II The price represents the combined cost for materials and labour. Some Level I catalogue numbers are designated as generic catalogue numbers. Generic catalogue numbers are a benchmark pricing model. Each catalogue number has a price maximum. Seating vendors must provide an item that meets the description at or below the price maximum. The price maximum is based on the manufacturer's retail price, less a 5% discount. Seating vendors must apply a 5% discount when using the generic catalogue numbers. Costs over the AADL price maximum are considered an upgrade and are the client's responsibility. of May Page 2 of 32 APL X-1

3 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List General Catalogue Number Information These catalogue numbers are used to provide commerically-available seating components for which there is no specific catalogue number. The equipment provided using a generic catalogue number must meet the following criteria: Product must be available from an AADL Approved Seating Manufacturer. Product must meet the AADL Commercial Seating Product Minimum Standards. AADL Commercial Seating Product Minimum Standards Warranty The manufacturer must warrant that the product will be free from defects in material and workmanship for the below noted minimum years from the date the equipment was purchased: Bases: 2 years Lateral Supports: 2 years Headrests: 2 years Pommels: 1 year Straps/Belts: 1 year Bolsters, Adductors/Abductors: 1 year Wedges: 1 year Foot/Leg Supportss: 1 year Arm/Shoulder Supports: 1 year Trays: 1 year Backs: 2 years Equipment Limitations Equipment must have been in production for a minimum of one year in the North American market. Liability Insurance Equipment provided must have a minimum two million dollars comprehensive general liability insurance provided by the manufacturer. Fire Retardancy Materials must meet at least the California 117 Fire Retardancy Standard. Pricing Example: Generic Catalogue Number Y-Belt Manufacturer s retail price = $85 Pricing procedure: $85 5% = $80.75 AADL Maximum Contribution = $80.75 (for cost-share exempt clients) Cost-Share Client portion (25%) = $80.75 x 25% = $20.19 AADL portion for cost-share client = $80.75 x 75% = $60.56 of May Page 3 of 32 APL X-2

4 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List AADL Approved Seating Manufacturers Manufacturer Manufacturer Representative Contact Bodypoint Invacare nxt Ottobock Jonathan Alexander Tom Corbett Brandon Strap Craig Royal jon@advancedhealthcare.ca Tcorbett@invacare.com brandonstrap@outlook.com Craig.Royal@ottobock.com Power Plus Mobility Jason Mohan jason@powerplusmobility.com ROHO Sunrise Medical Varilite Jonathan Alexander Jessica Mueller Braden Hirsch jon@advancedhealthcare.ca jessica.mueller@sunmed.com 15@49bespoke.com of May Page 4 of 32 APL X-3

5 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 01. Headrests, Neckrests, Hardware & Covers Generic Commercial Seating Component - Use generic pricing method Adaptor Kit or Mounting Plate for 1 Kit or Plate Per 4 Years Headrest/Neckrests Clamp To mount headrest or other seating component 2 Clamps Per 4 Years Hardware for Headrest/Neckrest 1 Headrest Hardware Per 4 Years X062 False X331 False X045 False This catalogue number is only for the hardware for a headrest, combine with X015 if required. Headrest/Neckrest Headrest with Lateral Support Daher No hardware included, combine with X045 if required. 1 Headrest Per 4 Years X035 False $ Max. Each $46.46 Max. Each $ Max. Each $ Max. Each Specialized Headrest X040 False Prior Approval Includes hardward, cannot be combined with X045. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Standard Headrest or Neckrest No hardware included, combine with X045 if required. Headrest Combination Headrest HC100 Large Headrest HL100 Headrest Hardware WS10 Future Mobility Headrest Multi-axial Headrest - On Chair 1 Headrest Per 4 Years 1 Hardware Per 4 Years 1 Headrest Per 4 Years Single Multi-axial Headrest, large foam pad and cover (no wings) includes hardware - Off Chair Headrest Extension Multi-axial Headrest Horizontal Extension Headrest Hardware Multi-axial Universal Hardware Invacare Jay Health - Professional Services and Health Benefits Elite Back Headrest Adaptor Headrest Jay 3 AXYS Mount 1 Extension Per 4 Years 1 Hardware Per 4 Years 1 Adaptor Per 4 Years 1 Headrest Per 4 Years X015 False X688 False X687 False X690 False X436 False X435 False X437 False X442 False I202 False X486 True $ Max. Each $82.76 Each $82.76 Each $ Each $ Each $ Each $52.25 Each $ Each $38.95 Each $ Each of May Page 5 of 32 APL X-4

6 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 01. Headrests, Neckrests, Hardware & Covers Jay Headrest Jay 3 COBRA Mount Headrest mount 1 Headrest Mount Per 4 Years Jay 3 back universal Maple Leaf Wheelchair Headrest 1 Headrest Per 4 Years Mounting plate not included Headrest Mounting Plate 1 Plate Per 4 Years Ottobock Headrest 1 Headrest Per 4 Years Lateral Control Headrest 430C2 1-7/3-7 Soft Headrest 430H2 Styles Lg/Sm 430C1 = 1-7/3-7, or 430H1 = 1-7/3-7 Headrest Adpator Kit 1 Adaptor Kit Per 4 Years 476D52 SK010/015/020/025/060/065 Headrest Hardware 1 Hardware Per 4 Years Gooseneck Mounting Kit 476L52-SK030 or Straight Mounting Kit 476L52-SK035 1 Headrest Per 4 Years X487 True $ Each X491 True $57.95 Each X463 False $ Each X467 False $95.00 Each X522 False $ Each X391 False $ Each X069 False $ Each X868 False $ Each X386 False $ Each Multi-Axis Offset or Multi-Axis Straight X078 False $ Each Mounted to wheelchair insert, can be used for neckrest also 476L52-SK020/025/010/015 Headrest Hardware Adaptor Kit 1 Adaptor Kit Per 4 Years X079 False $ Each Mounted to wheelchair uprights to back tubes of W/C using STS clamps 476D52-SK020/030/035/040/045/05 Headrest Hardware Clamp 1 Clamp Per 4 Years For any back (477152=SK039) X969 False $47.65 Each STS Clamps 2 Clamps Per 4 Years 477D52/434H1 X387 False $46.46 Each To attach headrest hardware Stealth Stealth i2i Headrest 1 Headrest Per 4 Years I210 False Prior Approval Prior Approval. Submit spec sheet/pricing and clinical rationale to AADL. Western Home Medical Cane Mount Bracket 1 Bracket Per 4 Years Bracket Only X364 True $ Each Including Aspen2 Headrest X365 True $ Each of May Page 6 of 32 APL X-5

7 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 01. Headrests, Neckrests, Hardware & Covers Western Home Medical Headrest Adjustable chair mount, Oxford 1 system 1 Headrest Per 4 Years X196 False $ Each Adjustable offset. Aspen1 & Aspen2 X195 False $ Each With multi-axle hardware Aspen1 X428 True $ Each With multi-axle hardware Aspen2 X429 True $ Each Hardware for Headrest Multi-axial Standard 1 Hardware Per 4 Years Headrest 1 Headrest Per 4 Years Headrest with lateral support, wood rigid shell, foam and covering with movable lateral extension With lateral support, kydex shell, foam and covering with movable lateral extension Headrest Cover (replacement only) Removable Cover For replacement only Headrest/Neckrest Rigid kydex shell, foam and covering, occipital support Rigid wood shell, foam and covering, occipital support 1 Cover Per 12 Months 1 Headrest Per 4 Years X348 False X606 True X003 True X378 True X072 True X449 True X010 True $ Each $ Each $ Each $ Each $ Each $ Each $ Each of May Page 7 of 32 APL X-6

8 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 02. Straps, Belts & Kits Generic Commercial Seating Component - Use generic pricing method Calf Strap or H Strap 1 Strap Per Leg Per 12 Months Posterior support for bilateral/positioning of the lower legs. Chest Strap 1 Chest Strap Per 12 Months Chest Harness, Butterfly Strap, or H-Strap, for torso/thoracic positioning Footstrap/Toe Loop 1 Footstrap Per Foot Per 12 Months Transverse Strap for positioning of foot Hardware Kit for Belt Heel Loop/Ankle Strap Strapping mechanism to secure ankle/foot. Pelvic Strap Y or K Strap/Belt, for pelvic positioning. Bodypoint Ankle Huggers Medium/large Chest Strap MonoFlex anterior trunk support Stayflex Anterior Trunk Support - with or without zipper Leg Harness HB 602/603/604 1 Kit Per 12 Months 2 Per 12 Months 1 Per 12 Months 1 Pair Footstraps Per 12 Months 1 Chest Strap Per 12 Months 1 Leg Strap Per 2 Years X065 False X225 False X954 False X107 False X070 False X227 False X971 False X498 False X393 False X664 False Pelvic Belt 1 Pelvic Belt Per 12 Months 4 point centre pull - small/med/large HB501CHB502C HB503C X427 False Padded Hip Belt 2 point centre pull - small/med HB104C Universal Strap Daher Chest Harness Small, medium, large Pelvic Belt K/Y Belt - 2" Jay AES Structured Y Shoulder Strap Chest Strap Jay 3 Chest Straps/Harnesses 1 Strap Per 2 Years 1 Chest Strap Per 12 Months 1 Pelvic Belt Per 12 Months 1 Trunk Support Per 12 Months 1 Chest Strap Per 12 Months X426 False X414 False X691 False X347 False X420 True X484 True $92.15 Max. Each $ Max. Each $28.50 Max. Each $24.70 Max. Each $92.63 Max. Each $ Max. Each $ Per Pair $97.85 Each $ Each $ Each $ Each $ Each $85.50 Each $86.64 Each $99.23 Each $ Each $ Each of May Page 8 of 32 APL X-7

9 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 02. Straps, Belts & Kits 1 Chest Strap Per 12 Months 1 Chest Strap Per 12 Months 1 Pelvic Strap Per 12 Months 1 Chest Strap Per 12 Months Lecky Waistcoat Nighthawk Chest Strap Female medium/large, male small/med/large Padded Chest Strap N4.037 Pelvic Belt Black webbing N4.031 K Belt, padded/black webbing & hardware N4.027 K Belt, padded/black webbing N4.028 Y Belt with safety/black webbing & hardware N4.021 Western Home Medical Chest Strap Butterfly Shoulder Harness - Small, small slim, med., med. slim, large, large slim Hip Belt 1 Pelvic Strap Per 12 Months Padded hip belt dual rear pulll #5035 X405 False X998 False X962 False X948 False X944 False X945 False X938 False X445 True X590 False $ Each $66.50 Each $ Each $47.50 Each $ Each $ Each $ Each $83.60 Each $ Each Abduction Strap Arm Strap To secure arm Axilia Strap Over-the-shoulder strap 1 Strap Per Leg Per 12 Months 1 Strap Per Arm Per 12 Months 1 Strap Per Arm Per 12 Months Calf Strap or H Strap 1 Calf Strap Per Leg Per 12 Months Chest Strap Butterfly Chest Strap To assist upper trunk control Horizontal strap to assist upper trunk control H-Strap, to assist upper trunk control. V-Strap, to assist upper trunk control Footstrap/Toe Loop of May 1 Chest Strap Per 12 Months 1 Strap Per Foot Per 12 Months X109 True X119 True X117 True X038 True X113 True X041 True X031 True X111 True X106 True $96.94 Each $96.94 Each $96.94 Each $ Each $ Each $ Each $ Each $ Each $ Each Page 9 of 32 APL X-8

10 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 02. Straps, Belts & Kits Halo Strap or Fitted Head Strap Attached to headrest 1 Halo Strap Per 12 Months X073 True $ Each Padded option to strap Clients are eligible for a maximum quantity of 3. 1 Padded Option Per Strap Per 12 Months X379 True $ Each Pelvic Strap Basic Y-Strap 1 Pelvic Strap Per 12 Months X033 True $ Each Strap of webbing including closure X042 True $ Each Safety Strap To secure insert to mobility base 1 Safety Strap Per 2 Years X044 True $ Each of May Page 10 of 32 APL X-9

11 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 03. Hooks, Brackets, Clips, Clamps & Links Generic Commercial Seating Component - Use generic pricing method Clamp 2 Clamps Per 4 Years To mount headrest or other seating component Drop Base Mount Clips 4 Per Back and Per Base Per 4 Years Growth Bracket/Hardware Hooks 1 Growth Bracket Per 4 Years 4 Hooks Per Back and Per Base Per 4 Years Twist Release (antigravity hooks), quantity 4 for base, and quantity 4 for back Locking Suspension Hook (L/R) Prefab component locks, insert to W/C Sliding 90 degree bracket Spacer Hardware Future Mobility Back Mounting Brackets Bariatric To transfer the back to 2nd W/C Lunar Back Brackets For second wheelchair Standard To transfer the back to 2nd W/C 4 Hooks Per 3 Years 1 Sliding Bracket Per 3 Years 1 Pair Per 4 Years 1 Pair Per 4 Years X331 False X634 False X108 False X635 False X138 False X505 False X110 False X193 False I227 False X192 False Invacare Antigravity Hooks 2 Pairs of Hooks Per 3 Years Quick Release Rail Clamp (anti-gravity hooks) X878 False This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base. Twist Release (antigravity hooks) for Ultimate curved/personal backs cane clamp /332 This is for replacement only. Back Mounting Brackets Matrx PB Brackets To transfer back to 2nd W/C Matrx PB Brackets - heavy duty To transfer back to 2nd W/C. Fixed Spacer Hardware For Elite backs of May 1 Pair Per 4 Years 1 Pair of Spacers Per 4 Years X615 False X451 False X452 False X665 False $46.46 Max. Each $26.30 Max. Each $60.08 Max. Each $14.90 Max. Each $34.63 Max. Each $46.07 Max. Each $ Max. Per Pair $ Per Pair $ Per Pair $ Per Pair $81.17 Per Pair $ Per Pair $ Per Pair $ Per Pair $ Per Pair Page 11 of 32 APL X-10

12 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 03. Hooks, Brackets, Clips, Clamps & Links 1 Growth Bracket Per 4 Years Invacare Growth Bracket X798 False Included with KSS. This is for replacement only. Hooks 4 Hooks Per 3 Years Drop Hooks X907 False This is for replacement only. It is included with Invacare Ultimate Base and Comfortmate Base. Drop Hooks for curved back (1") X616 False Each. This is for replacement only. Jay Back Mounting Brackets 1 Pair Per 4 Years For Jay 2, Jay 2 Deep, Jay Care Back - bottom universal post bracket 680C D395 X685 True For Jay 2, Jay 2 Deep, Jay Care Back - top quick release 1/4 turn bracket 681C X669 True To transfer back to 2nd W/C Jay 3 back hardware X490 True To transfer back to 2nd W/C nxt Back Mounting Brackets 1 Pair Per 4 Years Back Brackets I216 False To transfer back to 2nd W/C Ottobock Back Mounting Brackets 1 Pair Per 4 Years Backrest Hardware X392 False To transfer back to 2nd W/C Pride Mobility Back Mounting Brackets 1 Pair Per 4 Years Synergy Shape Back Hardware X457 False To transfer back to 2nd W/C $60.08 Each $32.49 Each $19.00 Each $91.20 Per Pair $43.70 Per Pair $ Per Pair $ Per Pair $ Per Pair $ Per Pair of May Page 12 of 32 APL X-11

13 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 04. Lateral Supports, Hardware & Pads Generic Commercial Seating Component - Use generic pricing method Thoracic Lateral 1 Lateral Per Side Per 4 Years Hardware and pad Invacare Matrx Elite Thoracic Lateral Off-Set Jay Rigid Jay 2 Thoracic Laterals Swing-Away Jay 3 Thoracic Laterals Fixed Laterals Ottobock OB STS Clamp 434H1=1 UPGRADE 1 Lateral Per Side Per 4 Years 1 Pair of Laterals Per 4 Years 1 Pair of Laterals Per 4 Years 1 Clamp Per Side Per 4 Years OB STS Pad 1 Lateral Pad Per Side Per 4 Years Large/med/small 434P1 STS Hardware Rod Assembly 434F1 1 Support Hardware Per Side Per 4 Years X214 True X652 False X649 False X607 True X485 True X911 False X812 False X713 False $ Max. Each $ Each $ Each $ Per Pair $ Per Pair $46.46 Each $ Each $ Each Lateral Thoracic Support Lateral Support, rigid support, foam and covering 1 Lateral Per Side Per 4 Years X017 True $ Each Lateral Thoracic Support Rigid support, foam and covering-kydex curved 1 Lateral Per Side Per 4 Years X473 True $ Each Swing-Away X349 True $ Each of May Page 13 of 32 APL X-12

14 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 05. Hip Bolsters Generic Commercial Seating Component - Use generic pricing method Lateral Pelvic Support/Hip Bolster 1 Support Per Leg Per 3 Years Western Home Medical Side Bolster 1 Bolster Per Side Per 3 Years X112 True X198 True $77.90 Max. Each $80.75 Each Hip Bolster 1 Bolster Per Side Per 3 Years X131 True $ Each of May Page 14 of 32 APL X-13

15 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 06. Wedges, Pommels, Abduction & Adduction Generic Commercial Seating Component - Use generic pricing method Lateral Thigh Support/Adductors 1 Thigh Support Per Leg Per 3 Years Price to include pad and hardware if required. Obliquity Pad/Build-up/Fluid Supplement Pommel/Thigh Abductor Price to include pad and hardware if required Seat/Base Full Wedge Jay Hemi Wedge Fluid Supplement F119 Jay Seat Wedge Adductor 1" B119J Adductor 2" B113J or B163 Base Wedge B114 Pelvic obliquity build-up B116R or L Western Home Medical Abductor Flip-down 1 Addition Per 3 Years 1 Pommel Per 3 Years 1 Wedge Per 3 Years 1 Fluid Supplement Per 3 Years 1 Pair of Adductors Per 3 Years 1 Abductor Per 3 Years X114 True X118 True X577 False X115 True X116 False X308 True X306 True X307 True X309 True X520 True X464 True $ Max. Each $51.30 Max. Each $ Max. Each $ Max. Each $49.40 Max. Each $51.30 Each $51.30 Per Pair $62.70 Per Pair $ Each $51.30 Each $ Each Abduction Stop 1 Abduction Stop Per Side Per 3 Years Rigid shell, foam & covering Pommel 1 Pommel Per 3 Years Flip Down Pommel, rigid support foam covering inner/outer hardware Non-removable Pommel, rigid support foam covering and hardware for attachment of non-removable pommel Removable Pommel, rigid support foam covering inner/outer hardware X053 True X350 True X133 True X023 True $ Each $ Each $ Each $ Each of May Page 15 of 32 APL X-14

16 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 07. Sub-ASIS Bars & Belts Generic Commercial Seating Component - Use generic pricing method Sub-ASIS Bar 1 Sub-ASIS Belt/Bar Per 4 Years Rigid Sub-ASIS pelvic control. Client eligible for either X100 or X105 Sub-ASIS Belt Soft Sub-ASIS pelvic control. Bodypoint Client eligible for either X100 or X105 Sub-ASIS Belt Medial 4pt center pull 1 Sub-ASIS Belt/Bar Per 4 Years 1 Sub-ASIS Belt/Bar Per 4 Years Metalcraft Swing Away Sub-ASIS Bar 1 Sub-ASIS Belt/Bar Per 4 Years With mid relief, includes 2-90 degree Brackets, 1 universal swing away bracket, 1 offset sub-asis bar with mid relief, 2 hours labour X100 False X105 False X472 False X580 False $ Max. Each $ Max. Each $ Each $ Each Sub-ASIS Bar Semi-rigid Sub-ASIS Bar, or ACH Y-belt To be added to X033 when appropriate. 1 Sub-ASIS Belt/Bar Per 4 Years X600 True $ Each of May Page 16 of 32 APL X-15

17 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 08. Foot & Leg Supports & Hardware Generic Commercial Seating Component - Use generic pricing method Footbox/Foot Pocket 1 Footbox Per Foot Per 2 Years Semi-enclosed leg and footrest If footbox/footpocket is for bilateral feet then use quantity of 2. X955 False $ Max. Each Modified Foot Support 1 Support Per Foot Per 4 Years Modified/adapted footplate, shoe holders, padded footrests or footboards. X080 True $ Max. Each Price represents cost for one foot, ie: 1 footboard = quantity of 2, or 1 shoe holder = quantity of 1 Bodypoint Ankle Huggers Medium/large Calf panel Maple Leaf Wheelchair Footbox Contractive Sling - 1 piece padded footbox Nighthawk 1 Pair Footstraps Per 12 Months 1 Calf Panel Per 12 Months 1 Footbox Per 2 Years Toe Loops 1 Toe Loop Per Foot Per 12 Months Variety Village Health - Professional Services and Health Benefits Foot Pockets 1 Footpocket Per Foot Per 2 Years Western Home Medical Footbox One Piece cushioned Footbox #5081 Western Split Cushion Footbox #5082 Rigid Shoe Holders 1 Footbox Per Foot Per 2 Years 1 Pair Shoe Holders Per 4 Years Toe Loops 1 Toe Loop Per Foot Per 12 Months X971 False X415 False X495 False X763 False X771 False X446 True X447 True X519 True #5086 X448 True $ Per Pair $92.15 Each $ Each $28.50 Each $56.64 Each $ Each $ Per Pair $ Per Pair $35.34 Each Calf Support Rigid shell, foam, covering 1 Support Per Leg Per 2 Years X061 True $ Each of May Page 17 of 32 APL X-16

18 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 08. Foot & Leg Supports & Hardware Footbox Includes both feet 1 Footbox Per 4 Years Footpocket 1 Footpocket Per Foot Per 2 Years Footrest Footstrap/Toe Loop Knee Block Rigid shell, foam, covering and straps Neoprene Padding of Front Rigging 1 Footrest Per Foot Per 4 Years 1 Strap Per Foot Per 12 Months 1 Knee Block Per 4 Years 1 Padding Per Leg Per 3 Years X127 True X059 True X057 True X106 True X129 True X468 True $ Each $ Each $ Each $ Each $ Each $ Each of May Page 18 of 32 APL X-17

19 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 09. Arm, Hand & Shoulder Supports Armrest with hardware 1 Pair Per 2 Years Elbow Stops 1 Elbow Stop Per Arm Per 2 Years Added to trays Shoulder Protraction Wedges 2 Wedges Per 2 Years X166 True X043 True X141 True $ Per Pair $ Each $96.94 Each of May Page 19 of 32 APL X-18

20 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 10. Trays Commercial Tray Customization 1 Tray Customization Per 2 Years To accommodate a power wheelchair control box Generic Commercial Seating Component - Use generic pricing method Bayonet Mounting on Tray 1 Mount Per 2 Years Communication Board Mount to Seating System 1 Mount Per 2 Years X587 False X068 False X060 False $67.85 Each $ Max. Each $ Max. Each Tray Including mounting hardware - padding Including mounting hardware, lexan, added lip Including mounting hardware, lexan, heavy duty bayonet, added lip Including mounting hardware, lexan, heavy duty bayonet, no lip To accommodate communication device, includes mounting hardware 1 Tray Per 2 Years X351 True X054 True X381 True X380 True X056 True $ Each $ Each $ Each $ Each $ Each of May Page 20 of 32 APL X-19

21 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 11. Backs & Replacement Covers Generic Commercial Seating Component - Use generic pricing method Back < 3" Contour Depth, 15" Tall, Any width X124 True < 3" Contour Depth, 20" Tall, Any width X126 True < 3" Contour Depth, 16" - 19" Tall, Any width X125 True 6" Contour Depth, 15" Tall, Any Width 6" Contour Depth, 20" Tall, Any width 6" Contour Depth, 16" - 19" Tall, Any width X150 True X155 True X152 True 3"-5" Contour Depth, 15" Tall, Any Width X130 True 3"-5" Contour Depth, 20" Tall, Any width X134 True 3"-5" Contour Depth, 16" - 19" Tall, Any width X132 True $ Max. Each $ Max. Each $ Max. Each $ Max. Each $ Max. Each $ Max. Each $ Max. Each $ Max. Each $ Max. Each Non-Standard/Custom Size X935 False Prior Approval Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Cannot be combined with X200. Planar "I"-Shape, 13" Wide, Any height Planar "I"-Shape, 13" Wide Any height X120 True X122 True $ Max. Each $ Max. Each Back Bariatric Option 3 Bariatric Option Per 4 Years Weight capacity over 300lbs or widths greater than 20" X200 False $ Max. Each Add to appropriate Back catalogue number. Invoice only for the difference in cost for bariatric size, up to $300 maximum. Combined total quantity of 3 in 4 years for X200 and X333. Back Cover 1 Replacment Cover Per 4 Years Custom size replacement cover for commercial systems for adults & peds. X169 False For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL. Standard size back replacement cover for commercial systems for adults & peds. X171 False For replacement only. Prior Approval. Submit spec sheets and clinical rationale to AADL. Future Mobility Air Back 14x14 16x18 17x16 17x20 18x18 19x16 19x20 20x18 16x16 16x20 18x16 18x20 20x16 20x20 Bariatric size Lunar Back Mid Back - No Lateral X412 False X411 False X371 False I220 False Prior Approval Prior Approval $ Each $ Each $ Each $ Each Max Back Option 1 Option Per 4 Years For Prism Air Back and Truefitt X409 False $ Each Use this catalogue number with the applicable Future Mobilty Air or Truefitt back. $105 is the maximum, not all Max Backs require full amount. Phantom Back 12-18" x 7" X443 False $ Each of May Page 21 of 32 APL X-20

22 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 11. Backs & Replacement Covers Future Mobility Prism Basic Back 10x12, 12x12, 16x16, 16x20, 18x16, 18x20, 20x16, 20x20 X369 False 11x12, 11x14, 12x14, 12x16, 13x12, 13x14, 13x16, 14x16, 15x12, 15x14, 15x16, 16x12, 16x14 X279 False 14x14, 16x18, 17x16, 17x20, 18x18, 19x16, 19x20, 20x18 X370 False TrueFitt Back 16x16, 18x16, 20x16 X417 False 16x18 16x20 17x16 17x20 18x18 18x20 20x18 20x20 Bariatric size X374 False X375 False Invacare Matrx PB Back 13-20" 250 lbs. max. X431 False Deep Back 13-19" 250 lbs. max. Heavy Duty Back 19-25" 500 lbs. max. Matrx PB Elite Back Deep Back Widths 12-20, ht 12, 16, 20 wt capacity 300 lbs. Personal Back 10 Reg. Height or Tall (13-20"), aluminum hardware Reg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. X433 False X432 False X199 False X455 False X213 False X368 False Personal Back 10 Plus 13-20", steel hardware X693 False Jay Reg. Height or Tall (22", 24", 26"), Bariatric, steel hardware, max. 500 lbs. J2 Back Fits 12-20" W/C Fits 20" Tall - fits 14, 15, 16, 17, 18, 19" W/C Tall - fits 20" X367 False X101 True X659 True X098 True X610 True J2 Deep Contour Back 14, 15, 16, 17, 18, 19" X970 True 20" X353 True J2 Plus Back 20-23", 23-26" without headrest mounting kit X373 True $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each of May Page 22 of 32 APL X-21

23 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 11. Backs & Replacement Covers Jay Health - Professional Services and Health Benefits Jay 3 Back Lower Thoracic (2.2" contour) -12, 14, 16, 18, 20, (SMT) Lower Thoracic (6" deep and post contour) -14,16,18,20, (SMT) Mid Thoracic (2.2" contour) - 12, 14, 16, 18, 20, (SMT) Mid Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) Mid Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) Shoulder Ht. (2.2" contour) 14, 16, 18, 20, (SMT) Shoulder Ht. (3" contour) 14, 16, 18, 20, (SMT) Shoulder Ht. (6" contour) 14, 16, 18, 20, (SMT) Shoulder Ht. (6" deep and post contour) 16,18,20, (SMT) Upper Thoracic (2.2" contour) 12, 14, 16, 18, 20, (SMT) Upper Thoracic (3" contour) 12, 14, 16, 18, 20, (SMT) Upper Thoracic (6" contour) 14, 16, 18, 20, (SMT) Upper Thoracic (6" deep and post contour) 14, 16, 18, 20, (SMT) Jay 3 Components 3 Components Per 4 Years X421 True X413 True X422 True X423 True X784 True X476 True X477 True X478 True I204 True X424 True X425 True X475 True X787 True $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each I211 False Prior Approval For base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay Active Back With Quick Release Brackets 520/522/525/527/528 (14", 15", 16", 17", 18") Jay Care Back 3500B/3505B 16" and 18" W/C X566 False X093 True " X658 True Jay Focus Back Maple Leaf Wheelchair Kyphotic Back Options Laterals ht. and back ht. 1 Option Per 4 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. ML Kyphotic Back ML Deep, Mid or Shallow shell bariatric width ML Deep, Mid or Shallow shell tall 22 /24 ML Deep, Mid or Shallow shell (1 increments) 18 ht., standard ht. Laterals (10 ½ ) X492 True X465 False X461 False X462 False X460 False $ Each $ Each $ Each $ Each Prior Approval $ Each $ Each $ Each of May Page 23 of 32 APL X-22

24 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 11. Backs & Replacement Covers nxt Fixed Height Plus Contour Support Contour or Active Contour Vicair Contour 16,17,18x16/20 18,19,20x16/20 20,222X16/20 Height Adjustable Support contour/active countour/plus count HA SC/AC/PC Support contour/plus contour HA SC/ PC Ottobock Back Back ", 18-20" Back ", 18-20" Back ", 18-20" with or without teardrop laterals Back ", 18-20" with or without teardrop laterals Floam Cells 8 Floam Cells Per 4 Years Pride Mobility Synergy Shape 2 Back 14, 16, 18, 19, 20", 300 lbs max. 4" depth adjustment angle adjustment from -33 to +57 degrees Ride Tall 16,18,20,22" X 23" 300 lbs max. 4" depth adjustment, angle adjustment from degrees Ride Back Corbac Adjustable Contour Custom Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. I231 False I217 False I228 False I214 False I215 False X660 False X978 False X979 False X980 False X981 False X434 False X466 False X489 False X488 False $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $ Each $17.78 Each $ Each $ Each $ Each Prior Approval Back Contoured X671 True Lumbar Support X049 True Planar Back Interface System X067 True Pressure reduction back with polymer or air floatation insert X179 False Prior Approval. Submit request to AADL. (custom back $ cost of pressure relief surface) Web Back Box X151 True of May $ Each $ Each $ Each Prior Approval $ Each Page 24 of 32 APL X-23

25 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 11. Backs & Replacement Covers Back Web Back Sling X670 True $ Each Neoprene Padding of Back Canes 1 Padding Per 4 Years X469 True $ Each Removable Cover Neoprene option Replacement only 1 Cover Per 4 Years X383 True $ Each Standard Replacement only X401 True $ Each of May Page 25 of 32 APL X-24

26 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 12. Bases, Cushions & Replacement Covers Wheelchair Cushions provided on "V" APL 1 Service Fee Per 3 Years Generic Commercial Seating Component - Use generic pricing method Cushion 1 Cushion Per 3 Years Non-Standard Size Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. X633 False X934 False Replacement Cushion Cover for Commercial 1 Cover Per 12 Months Custom Cushion I101 False For replacment only. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay Adult Adjustable Solid Seat 1 Seat Insert Per 3 Years #270/271/272 (adjusts 15-18", 10-11", ") 1.5" drop X249 True Large 273 (adjusts " wide) 2.5" drop Jay 3 Components 3 Components Per 4 Years X384 True $20.00 Each Prior Approval Prior Approval $ Each $ Each I211 False Prior Approval For base or back after device provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay 3 Cushion Air or fluid insert with seating component options. Ride 1 Cushion Per 3 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Bariatric, air or fluid insert with seating component options Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Ride Cushion Custom 1 Base Per 3 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. X496 False X497 False X430 False Prior Approval Prior Approval Prior Approval Base 1 Base Per 3 Years Anti-thrust Seat or Non-Removable Pommel Bariatric - over 250 lbs. Kid Kart Pressure Reduction Base (polymer or air floatation insert) Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Standard Cushion/Base T-Foam/Sunmate Cushion of May X149 True X382 True X618 True X999 False X066 True X051 True $ Each $ Each $ Each Prior Approval $ Each $ Each Page 26 of 32 APL X-25

27 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 12. Bases, Cushions & Replacement Covers Drop Base Padded 1 Drop Base Per 3 Years X356 True $ Each Standard Hooks not included. Previously X534. X197 True $ Each Removable Cover Neoprene option Replacement only 1 Cover Per 4 Years X383 True $ Each Standard Replacement only X401 True $ Each Solid Seat Insert Pre ischial shelf - for beneath an air floatation cushion 1 Seat Insert Per 3 Years X471 True $ Each With leg channels upholstered to base X470 True $ Each of May Page 27 of 32 APL X-26

28 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 13. Spinal Alignment Assessories Generic Commercial Seating Component - Use generic pricing method Accessories for Commercial Back 3 Accessories Per 4 Years Jay List each accessory and justification in benefit note on E-business. Jay 3 Spinal Alignment Accessories Large/Small Lumbar Lateral Shim Post/Lateral Pelvic Wedge 3 Spinal Alignment Accessories Per 4 Years X333 True X479 True X483 True X482 True X480 True $48.45 Max. Each $48.45 Each $42.75 Each $42.75 Each $38.95 Each of May Page 28 of 32 APL X-27

29 Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 14. Complete Seating Systems Generic Commercial Seating Component - Use generic pricing method Adult Commercial Custom Fit Seating System 1 Seating System Per 4 Years Must include back, base and all supports X190 False Prior Approval Must only provided when seating needs cannot be accomodated by off-the-shelf components. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Pediatric Commercial Custom Fit Seating System 1 Seating System Per 2 Years Must include back, base and all supports. For ages 17 years and younger. I229 False Prior Approval Must only provided when seating needs cannot be accomodated by off-the-shelf components. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Jay Additional Seating Components for SureFit System Lecky 4 Components Per 4 Years I207 False Prior Approval To be used only after original seating provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Squiggles Additional Seating Components Ottobock 4 Per 4 Years I201 False Prior Approval Components added to Lecky Squiggles seating insert after provision. To be used only after original seating provided. Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. Ottobock Shape System Replacement cover Pattern on client file must be sent to Ottobock 1 Cover Per 4 Years X454 False $ Each "Foam-in-Place" Back or Base 1 Back or Base Per 4 Years Custom-made foam back or base. X024 True $2, Each May be custom-made by Adaptive Seating Technician or using computerized scanning/carving. If both back and base required, do not submit QFR. Indicate rationale for override in the Override Notes on E- business. ACH - Custom Made Insert for Commercial Stroller 1 Seating System Per 4 Years Includes custom made headrest/neckrest, foam and covering and pelvic strap. X036 True $ Each X044 Safety Strap used to secure insert to mobility base added as separate catalogue number. Base Kid Kart Health - Professional Services and Health Benefits Commode Insert Includes: back, laterals, footstraps, chest straps - no seat. 1 Cushion Per 3 Years 1 Insert Per 4 Years Prior Approval. Submit spec sheets/pricing and clinical rationale to AADL. X618 True X047 False $ Each Prior Approval of May Page 29 of 32 APL X-28

30 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 14. Complete Seating Systems Glenrose Infant Seat 1 Seating System Per 4 Years Custom made insert for commercial stroller, includes custom made headrest/neckrest, foam and covering and pelvic strap. X636 True X044 CUSTOM MADE Safety Strap used to secure insert to mobility base added as separate cat# GRIP Seat Floor Sitter 1 Floor Sitting Per 4 Years X474 False $ Each $ Each of May Page 30 of 32 APL X-29

31 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 15. Service Fees Commercial Tray Customization 1 Tray Customization Per 2 Years To accommodate a power wheelchair control box Hand/Arm/Shoulder Supports as provided from "V" APL 1 Service Fee Per 2 Years Level I - Repairs/Modifications 50% of Replacement Cost Per 4 Years Repairs/modifications to an existing seating system; transferring seating system to another mobility base. Price includes labour and materials. Must be authorized on E-business. Benefit notes must document type of repairs and cost breakdown. X587 False X632 False X964 True $67.85 Each $15.00 Each $67.85 Per Hour Invoiced in 1/4 hour Increments - Cost under $67.85 are client's responsibility - Not to be used for repairs due to misuse of equipment - Each increment of $67.85 = Quantity of 1. Total materials/labour of $185 = Qty 3 $67.85, $49.30) - Repairs MUST be assessed and authorized by an AADL Authorizer, E1 forms will no longer be accepted. Recycle Fee for Seating Benefits List recycled components in Benefit Note - Maximum 4 hours Shipping Fee Commercial Seating Components/System Repairs Submit invoice to AADL Retrieval of Trial Seating Equipment Rural - One way Wheelchair Cushions provided on "V" APL 1 Recycle Fee Per Seating System 1 Fee Per Component 1 Service Fee Per 3 Years X651 False $67.85 Per HourPer Hour Invoiced in 1/4 hour Increments X357 False Prior Approval X783 False $57.00 X633 False $20.00 Each Level II - Repairs/Modifications 50% of Replacement Cost Per 4 Years Repairs/modifications to an existing seating system; transferring seating system to another mobility base. Price includes labour and materials. Must be authorized on E-business. Benefit notes must document type of repairs and cost breakdown. X172 True $67.85 Per Hour Invoiced in 1/4 hour Increments - Cost under $67.85 are client's responsibility - Not to be used for repairs due to misuse of equipment - Each increment of $67.85 = Quantity of 1. Total materials/labour of $185 = Qty 3 $67.85, $49.30) Recycle Fee for Custom Seating Benefits List recycled components in Benefit Note - Maximum 4 hours of May 4 Hours Per Seating System X377 False $67.85 Per Hour Invoiced in 1/4 hour Increments Page 31 of 32 APL X-30

32 Health - Professional Services and Health Benefits Health - Professional Services and Health Benefits Aids to Daily Living Manual X - Seating Approved Product List Aids to Daily Living - Manual X - Approved Product List 15. Service Fees Shipping Fee Seating Components/System Repairs Submit invoice to AADL 1 Fee Per Component X358 False Prior Approval of May Page 32 of 32 APL X-31