Alberta Health Approved Products List Pediatric Equipment Pricing effective October 1, 2017 Benchmark Benefits Pediatric Toileting Equipment... APL K-1 Pediatric Bathing Equipment APL K-2 Pediatric Bathing/TOILETING Equipment... APL K-3 Pediatric Sitter/Feeder Seats APL K-4 Recycle Pediatric Equipment Pediatric Standing Frames and Accessories.. APL K-5 Pediatric Mobile Standing Frames and Accessories. APL K-7 Pediatric Walkers and Accessories.. APL K-8 Discontinued/Removed from APL. APL K-11
PEDIATRIC EQUIPMENT BENCHMARK BENEFITS Benchmark Benefits are not returned to. When no longer required by the client, these items may be donated at the client s discretion and are never to be sold. Eligibility: Clients must be under the age of 18 years. Clinical rationale required for tilt options and positioning package. Rationale to be written directly on 1250 form to confirm eligibility. Only one toileting/bathing aid permitted per function ( e.g. may not have both a commode and toilet support) Costs: Clients are responsible for any charges above benchmark maximum price. Vendors must offer at least one item at or below benchmark price. Equipment Standards for Pediatric Equipment: Manufacturer must have an active representative in the province available for consult. Distribution of equipment is through Approved Vendors with a facility maintained in Alberta. Parts must be available from a Canadian Distributor warehouse vendor to carry common maintenance parts (e.g. straps, casters) Minimum 3 year warranty. Approved Manufacturers of Pediatric Equipment: Drive (Inspired/Columbia), Invacare, Lecky/Otto Boc, Maple Leaf, Rifton, Snug Seat, Special Tomato/Nuvision, Tumble Form/Performance Health. Manufacturer and model must be indicated on the 1250. Generic Description PEDIATRIC TOILETING EQUIPMENT Additional Details Quantity and Frequency Limit Maximum K015 Toilet Support Toilet Seat with back designed to fit on adult fixed toilet seat. includes cost for footrest/armrest assembly. 1 per 4 years $1,348.20 K027 Commode Stationary Non-Tilt Commode with armrests on stationary base, designed to fit over toilet or at bedside. Wheels an upgrade if client not 1 per 4 years $1218.00 eligible for K029. K028 Commode Wheeled Tilt Commode with armrests, headrest and tilt feature on mobile base. Clinical rationale for tilt option required on 1250. 1 per 4 years $2,070.00 K029 Commode Wheeled Non-Tilt Commode with armrests on mobile base. For use by clients who are difficult transfers. Examples: inability to use lifters due to limited space; weight considerations; and/or unpredictable movements. 1 per 4 years $1515.00 K031 Hip Guides For anticipated growth. 1 per 4 years $160.00 K032 May choose lateral supports, harness, chest strap and/or abductor as part of package. Upgrade costs may apply when Positioning Options package for 1 pkg. per 4 choosing more than one or two positioning devices. commodes years based on chest harness and abductor as basic need. Clinical rationale must be written on the 1250. $326.00 October 1, 2017 APL K-1
PEDIATRIC BATHING EQUIPMENT (Benchmark Benefit) Eligibility: Clients must be under the age of 18 years. Only one toileting/bathing aid permitted per function ( e.g. may not have both a shower commode and bath seat) Costs: Clients are responsible for any charges above benchmark maximum price. Vendors must offer at least one item at or below benchmark price. Equipment Standards for Pediatric Equipment: Manufacturer must have an active representative in the province available for consult. Distribution of equipment is through Approved Vendors with a facility maintained in Alberta. Parts must be available from a Canadian Distributor warehouse vendor to carry common maintenance parts (e.g. straps, casters) Minimum 3 year warranty. Approved Manufacturers of Pediatric Equipment: Drive (Inspired/Columbia), Invacare, Lecky/Otto Boc, Maple Leaf, Rifton, Snug Seat, Special Tomato/Nuvision, Tumble Form/Performance Health, Manufacturer and model must be indicated on the 1250. K044 K046 K047 Generic Description Bath support Low Back Bath support High Back Bath Seat - Recline Additional Details Provides trunk support for upright sitting in tub. Mesh sling seat sits on floor of tub, has low back. Provides trunk support for upright sitting in tub Mesh sling seat sits on floor of tub, has high back. Adjustable, allows recline position. High back, supports trunk and head, includes headrest and adjustable straps. Removable fabric. Quantity and Frequency Limit Maximum 1 per 4 years $827.00 1 per 4 years $871.00 1 per 4 years $1285.00 October 1, 2017 APL K-2
PEDIATRIC BATHING/TOILETING EQUIPMENT (Benchmark Benefits) Eligibility: Clients must be under the age of 18 years. Only one toileting/bathing aid permitted per function ( e.g. may not have both a shower commode and bath seat) Costs: Clients are responsible for any charges above benchmark maximum price. Vendors must offer at least one item at or below benchmark price. Equipment Standards for Pediatric Equipment: Manufacturer must have an active representative in the province available for consult. Distribution of equipment is through Approved Vendors with a facility maintained in Alberta. Parts must be available from a Canadian Distributor warehouse vendor to carry common maintenance parts (e.g. straps, casters) Minimum 3 year warranty. Approved Manufacturers of Pediatric Equipment: Drive (Inspired/Columbia), Invacare, Lecky/Otto Boc, Maple Leaf, Rifton, Snug Seat, Special Tomato/Nuvision, Tumble Form/Performance Health. Manufacturer and model must be indicated on the 1250. K023 K030 K031 K032 Generic Description Wheeled Shower Commode Wheeled Shower Commode with Tilt Hip Guides Positioning Options package for commodes Additional Details Includes armrests, seat pad, commode pan, deflector. Up to 15 seat width. Maximum weight capacity 150 lbs. Includes armrests, seat pad, commode pan, deflector and headrest. Up to 15 seat width. Maximum weight capacity 150 lbs. For anticipated growth required in commodes or shower commodes. For use with commodes or shower commodes. May choose lateral supports, harness, chest strap and/or abductor. Upgrade costs may apply when choosing more than one or two positioning devices. based on harness and abductor as basic need. Clinical rationale must be written on the 1250. Quantity and Frequency Limit Maximum 1 per 4 years $2033.00 1 per 4 years $2677.00 1 per 4 years $160.00 1 pkg. per 4 years $326.00 October 1, 2017 APL K-3
SITTER/FEEDER SEATS (Benchmark Benefits) Eligibility: Clinical rationale must be written on 1250 form for any of the following options: Shower Commode hip guides and positioning option package. Only one sitter/feeder seat permitted per child (e.g. may not have a sitter/feeder seat for home and school). Cost: Clients are responsible for any charges above benchmark maximum price. Equipment Standards for Large Pediatric Equipment: Manufacturers must have an active representative in the province available for consult. Distribution of equipment is through Approved Vendors with a facility maintained in Alberta. Minimum 3 year warranty. Parts must be available from a Canadian Distributor/warehouse vendor to carry common maintenance parts (e.g. straps). Approved Manufacturers of Pediatric Equipment: Drive (Inspired/Columbia), Invacare, Lecky/Otto Boc, Maple Leaf, Snug Seat, Special Tomato/Nuvision, Tumble Form/Performance Health Manufacturer and model must be indicated on the 1250. K252 K254 K269 K260 Generic Description Sitter/Feeder Seat all sizes Sitter/Feeder Seat with base- Small/Medium Sitter/Feeder Seat with base- Large/Extra Large Corner Sitter/Feeder Seat Additional Details Seat only, comes with harness or two way belt. Some models may include a strap option to secure seat to chair for table top activities. Includes wedge/wood tilt base to allow upright and recline position. Comes with harness. Some models may include attachment straps for securing to chair or tilt base. Includes wedge/wood tilt base to allow upright and recline position. Comes with harness. Some models may include attachment straps for securing to chair or tilt base. Broad base, comes with tray. Includes abductor blocks, hip belt, adjustable H harness. Quantity and Frequency Limit Maximum 1 per 4 years $1557.92 1 per 4 years $1312.89 1 per 4 years $2056.00 1 per 4 years $895.00 October 1, 2017 APL K-4
PEDIATRIC RECYCLE EQUIPMENT Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: Standing frames are provided to children who are wheelchair bound, allowing them to participate in an alternate position. An Assessment Summary for Pediatric Standing Frame Benefits form must be attached to the 1250 Authorization form for static and mobile standing frame authorizations. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. Equipment Standards for Large Pediatric Recycle Equipment: Manufacturers must have an active representative in the province available for consult. Distribution of equipment is through Approved Vendors with a facility maintained in Alberta. Minimum 3 year warranty. Parts must be available from a Canadian Distributor/warehouse vendor to carry common maintenance parts (e.g. straps). K245 K246 K247 STATIC STANDING FRAMES Manufacturer/Model Description Size(s) Otto Bock Squiggles Otto Bock Totstander Otto Bock Freestander Supine and prone available Able to get low to the ground and stand at eye level with peers Headrest for supine use For use with smaller children with impaired head/trunk control. Easy to move and is adjustable with basic tools. Prone One Size One size Weight Capacity 48 lbs. 44 lbs. Options Client Upgrade Base & Mast $2,557.38 Mobile Base & Mast $835.54 Headrest $314.00 Laterals (one set) $458.00 Sandals $210.00 Tray $374.00 Padding $574.00 $992.75 Size 1 132 lbs. Base & Mast $2134.65 Size 2 176 lbs. Base & Mast $2,355.05 Size 3 198 lbs. Base & Mast $2,663.80 One size Headrest with Hardware $868.30 October 1, 2017 APL K-5
STATIC STANDING FRAMES (Recycle Equipment) Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: Standing frames are provided to children who are wheelchair bound, allowing them to participate in an alternate position. An Assessment Summary for Pediatric Standing Frame Benefits form must be attached to the 1250 Authorization form for static and mobile standing frame authorizations. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. K248 K222 Manufacturer/Model Description Size(s) Prime (AHC) Superstand HLT Prime (AHC) Youth Multi-Position Stander Large footprint, no front access Good for use in school Color black/candy blue Can be positioned in prone, supine or multi-position Hip OR chest sliding track funded Body support vest not funded if lateral chest support ordered Multi-position capability prone/supine/upright Movable rolling casters Manual standing angle adjustable 30 to 90 in 7 degree increments Adjustable knee system height/width/depth One piece depth adjustable foot platform with heel block Weight Capacity Options Size E1/1 65/125 lbs. Base & Mast $3,125.50 Size 2 150 lbs. Base & Mast $3,842.00 Size 1 Lateral Chest support $218.50 Size 2 Lateral Chest support $251.70 One size Body Support Vest $248.90 One size Chinrest (prone use) $148.20 One size Headrest (supine use) $332.50 Sliding adjustable track $207.11 Chest belt $81.70 Tray multi-positional $597.55 Independent footrests (pr) $286.90 D-ring footrests (pr) $81.70 Soft Hip Support $211.80 125 lbs. Base & Mast $2,764.20 Lateral chest support $179.10 Upper Body Support $163.10 Padded Head Strap $101.65 Chin Rest $124.90 Headrest padded $198.50 Heel Loops $53.25 Foot Straps $53.25 D-ring foot straps $82.50 Pommel $217.85 Sm/Med/L Shoe Holder $208.15 Angle Adjustable Tray $488.95 Steel Casters $208.15 October 1, 2017 APL K-6
MOBILE STANDING FRAMES (Recycle Equipment) Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: Mobile Standers are provided to children who are 7 years and older who are wheelchair bound, allowing them to participate in an alternate position. Clients may be funded for either a Mobile Stander OR Walker. Mobile Standing Frames are considered dual function. An Assessment Summary for Pediatric Standing Frame Benefits form must be attached to the 1250 Authorization form for static and mobile standing frame authorizations. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. K291 K292 Manufacturer/Model Description Size(s) Weight Options Capacity Small 52 lbs. $3,696.90 Rifton Includes body support with Medium 123 lbs. $4,610.35 Pacer Mobile Stander padding, straps, fleece, wheels Large 180 lbs. $5,600.25 and brakes. Arm prompts & mounting Large wheels for self-propelling $631.00 hardware Size 1 88 lbs. Base & Mast $3,151.00 Snug Seat Includes adjustable frame, Size 2 110 lbs. Base & Mast $4,247.00 Rabbit Mobile Stander base, quick release wheels, Size 3 132 lbs. Base & Mast $4,247.00 central brake system, spoke Size 4 154 lbs. Base & Mast $4,247.00 protectors. Sizes 1-3 Chest Support $275.00 Tray is an upgrade cost Size 4 Chest Support $302.40 All sizes Knee Supports $542.10 Sizes 1-3 Hip Support with pommel $678.70 Size 4 Hip Support with pommel $762.50 Sizes 1-3 Separate footrest with sandal (Client upcharge $53.80) $477.00 Footrest flip-up $295.60 Hinged Sandals $181.40 October 1, 2017 APL K-7
PEDIATRIC WALKERS POSTERIOR GAIT TRAINERS (Recycle Equipment) Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: Clients may be funded for either a Mobile Stander OR Walker. Mobile Standing Frames are considered dual function. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. K276 K278 Manufacturer/Model Description Size(s) Weight Options Capacity YA $388.35 Drive Medical YA = Young adult Tyke (T) $345.15 Nimbo Walker Junior (J) $373.90 Youth (Y) $402.70 All sizes Pelvic Stabilizer $124.65 All sizes Forearm Platform $95.85 Sm/L Seat Harness $215.70 T/J/Y Seat $124.65 Size 1 55 lbs. $890.20 Ottock Bock Size 2 88 lbs. $902.05 Nurmi Neo Walker Size 3 121 lbs. $921.80 Sizes 1-3 Grip bar - Standard (pr) $187.55 Sizes 1-3 Driving brake Standard (each) $202.55 Sizes 1-3 Grip Bar Universal (pr) $326.50 Sizes 1-3 Driving Brake Universal $245.00 (each) Sizes 1-3 Grip Bar X-High $430.20 with Forearm supports Sizes 1-3 Driving Brake- X-High (each) $245.00 Sizes 1-3 Fold-up seat $331.00 Sizes 1-3 Sling Seat $258.85 Caster Swivel Wheel Locks $201.55 Sizes 1-3 Anti-tippers $161.05 Friction Brake $119.55 October 1, 2017 APL K-8
PEDIATRIC WALKERS ANTERIOR/POSTERIOR GAIT TRAINERS (Recycle Equipment) Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: For clients who are partial weight bearing, able to take reciprocal steps, supports available seat, trunk pad etc. Clients may be funded for either a Mobile Stander OR Walker. Mobile Standing Frames are considered dual function. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. K279 Manufacturer/Model Description Size(s) Weight Options Capacity Mini 891.10 Rifton *If ordering the Multi-position Sm 75 lbs. $1,210.30 Pacer Gait Trainer saddle, clients are not eligible for funding for pelvic support, Med 150 lbs. $1,634.95 chest prompt, thigh prompt or Large 200 lbs. $2,072.90 hip positioner with hand hold. Small Arm Prompt $599.45 Large Arm Prompt $686.85 All Arm Platform (alternative to prompt) $523.45 All Hand Holds $134.90 Sm/Med Hip positioner pad $127.30 Large Hip Positioner Pad $167.20 Sm Ankle Prompt set $195.70 Med Ankle Prompt set $226.10 Large Ankle Prompt set $248.90 Multi-position Saddle* $1,396.50 Sm Pelvic Support $495.90 Med Pelvic Support $526.30 Large Pelvic support $553.85 Sm Chest Prompt $693.50 Med Chest Prompt $736.25 Large Chest Prompt $780.90 Sm/Med Thigh Prompt $495.90 Large Thigh Prompt $599.45 Sm Hip positioner with hand hold $495.90 Large Hip positioner with hand hold $553.85 October 1, 2017 APL K-9
PEDIATRIC WALKERS (Recycle Equipment) Recycle Equipment must be returned to an vendor when the client no longer required it. Eligibility: Clients may be funded for either a Mobile Stander OR Walker. Mobile Standing Frames are considered dual function. Only those sized listed on the APL are funded by. Cost: Clients are responsible for any upcharges for options not listed on the Approved Product List (APL) or for options the client is not eligible for. Clients are responsible for costs for additional quantities over those listed on the APL. includes vendor discount per contract with. Vendor must provide equipment for prices listed. K283 K285 K287 Manufacturer/Model Description Size(s) Snug Seat Crocodile Gait Trainer Snug Seat Gator Gait Trainer Prime (AHC) Kidwalk 2 Weight Options Capacity Size 1 66 lbs. Size 2 99 lbs. $1,164.00 Size 3 175 lbs. $1,581.10 Sizes 1-3 Forearm Support with hand grips (pr) $494.70 Sizes 1-3 Seat: Solid $$232.80 Sizes 1-2 Seat: Sling $174.60 Sm/L Pelvic Pad $169.75 Size 3 Crossbar to attach accessories $126.10 All Lateral strap and pad $179.45 All Anti-tip device, fixed, (set) $101.85 Size 1 $1,624.75 Forearm Support Left and/or right $232.40 Size 1 65 lbs. $3,372.50 Size 2 110 lbs. $4,080.25 Upper body soft support OR $316.38 Upper body support $589.00 Extended Seat $364.80 Directional locks (pr) $299.25 October 1, 2017 APL K-10
DISCONTINUED LARGE PEDIATRIC EQUIPMENT (Recycle Equipment) Discontinued equipment may be requested from the vendor s in house stock or from recycle pool only (subject to availability). Contact the benefit clerk assigned to your client s preferred vendor to determine if there are any available in the recycle pool. Parts to discontinued products may not be available. Manufacturer/Model Comments Options/Parts price K255 Snug Seat Buffalo Standing Frame Discontinued by Manufacturer Trunk Extension -size 1 9.5 or 12 $305.55 Trunk Extension -size 2 14 /4 $320.10 K275 Snug Seat Pony Training Walker Discontinued by Manufacturer Sizes 0-3 Trunk Extension -size 2 12 /10 $388.00 Trunk Extension -size 3 18 /6 $354.05 Trunk Extension -size 3 10.5/8.5 $421.95 Laterals (one set only) $421.95 Pommel size 1 $179.45 Pommel size 2 $184.30 Pommel size 3 $194.00 Knee Supports sizes 1-3 $470.45 PVC Tray $693.55 K275 Cricket Training Walker Trunk Support - small $206.50 Trunk Support - large $223.40 Handle Bar $314.30 Saddle $223.05 Banana Seat $327.39 Seat Cushion $116.07 October 1, 2017 APL K-11