Alberta Health AADL Approved Products List Custom Compression Garments Pricing effective March 1, 2017 Base Compression Garments... APL T-1 Compression Garment Features... APL T-3 Revised June 2018
BASE COMPRESSION GARMENTS AADL Cat # Description of Base Burn Garment Additional Details Quantity and Frequency Limit J401 Silicone band For arm/forearm sleeve 2/garment/yr 16.80 J405 J407 Vest sleeveless Vest with sleeves Includes one zipper and hook and loop tabs to attach vest to lower torso garments at no extra charge Includes one zipper and hook and loop tabs to attach vest to lower torso garments at no extra charge 2/yr $257.80 2/yr $399.08 J415 Body Brief sleeveless Includes one zipper 2/yr $363.61 J426 Gauntlet Has thumb and opening for four digits 2/limb/yr $95.75 J427 Glove to Wrist CUSTOM COMPRESSION GARMENTS CUSTOM COMPRESSION GARMENT MANUFACTURERS must meet the following criteria to provide custom compression garments through the AADL program: Provide Measuring Manual and measuring charts/forms Have a warranty on fit (minimum 10 days from receipt of delivery) and a warranty on stated compression for six months duration. Be accessible by phone to authorizers for issues/problem solving Method in place to ensure materials provide stated compression, participate in accreditation process AADL accepted Custom Garment Manufacturers: Mediven, BSN/Jobst, Bio-Concepts, Juzo and Venosan Has at least one finger Extends no more than 4.5 inches past wrist 2/limb/yr $262.60 J428 Glove to Elbow 2/limb/yr $234.69 J430 Arm Sleeve wrist to elbow 2/limb/yr $91.65 J432 Forearm Sleeve with Gauntlet 2/limb/yr $157.03 J434 Arm Sleeve wrist to axilla 2/limb/yr $181.48 J436 Arm Sleeve (full) and Gauntlet Gauntlet attached to arm sleeve 2/limb/yr $241.25 J437 Arm Sleeve with shoulder flap 2/limb/yr $230.31 J438 Arm Sleeve with shoulder flap and gauntlet 2/limb/yr $182.20 Revised June, 2018 APL T-1
AADL Cat # Description of Base Burn Garment Additional Details Quantity and Frequency Limit J439 Half Arm Sleeve with shoulder flap 2/limb/yr $139.56 J440 Stump Sleeve - to axilla 2/limb/yr $119.30 J441 Stump Sleeve with Shoulder Flap 2/limb/yr $183.03 J442 Stump Sock - below knee Below knee amputation 2/limb/yr $238.63 J443 Stump Stocking to Waist (2 limbs) One stump and one leg or two stumps 2/limb/yr $362.17 J444 Stump Support to Waist (one stump) 2/limb/yr $316.08 J445 Foot Glove 2/limb/yr $185.15 J446 J447 J448 J449 J451 Stocking to knee Stocking to thigh Stockings - waist height Stocking waist height one leg Waist Height Leg Support Open, soft or enclosed toe included Clinical rationale for custom required Open, soft or enclosed toe included Clinical rationale for custom required Two legs Closed, open pubis Requires prior approval except for lymphedema use. Closed, open pubis or chap style Panty brief or chap style One Leg Open Pubis 2/limb/yr $99.00 2/limb/yr $135.05 2/yr $381.74 2/yr $333.10 2/yr $296.19 J452 Stump Support above knee Above knee amputation 2/limb/yr $270.98 J453 Chap style two legs Both legs are involved 2/yr $323.85 J454 Chap style one leg Only one leg is involved May not be ordered when two legs are involved. J455 Stockings waist height pregnancy Two legs Closed or open pubis Requires prior approval except for lymphedema use. s reflect the maximum contribution by the Alberta Aids to Daily Living (AADL) program and is subject to COST SHARE 2/yr $254.27 2/yr $338.28 J457 Anklet Extends no more than 4.5 inches above ankle 2/limb/yr $92.82 Revised June, 2018 APL T-2
s reflect the maximum contribution by the Alberta Aids to Daily Living (AADL) program and is subject to COST SHARE COMPRESSION GARMENT FEATURES/ADDITIONS AADL Cat # Description of Burn Garment Feature Quantity and Frequency Limit J135 Contracture Seams 2/garment/yr $17.86 J403 Self-enclosed Toe 2/limb/yr $17.77 J404 Soft-enclosed Toe 2/limb/yr $20.00 J408 Silicone band For knee or thigh high garment 2/limb/yr $59.52 J409 Lining Silon Tex 6 x 6 2/gar/yr $59.04 J467 Extra Large Waist Support (60-69.9 ) (152-178 cm) 2/yr $32.33 J470 Reinforced Knee (per stocking) 2/limb/yr $29.81 J471 Zippers Knee High 2/gar/yr $51.32 J461 Zippers Thigh High 2/gar/yr $102.64 J473 ABD Uplift 2/yr $26.62 J475 Adjustable Shoulder Flap 2/yr $48.05 J476 Large Waist Support (50-59 ) (127 cm-150 cm) 2/yr $26.62 J477 Reinforcement Top of full length support 2/yr $32.76 J478 Reinforced Inner Thighs Addition to waist height support garments 2/yr $53.54 J479 Reinforced Heel 2/llmb/yr $17.94 J483 Slant Inserts For gloves only if not included in base price of glove 2/Limb/yr $27.60 J492 Pocket for Padding 2/yr $40.00 J493 Expansion Panel 2/yr $32.97 J495 Lining Inside Elbow 2/limb/yr $27.68 J496 Lining Full Elbow 2/limb/yr $27.68 Revised June, 2018 APL T-3
COMPRESSION GARMENT FEATURES/ADDITIONS AADL Cat # J497 Additional Linings 2/gar/yr $27.68 J498 Inserts 2/gar/yr $47.60 Revised June, 2018 APL T-4