Pride Mobility Mobility Device Product Manual

Mobility Devices

Product Manual

Effective Date : February 01, 2015

Assistive Devices Program

Ministry of Health and Long-Term Care

Printed Date: Feb 3, 2015 Page: 1 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

Device Type Manufacturer

Effective From: February 01, 2015

Device Device Code

Adult Wheeled Walker Type 1

Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels (less than 6" diameter) and braking system (if available). See Ambulation

Aids Options Chart if heavy duty frame and/or forearm attachments required.

Adult Wheeled Walker Type 2

Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See

Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Airway Surgical

Amg Medical

Drive Medical

Guardian

Human Care Canada

Inc.

Invacare

Lumex

Rubbermaid

Sunrise Medical

Airway Surgical

Amg Medical

Drive Medical

Evolution Medical

Human Care Canada

Inc.

Invacare

MEDLINE

INDUSTRIES INC.

Nighthawk

Top Release 5051/5051-J MW1AR0005

Deluxe Folding Wheeled Walker MW1GM0010

10263KDR Travel Folding

Walker

AA0000560

MW1D50005 One Button Or Dual Trigger

Release

Red Dot Extra Wide G07767

Red Dot G07756

Red Dot Standard G07755 &

G07756

Deluxe Regular

Deluxe Small

Adult

MW1GU0020

MW1GU0035

MW1GU0015

MW1DG0020

MW1DG0025

MW1IN0010

Dual Release Adult/Junior

Lightweight Adult/Junior

Deluxe

Breezy Everyday Folding

Walking Frame with wheels

MW1LU0020

MW1LU0010

MW1C60010

AA0001152

5314

Airgo Adventure 6

Airgo Ultra Light

Duet 795b Rollator

Go-Lite Deluxe

Challenger Grande

Challenger Mini

Sprite & Sprite Mini

Sprite Grande

4200 Dx

4200 Lx

Nexus 1 (Cable Brake)

Rollite 65100

Three Wheels

Translator

MW2AR0010

MW2GM0040

MW2GM0050

MW2D00010

MW2D50005

MW2EV0025

MW2EV0010

MW2EV0005

MW2EV0020

MW2DG0010

MW2DG0005

MW2DG0050

MW2IN0050

MW2IN0030

AA0000459

Ats 902 Handi Lite

Ats 903 Handi Lite

Ats 904 Handi Lite

Ovation Compact 807-6

MW2NM0005

MW2NM0010

MW2NM0015

MW2NM1005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Max

Allowed

Qty.

1

1

1

Approved

Price

$82.00

$82.00

$82.00

1

1

1

1

1

1

1

1

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$82.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

$324.00

Page: 2 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

Device Type Manufacturer

Effective From: February 01, 2015

Adult Wheeled Walker Type 2

Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See

Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Adult Wheeled Walker Type 3

Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See

Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Prode3

Sunburst Medical

Access Vital As

Airway Surgical

Amg Medical

Dolomite

Drive Medical

EUROVEMA AB

Enkatsu Solutions

Evolution Medical

Device

ProDe3 Victr/ 17,19 21 inches

Freedom Plus

Freedom Plus Short

Active

Breeze

5305 Adult Type 3 Walker

5307 Rollator

AIRGO EXCURSION XWD

Airgo Adventure 8

Airgo Comfort Plus Xwd

Airgo Comfort-Plus

Airgo Duo

Airgo Excursion

Airgo Fusion Rollator

Airgo Navigator

Alpha Advanced

Alpha Basic

Jazz

Opal Futura Symphony

Opal Legacy

Opal Maxi / Maxi+

Soprano

Diamond 740r Rollator

Nitro

Nitro Hemi

Nitro Tall

Volaris S7

Volaris S7 Smart

Prima Rollator

Challenger Low Wide

Challenger Wide

Evolution Dx, Ldx, Wdx, Lwdx

Horizon Dx, Wdx, Lwdx, Tdx

Piper Dx, Mdx, Smdx, Tdx

Xpresso, Xpresso Lite

Device Code

AA0000320

MW22S0005

MW22S0010

MW3DO1055

MW3DO1040

MW3DO1035

MW3DO1095

MW3D50010

AA0001036

AA0001193

AA0001194

AA0000456

AA0000457

MW3EH0005

MW3EV0035

MW3EV0030

MW3EV0005

MW3EV0010

MW3EV0020

MW3EV0040

MW3V80005

MW3V80010

AA0000315

AA0000460

AA0000124

MW3GM0060

MW3GM0055

MW3GM0050

MW3GM0040

MW3GM0065

AA0000694

MW3GM0015

MW3DO1085

MW3DO1080

MW3DO2000

Max

Allowed

Qty.

1

Approved

Price

$324.00

1 $324.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$324.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

Page: 3 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

Device Type Manufacturer

Adult Wheeled Walker Type 3

Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See

Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Effective From: February 01, 2015

Device Device Code

GF HEALTH

PRODUCTS

Handicare

Human Care Canada

Inc.

Nighthawk

Prode3

Sunburst Medical

HYBRID LX Rollator AA0000453

Gemino

4200swx

4200wx

Nexus Ii (Cable Brake)

Nexus Iii (Cable Free Braking

System)

Solo

AA0001082

MW3DG0035

MW3DG0030

MW3DG0040

MW3DG0045

MW3DG0010

Ats 906 0vation

Ovation Compact 805-8

MW3NM0015

MW3NM1005

Ovation Compact 806-8 MW3NM1010

ProDe3 Aurora 19/21/23 inches AA0000321

ProDe3 Balius/21 wide

Freedom All Terrain

Freedom Xl

Freedom Xls

Mirage 4900

Mirage 4925

Mirage 4950

Shopper 4700

AA0000319

MW32S0010

MW32S0015

MW32S0005

MW32S0030

MW32S0040

MW32S0035

MW32S0020

Topro

Titan

Olympos

Troja

Triumph Mobility Inc Escape

Approved ADP

Manufacturers Only

Forearm Crutches

MW32S0050

MW3TV0020

MW3TV0010

AA0001084

MKZND0005

Max

Allowed

Qty.

1

Approved

Price

$417.00

1

1

1

1

1

$417.00

$417.00

$417.00

$417.00

$417.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$417.00

$121.00

Forearm Crutches

1 Pair of Forearm Crutches from the following manufacturers may be billed under this code.

Paediatric Specific Walking Frame

ADP price includes frame, four wheels, hand grips (including arm supports), and built in sitting support (e.g. sling/saddle seat). See

Ambulation Aids Options Chart for adolescent sizes.

Can-Dan Rehatec

Drive Medical

Hoggi

Ormesa

Buddy Roamer

Meywalk 3, Meywalk 4

Meywalk, Medium & Large

Mini-Meywalk

Nimbo KA1200N

Nimbo KA2200N

Nimbo KA3200N

Nimbo KA4200N

Flux Gait Trainer

Dynamico

AA0001101

MW6CD0045

MW6CD0040

MW6CD0050

AA0000110

AA0000111

AA0000112

AA0000105

MW6K20005

MW6R80055

1

1

1

1

1

1

1

1

1

1

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$220.00

$220.00

$220.00

$220.00

$2,578.00

$2,578.00

Page: 4 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

Device Type Manufacturer

Effective From: February 01, 2015

Paediatric Specific Walking Frame

ADP price includes frame, four wheels, hand grips (including arm supports), and built in sitting support (e.g. sling/saddle seat). See

Ambulation Aids Options Chart for adolescent sizes.

Ormesa

Prime Engineering

Rifton Equipment

Snug Seat Inc.

Paediatric Specific Wheeled Walker

Type 1

Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels, and braking system (if available).

See Ambulation Aids Options Chart for adolescent sizes.

Guardian

Kaye

Paediatric Specific Wheeled Walker

Type 2

Walker type most suitable for active use on most terrains. ADP price includes all components and options.

Paediatric Standing Frame Type 1

ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray.

See Ambulation Aids Options Chart for adolescent sizes.

Otto Bock

Otto Bock

Prime Engineering

Device Device Code

Grillo

Kidwalk

Pacer Gait Trainer

Bronco,Sizes 0,1,2

Crocodile Reverse Walker

Gator

Mustang Gait Trainer

Pony,Size 0

Pony,Size 1

Pony,Size 2

Pony,Size 3

Strider Tweener G07783

Strider Tyke G07782

Tyke G07751

Adolescent 2 Wheels

Adolescent 4 Wheels

Adolescent 4 Wheels/Swivel

Child 2 Wheels

Child 4 Wheels

Child 4 Wheels/Swivel

Child Small 2 Wheels

Child Small 4 Wheels

Child Small 4 Wheels/Swivel

Pre-Adolescent 2 Wheels

MW4KY0070

MW4KY0075

MW4KY0020

MW4KY0025

MW4KY0030

MW4KY0005

MW4KY0010

MW4KY0015

MW4KY0050

Pre-Adolescent 4 Wheels MW4KY0055

Pre-Adolescent 4 Wheels/Swivel MW4KY0060

Youth 2 Wheels

Youth 4 Wheels

MW4KY0035

MW4KY0040

Youth 4 Wheels/Swivel

Nurmi Neo

MW4KY0045

MW5OB0005

MW6OA0005

MW62P0005

MW6RF0005

MW6R80060

MW6R80070

MW6R80005

AA0000693

MW6R80040

MW6R80045

MW6R80050

MW6R80052

MW4GU0035

MW4GU0030

MW4GU0010

MW4KY0065

Approved

Price

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$220.00

$1,524.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$2,578.00

$220.00

$220.00

$220.00

$220.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Max

Allowed

Qty.

1

1

1

1

1

1

1

Yogi Walker

Vertical Stander

Up-Right Stander

AA0000683

MS1HY0005

MS12P0015

1

1

1

$1,524.00

$1,219.00

$1,219.00

Page: 5 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

Device Type Manufacturer Device

Paediatric Standing Frame Type 2

ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray.

See Ambulation Aids Options Chart for adolescent sizes.

Altimate Medical

Ormesa

Otto Bock

Prime Engineering

Prodije

Snug Seat Inc.

Easy Stand 5000&7000

Magician

Easy Stand Bantam

Easy Stand Evolv

Dondolino, Size 1

Dondolino, Size 2

Dondolino, Size 3

Mini Standy

Standy

Leckey Mygo Stander

Squiggle Stander

Kidstand & Grandstand 111

Superstand,Small & Youth

Symmetry Standing Frame

Baby,Kid & Junior

Buffalo/ Caribou, all sizes

Gazelle,Size 1

Gazelle,Size 2

Gazelle,Size 3

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

MS2HC0005

MS2HC0015

MS2HC0010

MS2OA0010

MS2OA0015

MS2OA0020

MS2OA0030

MS2OA0035

AA0000692

AA0000700

MS22P0010

MS22P0005

MS22P0015

MS2JP0010

MS2R80005

MS2R80020

MS2R80025

MS2R80030

Device Code Max

Allowed

Qty.

1

Approved

Price

$3,285.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

$3,285.00

Page: 6 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

OPTIONS:

Device Type Manufacturer

AA - Custom Modifications

The MOCM code may be used when custom modifications are required to an ADP listed ambulation aid or paediatric stander, and there is no ADP code with assigned funding available. The following documentation must be submitted: 1. Authorizer must provide clinical rationale to support the request. 2. Vendor must provide a breakdown of the cost of labour (not to exceed $40.00/hour), and parts.

Adolescent Size Paediatric Specific

Walker

Additional funding for adolescent sized paediatric walkers. Authorizer must document clinical requirements. Selected device must meet size requirements.

Adolescent Size Paediatric Standing

Frame

Additional funding for adolescent sized paediatric standing frames (device type ms1 & ms2). Authorizer must document clinical requirements. Selected device must meet size requirements.

Adolescent Size Paediatric Walking

Frame

Additional funding for adolescent sized paediatric walking frames (device type mw6).

Authorizer must document clinical requirements. Selected device must meet size requirements.

Extra Wide Adult Wheeled Walker

Extra wide adult wheeled walker (greater than

18" between push handles) due to client stature. Client weight less than 275lbs.

Authorizer must document client's requirements.

Forearm Attachments

Forearm attachments for wheeled walkers.

Authorizer must provide clinical rationale to support request (maximum 2).

Heavy Duty Package Client Weight

275-350 lbs

Heavy duty package for wheeled walkers, client weight 275-350 lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Heavy Duty Package Client Weight

350-400 lbs

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Device Code

MOCM

Max

Allowed

Qty.

1

Approved

Price

AA5

AA7

1 $100.00

1 $300.00

AA6 1 $200.00

AA8

AA1

AA2

AA3

1 $100.00

2 $200.00

1 $100.00

1 $150.00

Page: 7 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Ambulation Aids

OPTIONS:

Device Type Manufacturer

Heavy duty package for wheeled walkers, client weight 350-400 lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Heavy Duty Package Client Weight

Exceeded 400 lbs

Heavy duty package for wheeled walkers, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Unilateral Hand Brake

Unilateral hand brake. allows locking/braking of both brakes using one hand. Authorizer must document clinical requirements. (max 1)

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

AA4 1 $200.00

AA9 1 $100.00

Page: 8 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$450.00

Action Products Twister Cb Back 15"-16" Width X

11"-16" Height

Twister Cb Back 15"-16" Width X

17"-21" Height

Twister Cb Back 17"-18" Width X

11"-16" Height

Twister Cb Back 17"-18" Width X

17"-21" Height

Twister Cb Back 19"-20" Width X

11"-16" Height

Adaptive

Engineering Lab

Twister Cb Back 19"-20" Width X

17"-21" Height

Twister Cb Back 21"-23" Width X

11"-16" Height

Twister Cb Back 21"-23" Width X

17"-21" Height

Drop-In R-Back Curved With 1.5" Poly

Foam

Drop-In R-Back Curved With Sun-Mate

Or Pudgee Foam

Drop-In R-Back Curved With Sun-Mate

Or Pudgee Foam

Adaptive

Equipment

Systems (Aes)

SEBAN0005

SEBAN0025

SEBAN0010

SEBAN0030

SEBAN0015

SEBAN0035

SEBAN0020

SEBAN0040

SEBE10030

SEBE10035

SEBE10040

Drop-In R-Back With 1" Poly Foam

Drop-In R-Back With 1.5" Poly Foam

Drop-In R-Back With Sun-Mate Or

Pudgee Foam

Drop-In T-Back Curved With Sun-Mate

Or Pudgee Foam

SEBE10005

SEBE10010

SEBE10020

SEBE10075

Drop-In T-Back Curved With Sun-Mate

Or Pudgee Foam

Drop-In T-Back With Sun-Mate Or

Pudgee Foam

Adjustable Bi-Angular Solid Back Insert,

Includes T-Nuts

& Adjustment Brackets.

SEBE10080

SEBE10060

SEB2L1025

I Or T Or Curved Syle Solid Back Insert,

Includes T-Nuts.

SEB2L1015

Oversize Upcharge For Backs Over 2o"

But Less Than 28".

SEB2L1040

Quick-Fit Contour/Bi-Angular Solid

Back Insert,

Incudes T-Nuts.

Sculptured Solid Back Insert, Includes

T-Nuts.

SEB2L1030

SEB2L1035

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$450.00

$450.00

$450.00

$530.00

$530.00

$530.00

$530.00

$223.00

$233.00

$267.00

$177.00

$195.00

$195.00

$289.00

$254.00

$251.00

$438.00

$274.00

$80.00

$602.00

$999.00

Page: 9 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Adaptive

Equipment

Systems (Aes)

Advanced

Mobility

Amysystems

Blake Medical

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$1,236.00

Sculpturefit Back W/Attaching

Hardware, Custom.

Solid Back Insert Package W/Universal

Hardware Or E-Z Mount

Mount Hardware & Rotating Hold

Downs.

SEB2L0015

SEB2L0005

Solid Back Insert Package, Li'L Kiddos,

14" Wide Or Less.

Solid Back Insert Package, Li'L Kiddos,

Contoured, 14" Wide.

Solid Back Insert, Includes T-Nuts, Li'L

Kiddos,

14" Wide Or Less.

Solid Back Insert, Includes T-Nuts.

Solid Back W/Drop Hooks & Fixed Hold

Downs.

Contoured Back

SEB2L0020

SEB2L0025

SEB2L1010

SEB2L1005

SEB2L0010

Deep "U" Back

Ez Back Basic

Ez Back System Complete

Pro Back Support

SEBAO0040

SEBAO0035

SEBAO0060

SEBAO0055

SEBAO0065

U Form Deep Contour Back Support SEBAO0050

Contour Back Support For Heavy Duty SEB4P0020

Contour Back Support, Non-Standard

Sizes

SEB4P0015

Contour Back Support, Standard Sizes SEB4P0010

Silverback Max 16/18/20" wide

Silverback Prime 16/18/20" wide

JazzRX

SE0001109

SE0001108

SE0001205

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$643.00

$733.00

$898.00

$247.00

$183.00

$267.00

$300.00

$340.00

$352.00

$411.00

$520.00

$863.00

$956.00

$607.00

$513.00

$1,011.00

$860.00

$73.00

Body Ryzm Life

Sciences /

Perspectis, Inc.

Broda

Custom

Fabricated

Back Pad

Back With Permanent Lateral Supports,

Vinyl Cover,

Without Mounting Hardware

Complex Indirect Molded Back,

Without Cover And Mounting Hardware

Complex Molded Back (Foam In Place),

Without Cover And Mounting Hardware

Contoured Back (Foam On Rigid Base),

Minimal Trunk Support,

Vinyl Cover, Without Mounting

Hardware

SEBB-0010

SEBCF114L

SEBCF118L

SEBCF117L

SEBCF112L

1

1

1

1

1

$67.00

$650.00

$1,460.00

$1,301.00

$500.00

Page: 10 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Custom

Fabricated

Dynamic Health

Care Solutions

Future Mobility

Device Device Code

SEBCF113L

Max

Allowed

Qty.

1

Approved

Price

$780.00

Custom Contoured Back, Moderate

Trunk Support,

Vinyl Cover, Without Mounting

Hardware

Custom Shaped Sculptured Back,

Includes Cover,

Without Mounting Hardware

Flat Back/Planar Design, Vinyl Cover

Without Mounting Hardware

Simple Molded Back (Foam In Place),

Without Cover And Mounting Hardware

Cushion Sizes 14" - 21"

Cushion Sizes 14" - 21"

Cushion Sizes 14' - 21"

HAKC Back Support 10" - 14"

MAPS Back Support 14" - 24"

NXT AC BACK 12" TO 20"

NXT HA AC BACK - 22 "

NXT HA AC BACK 16" TO 20"

NXT HA PC BACK 16" TO 20"

NXT HA PC BACK 22"

NXT HA SC 22"

NXT PC BACK 12" TO 20"

NXT SC BACK 12" TO 20"

NXT VC BACK

Nxt Carbon Fiber FHAC Back, FM

Nxt Carbon Fiber FHAC Back, QR

Nxt FH AC 22" HD Back

Nxt FH PC 22" HD Back

Nxt Optima FH AC Back

Nxt Optima FH PC Back nxt HA SC Back 16" to 20"

Custom Lunar Back

Custom Lunar Back HD

Full Back - Sizes From 14" To 22" -

Lateral

Full Back - Sizes From 14" To 22" -

Ultra Lateral

Full Back - Sizes From 18" To 24" No

Lateral

SEBCF115L

SEBCF110L

SEBCF116L

SEBD30005

SEBD30015

SEBD30010

SE0001129

SE0001130

SE0000340

SE0001182

SE0000335

SE0000336

SE0000338

SE0000334

SE0000341

SE0000339

SE0000120

SE0001221

SE0001222

SE0001215

SE0001216

SE0001217

SE0001219

SE0000337

SE0000684

SE0000685

SEBFM3040

SEBFM3050

SEBFM3020

1

1

1

1

1

$950.00

$300.00

$939.00

$684.00

$588.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$876.00

$876.00

$876.00

$576.00

$656.00

$552.00

$632.00

$551.00

$760.00

$1,440.00

$636.00

$551.00

$671.00

$575.00

$552.00

$796.00

$575.00

$576.00

$551.00

$551.00

$575.00

$575.00

$671.00

$551.00

Page: 11 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Future Mobility

Effective From: February 01, 2015

Device

Full Back Style Heaby Duty

Low Back - Sizes From 14" To 22" -

Lateral

Low Back - Sizes From 16" To 20" - No

Lateral

Device Code

SEBFM3060

SEBFM3035

SEBFM3010

Mid Back - Sizes From 14" To 22" -

Lateral

Mid Back - Sizes From 14" To 22" -

Ultra Lateral

Mid Back - Sizes From 16" To 20" - No

Lateral

Mid Back Style Heavy Duty

Orion Back

Prism Air Back - Custom Sizes

SEBFM3030

SEBFM3045

SEBFM3015

SEBFM3055

SEBFM3005

SEBFM0045

Prism Air Back - Non Standard Sizes

Prism Air Back Fits 16,18,20" Wide

W/C

SEBFM0040

SEBFM0035

Prism Bariatric Air Back 21x16 Though

24x20

SEBFM2025

Prism Bariatric Air Back- Custom Size SEBFM2030

Prism Bariatric Basic Back - Custom

Size

Prism Bariatric Basic Back 21x16

Through 42x20

Prism Bariatric Ultra Back 21x16

Through 24x20

SEBFM2010

SEBFM2005

SEBFM2015

Prism Bariatric Ultra Back- Custom Size SEBFM2020

Prism Basic Back - Custom Sizes SEBFM0015

Prism Basic Back - Non Standard Sizes SEBFM0010

Prism Basic Back Fits 16,18,20" Wide

W/C

SEBFM0005

Prism Max Back - Upcharge

Prism Phantom Back 12-18" Width X 7"

Height

Prism Super Back For Kids - Custom

Sizes

SEBFM0150

SEBFM0070

SEBFM0090

SEBFM0085 Prism Super Back For Kids - Non

Standard Sizes

Prism Super Back For Kids Fits 10, 12,

14 And 16" Wide W/C

Prism Truefitt Back - Bariatric Sizes

Prism Truefitt Back - Custom Sizes

SEBFM0080

SEBFM0060

SEBFM0065

Max

Allowed

Qty.

1

1

Approved

Price

$840.00

$560.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$500.00

$616.00

$664.00

$568.00

$800.00

$464.00

$860.00

$760.00

$640.00

$960.00

$1,060.00

$860.00

$800.00

$808.00

$920.00

$660.00

$600.00

$492.00

$100.00

$319.00

$660.00

$572.00

$500.00

$1,000.00

$820.00

Page: 12 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Future Mobility

Handicare

Hoggi

Innovators 1993

Inc

Invacare

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$740.00

Prism Truefitt Back - Non Standard

Sizes

Prism Truefitt Back Fits 16,18,20" Wide

W/C

Prism Ultra Back - Custom Sizes

SEBFM0055

SEBFM0050

SEBFM0030

Prism Ultra Back - Non Standard Sizes SEBFM0025

Prism Ultra Back Fits 16,18,20" Wide

W/C

SEBFM0020

Back Cushion 16x20,18x20, 20x20 SEBM90005

Backrest "Plush", Deep Or Active

Contour

SEBM90020

Lateral Support Backrest 16x20,18x20 SEBM90010

Sedeo Pro-Comfort Backrest 16"w to

18"w x 20"h

SE0000655

SE0000656 Sedeo Pro-Comfort Backrest 20"w x

20"h

Sedeo Pro-comfort Backrest 22"w x 20" h

Sedeo Pro-deep Backrest 16"w to

18"w x to 20"h

SE0000657

SE0000658

Sedeo Pro-deep Backrest 20"w x 20"h SE0000659

Sedeo Pro-deep Backrest, Active cut

16"w to 18"w x 20"h

SE0000661

SE0000662 Sedeo Pro-deep Backrest, Active cut

20" w x 20"h

Sedeo Pro-deep Backrest, Active cut

22"w x 20" h

SE0000663

Sedeo Pro-deep backrest 22"w x 20 h SE0000660

Smartsit Comfort Back - All Sizes SEBM90100

Back Cushion Shaped SE0000469

Back Cushion trough Shaped

Xps Adaptive Back Cushion

K Special Back-Custom

K Special Back-Standard

K-Combo Back

K-Combo Back Custom

Key-Hole Back

Key-Hole Back Custom

SE0000466

SEBK20050

SEBI30020

SEBI30010

SEBI30060

SEBI30065

SEBI30030

SEBI30040

Key-Hole Back Custom Adjustable Top SEBI30045

Contour U Back Includes All

Modifications & Vacuum/Vinyl

SEBNS1030

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$700.00

$808.00

$720.00

$620.00

$196.00

$532.00

$344.00

$600.00

$640.00

$680.00

$680.00

$719.00

$680.00

$719.00

$760.00

$760.00

$636.00

$315.00

$373.00

$300.00

$176.00

$151.00

$200.00

$222.00

$176.00

$196.00

$196.00

$1,340.00

Page: 13 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Invacare

Invacare - Matrx

Seating

Device Device Code Max

Allowed

Qty.

Approved

Price

Upholstery

Curved Back Fits 10" To 20" Wide W/C SEBNS0030

Curved Back Pneumatic Fits 10" To 20"

Wide W/C

SEBNS0040

SEBNS0045 Curved Back Pneumatic Special Size &

Modifications

Curved Back Special Size &

Modifications

Matrx Elite TR - Adult

Matrx Mini - Paediatric

Naked Contour U Back, Includes All

Modifications

& Vacuum/Moisture Proof

Coating/Removable Cover

& Cover Pattern.

Personal Back Bariatric Builder Size

Personal Back Fits 16", 18", 20" Wide

W/C

Personal Back Plus - Bariatric Builder

Size

Personal Back Plus - Fits 16", 18", 20"

Wide W/C

SEBNS0035

SE0001214

SE0001213

SEBNS1035

SEBNS0058

SEBNS0052

SEBNS0088

SEBNS0062

Silhoutte Back Support

Deep Heavy Duty Posture Back, All

Sizes

Deep Posture Back, All Sizes

Genera Back

Heavy Duty Posture Back Fits W/C

20"-25" Width & 16"-20" Height

Matrx Elite HD, greater than 24"

Matrx Elite HD, up to 24"

Matrx High Back Fits W/C 16" - 21"

Width & 20" - 30" Height

Matrx MX1 Superlite, 12"

Matrx MX1 Superlite, 16"

Matrx MX1 Superlite, 9"

PB Elite Deep All Sizes

PB Extra Wide Deep Heavy Duty Backs

From 16 To 20 Inches

PB Extra Wide Heavy Duty Backs Sizes

16 To 20 Inches

PB Posture Back Elite, Posture Back

SEBNS1020

SEB1M0020

SEB1M0015

SEB1M0050

SEB1M0010

SE0001052

SE0001051

SEB1M1005

SE0001054

SE0001055

SE0001053

SEB1M0026

SEB1M0040

SEB1M0035

SEB1M0025

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$501.00

$550.00

$652.00

$602.00

$660.00

$676.00

$1,594.00

$762.00

$515.00

$894.00

$647.00

$632.00

$1,069.00

$789.00

$443.00

$929.00

$1,290.00

$815.00

$649.00

$910.00

$990.00

$830.00

$716.00

$1,437.00

$1,314.00

$677.00

Page: 14 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Invacare - Matrx

Seating

Jay Medical

Device Device Code Max

Allowed

Qty.

Approved

Price

Elite Full Back, All Sizes

Posture Back Fits W/C 13"-20" Width &

12"-20"Height

Trx Rehab Back, Fits W/C 18" - 25"

Width

Foam Back

J2 Deep Contour Back 14w-19w,

Includes Mounting

Hardware, Cover, Lumbar Supports &

Lateral Wedges

J2 Deep Contour Back 20wx20h,

Includes Mounting

Hardware, Cover, Lumbar Supports &

Lateral Wedges

J3 Lower Thoracic Back, All Sizes

J3 Mid Thoracic Back, All Sizes

J3 Shoulder Height Back, All Sizes

J3 Upper Thoracic Back, All Sizes

JAY 2 Plus 20-23", 23-26" J2 Back

Assembly

For 0 Or 8 Degree Backposts

JAY Zip Back All Sizes

Jay 2 Back Includes Mounting

Hardware (""K"" Or ""G"" Type),

Cover & Lumbar Supports (14""-19"")

Jay 2 Back Includes Mounting

Hardware, Cover

& Lumbar Supports (12"/13")

Jay 2 Back- Includes Mounting

Hardware (""K"" Or ""G"" Type),

Cover & Lumbar Supports (20"")

Jay 2 Plus 20-23", 23-26" Back

Assembly For 0 To 8 Degree

Backposts,

With Headrest Mounting Kit

Jay 2 Tall Back- Includes Mounting

Hardware, Cover & Lumbar Supports

(20")

Jay 2 Tall Back- Includes Mounting

Hardware, Cover

& Lumbar Supports (14"/16"/17"/18")

Jay 3 Back Shoulder Height - Sizes 21

Height To 22 Width

Jay 3 Back- Posterior Upper thoracic-

Sizes 18 Height To 24 Width

SEB1M0005

SEB1M1050

SEBJA5040

SEBJA7000

SEBJA7005

SEBJA0900

SEBJA0905

SEBJA0915

SEBJA0910

SEBJA0300

SE0000640

SEBJA0100

SEBJA0105

SEBJA0110

SEBJA0310

SEBJA0130

SEBJA0120

SEBJA8215

SEBJA8210

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$649.00

$236.00

$115.00

$606.00

$646.00

$440.00

$592.00

$716.00

$696.00

$1,138.00

$680.00

$581.00

$581.00

$649.00

$1,220.00

$768.00

$666.00

$1,416.00

$1,300.00

Page: 15 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Jay Medical

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$1,220.00

Jay 3 Back- Posterior mid thoracic -

Sizes 12 Height To 26 Width

Sizes 15 Height To 26 Width

Jay Active Back 18"-14" Quick Release

Mount

Jay Active Back 18"-14" Rigid Mount

Jay Active Back 18"/16" Tall Quick

Release Mount

Jay Active Back 20" Tall

Jay Active Back With Permanent Mount

(Large)

Jay Basic Back, Fixed Clamp Style, All

Sizes

Jay Basic Back, Fixed Strap Style, All

Sizes

Jay Care Back 15-18" Wide

Jay Care Back 19-20" Plus Width

Jay Care Back Foam Large Size

Jay Care Back Shell Large Size

Jay Encompass Back

Jay Fit Back Adjustable Contour Back

For 10" Or 12" Frame Width,

Various Back Heights

Jay Fit Back Adjustable Contour Back

For 14" Or 16" Frame Width,

Various Back Heights

Jay Fit Back Adjustable Contour Back

For 18" Frame Width,

Various Back Heights

Jay Focus Point Back, All Sizes

Jay Modual Back Custom Contoured

Insert 18"/16"/14"

Jay Modual Back Custom Contoured

Insert 20"

Jay Modual Back Standard Insert

18"/16"/14"

Jay Modual Back Standard Insert 20"

Jay Modular Back Adjustable

Aluminum Shell 20"

Jay Modular Back Adjustable Aluminum

Shell (18",16",14")

Jay Union Back Standard with 4 point hardware

SEBJA8205

SEBJA1010

SEBJA1015

SEBJA1012

SEBJA1014

SEBJA1019

SEBJA2025

SEBJA2020

SEBJA5000

SEBJA5010

SEBJA5045

SEBJA5055

SEBJA8200

SEBJA4005

SEBJA4010

SEBJA4015

SEBJA8100

SEBJA3050

SEBJA3055

SEBJA3005

SEBJA3010

SEBJA3002

SEBJA3000

SE0000644

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$422.00

$391.00

$459.00

$538.00

$501.00

$406.00

$373.00

$510.00

$611.00

$158.00

$327.00

$360.00

$336.00

$380.00

$424.00

$626.00

$698.00

$806.00

$416.00

$544.00

$742.00

$640.00

$719.00

Page: 16 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type

Back Support

Effective From: February 01, 2015

Manufacturer Device Device Code

Jay Medical Jay Union Back Standard with standard hardware

Jay Union Back Tall with 4 point

Hardware

Jay Union Back Tall with Standard

Hardware

Kid Kart I-Back Cushion Tlc

Xpress T-Back 1" Short, Regular, Or

Tall

Xpress T-Back 2.5" Short, Regular, Or

Tall

Lpa Medical Inc.

Adjustable Tension Back

Contour Back Cushion

Maple Leaf

Wheelchair

Contour Padded Personal Back

ML Deep

ML Kyphothic

ML Mid

ML Shallow

ML Shape

SE0000643

SE0000646

SE0000645

SEBKT2015

SEBKT2025

SEBKT2030

SEBO12010

SEBO12005

SEBWM0005

SE0001085

SE0001089

SE0001086

SE0001087

SE0001088

Motion Concepts MX1 Dual Mount 14-18 wide x 9 hgh

MX1 Dual Mount 14-18 x 16 high

SE0000135

SE0000137

MX1 Dual mount 14-18 wide x 12 high SE0000136

MX1 Mono Mount 14-18 wide x 16 high SE0000134

MX1 Mono Mount 14-18 wide x 9 high SE0000132

MX1 Mono mount 14-18 wide x 12 high SE0000133

MX1 Quick Release Dual Mount 14-18 wide x 16 high

SE0000140

SE0000139 MX1 Quick Release Dual Mount 14-18 x 12 high

MX1 Quick Release Dual Mount 14-18 x 9 high

Trx Contour Back, For Trx Systems, 16,

18, 22" Wide

Wheelchairs, Height Adjustable 18-26"

SE0000138

SEBZG0005

SEBZG0020

Nighthawk

Trx Onyx Contour Back & Trx Single

Post Cloth Contour Back,

For Trx Systems

Trx Single Post Onyx Contour Back For

Trx Systems

Key-Hole Back

Relaxed Back High

SEBZG0025

SEBNM0050

SEBNM0010

Max

Allowed

Qty.

1

Approved

Price

$679.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$815.00

$775.00

$117.00

$130.00

$130.00

$1,056.02

$976.22

$275.00

$369.00

$369.00

$228.00

$184.00

$199.95

$108.00

$288.00

$486.00

$666.00

$560.00

$435.00

$656.00

$956.27

$1,113.21

$1,036.07

$1,075.97

$916.37

$996.17

$1,135.82

Page: 17 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Nighthawk

Orthofab

Otto Bock

Performance

Health Products

Permobil

Physipro

Power Plus

Device Device Code

Relaxed Back High With Flap

Relaxed Back Low

High Profile Contoured 14-20"Width,

16-20" Height

High Profile Contoured Non Standard

Sizes

High Profile Tall Contoured 14-20"

Width, 18-22" Height

High Profile Tall Contoured Non

Standard Sizes & Options

Low Profile Contoured 14-20" Width,

16-20" Height

Low Profile Contoured Non Standard

Sizes

Modular Mild Or Deep Contour 14-20"

Width & 16,18,20" Height

Modular Mild Or Deep Contour Non

Standard Sizes

Back System 1, 15" To 17" & 18" To

20"

Back System 2, 15" To 17" & 18" To

20"

SEBNM0020

SEBNM0005

SEBOF2005

SEBOF2010

SEBOF2015

SEBOF2020

SEBOF2025

SEBOF2030

SEBOF1005

SEBOF1010

SEBOB9555

SEBOB9600

Back System 3, 15" To 17" & 18" To

20"

Back System 4, 15" - 20" Sizes

Back-Finished With Spray

Coating,Cover,Sewing Pattern

Back-Itemized Cushion (Unfinished)

V-Trak Ax-Sb Back Support Connisting

Of 1 Insert, All Sizes

V-Trak Ax-Sb Back Support Consisting

Of 2 Inserts, All Sizes

SEBOB9605

SEBOB9610

SEBOB9650

SEBOB9655

SEBP00015

SEBP00020

V-Trak Ax-Sb Back Support Consisting

Of 3 Inserts, All Sizes

V-Trak Axh Back Support, All Sizes

V-Trak Axs Back Support, All Sizes

Ergo Back - Fixed - All Sizes

SEBP00025

SEBP00010

SEBP00005

SEB1P0005

Ergo Back - Recline - All Sizes

Rectangular Back - All Sizes

SEB1P0010

SEB1P0015

HP2 Back Support, all models, all sizes SE0001071

Premium Back Support, all sizes SE0001072

Deep U Back Custom Sizes SEBWM0015

Max

Allowed

Qty.

1

1

1

Approved

Price

$195.00

$184.00

$426.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$472.00

$400.00

$472.00

$400.00

$472.00

$520.00

$576.00

$397.00

$508.00

$606.00

$793.00

$1,983.00

$1,453.00

$644.00

$1,016.00

$1,336.00

$872.00

$780.00

$802.00

$802.00

$1,220.00

$556.00

$556.00

$720.00

Page: 18 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Effective From: February 01, 2015

Mobility

Precision Rehab

Manufacturing

Pride Mobility

Products

Device Device Code

Deep U Back Standard Sizes

Kyphotic Tension Back Rest - Shallow

Or Deep U

Mid U Back Standard Sizes

Shallow U Back Standard Sizes

Shallow U Back Custom Sizes

Shape U Back Standard Sizes

Upcharge For Custom Height

Upcharge For Custom Width

Back Sewn Cover Waterproof Foam,

Includes Labour For

Digitizing Or Plastering

Back Vacuum Formed, Includes Labour

For Digitizing Or

Plastering

Base Cushion Back, Includes All

Modifications & Labour

For Digitizing Or Plastering

Precision - Fit Back Cushion Upcharge,

Extra

Wide Or Extra Tall, 20" - 24"

Precision - Fit Back Cushion, Subtle,

Moderate Or Aggresive

Positioning. Includes Hinged Or Fixed

Laterals And Cover.

Adjustable Height Back System

Back Cushion - All Sizes

Synergy Shape 2 Back - Low

Synergy Shape 2 Back - Standard

Synergy Shape 2 Back - Tall

Synergy Shape Back Sizes 14x19 &

22x19

Synergy Shape Back Sizes 16x19,

18x19, 20x19

Synergy Shape Deep Standard Sizes

Synergy Shape Deep Tall Sizes

Synergy Shape GP Back Sizes 14x19

16x19 18x19

Synergy Shape GP Sizes 20x19 And

22x19

Synergy Standard Back Support, up to

20". For additional sizing see

SEBND0015.

SEBWM0010

SEBWM0030

SEBWM0027

SEBWM0020

SEBWM0025

SEBWM0026

SEBWM0040

SEBWM0035

SEBWB0010

SEBWB0005

SEBWB0015

SEBWB0022

SEBWB0020

SEBK20060

SEBK20005

SEBX10030

SEBX10035

SEBX10040

SEBX10005

SEBX10010

SEBX10055

SEBX10060

SEBX10045

SEBX10050

SE0000971

Max

Allowed

Qty.

1

1

Approved

Price

$608.00

$832.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$700.00

$544.00

$608.00

$820.00

$176.00

$176.00

$1,711.00

$1,439.00

$2,079.00

$240.00

$1,078.00

$340.00

$300.00

$522.00

$575.00

$594.00

$639.00

$639.00

$660.00

$680.00

$396.00

$435.00

$360.00

Page: 19 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Pride Mobility

Products

Quickie

Ride Designs

Roho

Starkey -

Viennatone

Supracor

The Comfort

Company

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$600.00

Synergy Tru Comfort Back Standard,

Reclining Or Tilt And

Recline Back Greater Than 20" Wide

Synergy Tru-Comfort Back Synergy Tru

Comfort Back Standard, Reclining Or

Tilt And Recline Back Up To 20" Wide

BREEZY RELAX2 COMFORT BACK

ANATOMICAL SHAPE

Contour Back - Tilt Fx

Corbac Adjustable Contour Back

Support,

All Sizes

Ride Custom Back Support

Ride Decaf, all sizes

Ride Java Back Grande

Ride Java Back Grande Deep

Ride Java Back Regular/Tall Deep

Agility Back - Custom Design - All

Variation

Agility Back Support

Agility Max Contour Back - all sizes

Low Back (10" Height) All Standard

Sizes 14" - 18"

Lumbar Support Cushion (Made To

Order)

Recliner Wheelchair Cushion Made To

Order

(One Piece Back & Seat- 2 Sections,2

Valves)

Recliner Wheelchair Cushion-Custom

(More Than 2 Sections And/Or 2

Halves)

Standard Back (16" Height) All

Standard Sizes 14" - 18"

Butterfly Back System

SEBX10025

SEBX10020

SE0000117

SEBQU0400

SEBR40005

SEBR40010

SE0001045

SE0001144

SE0001145

SE0001143

SE0001167

SE0000970

SE0001118

SEBRO3010

SEBRO2015

SEBRO2005

SEBRO2010

SEBRO3005

SEBV10005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$556.00

$1,996.00

$416.00

$392.00

$2,613.00

$628.00

$651.00

$740.00

$716.00

$1,668.00

$737.00

$953.00

$1,195.00

$395.00

$1,200.00

$1,400.00

$1,495.00

$340.00

Stimulite Lumbar Support

Acta Relief Back - All Variations

SEBRR0010

SE0001168

Acta-Back, All Variations, All Sizes SEB7C0010

Acta-Back, All Variations, Custom Sizes SEB7C0015

Incrediback, Modable, Tall, Deep, Tall-

Deep,

Custom Sizes

SEB7C0025

1

1

1

1

1

$127.00

$1,017.00

$754.00

$1,339.00

$1,520.00

Page: 20 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Back Support

Complete Assembly

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$747.00

The Comfort

Company

Incrediback, Moldable, Tall, Deep, Tall-

Deep,

All Sizes

Tops Back Cushion (10" & 12" Width)

SEB7C0020

Toronto

Orthopedic Ltd.

Varilite Medical

Products

Vision

Wheelchair

Seating Systems

Inc.

Adaptive

Engineering Lab

Adaptive

Equipment

Systems (Aes)

Amysystems

Broda

SEBTP0005

Evolution Back - Regular

Evolution Back - Regular Bariatric

Evolution Back - Tall

Evolution Deep Back - All Sizes

Icon Back - Bariatric

Icon Back - Deep

Icon Back - Low

Icon Back - Tall

SEBVP0050

SEBVP0055

SEBVP0060

SEBVP0070

SEBVP0120

SEBVP0115

SEBVP0100

SEBVP1110

Icon Back -Mid

Junior Backs

Talon Back - All Sizes

Viscount Tall Back Support For 16' Or

18" W/C

Viscount Tall Back Support, Custom

Sizes

Viva Contoured Postural Back

14"-16" W/C Or 16"-18" W/C

Contoured Seat System

(Includes Seat, Back, Support Pads,

Hardware)

Basis Contoured Seat & Back Including

Connecting Hinge

(Select Type). Does Not Include

Mounting Hardware.

Basis Contoured Seat & Back Including

Connecting Hinge

Package. Li'L Kiddos,14" Wide Or Less.

Does Not Include

Mounting Hardware.

Basis Seat & Back Including

Connecting Hinge (Select Type).

Does Not Include Mounting Hardware.

Basis Seat & Back Including

Connecting Hinge Package. Li'L

Kiddos,14" Wide Or Less. Does Not

Include Mounting Hardware.

Bariatric Power Recline With Integrated

Shear Reduction (Isr)

Hsp Padding Package

SEBVP0105

SE0001147

SEBVP0080

SEBVC0030

SEBVC0035

SEBVC0015

SECE10020

SEC2L0010

SEC2L0020

SEC2L0005

SEC2L0015

SEC4P0065

SECB-0005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$246.00

$1,517.00

$229.00

$1,225.00

$860.00

$1,040.00

$592.00

$690.00

$8,115.00

$563.00

$781.00

$1,092.00

$865.00

$1,134.00

$1,119.00

$1,025.00

$717.00

$839.00

$746.00

$746.00

$555.00

$1,201.00

Page: 21 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Complete Assembly

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Custom

Fabricated

Hoggi

Invacare

Kid Kart

(Includes Short Wing Cover, Extended

Shoulder Bolsters,

Full Extension Foot Pad, F-2 Foot Rest,

Thigh Belt)

Modify Or Refurbish Existing Custom

Seating System.

Includes Parts,Hardware,Labour

Changes To Head Rest,Back

Support,Seat, & Footrest Etc.

Adjustible Height Back System Planar

Back Cushion

Bingo Ius Or Xps Seat Frame Size 1

Bingo Ius Or Xps Seat Frame Size 2

Configurable Adjustible Height I Back

System

Ius Adaptive Seat And Back Cushions

With Airflex

Ius Adaptive Seat And Back Cushions -

Breathable

Kinesthetic Seating System Fits 10" To

14" Wide W/C,

(Includes Basic Headrest, Lateral

Supports, Padded Lap Belt,

Ulti-Mate Base, Curved Back & Growth

Bracket)

Kinesthetic Seating System Fits 16" To

20" Wide W/C,

(Includes Basic Headrest, Lateral

Supports, Padded Lap Belt,

Ulti-Mate Base & Curved Back)

Tlc Shell Assembly With Contour

Seating

SEMCF900L

SE0000467

SECK20005

SECK20010

SE0000468

SECK20105

SECK20100

SECNS0005

SECNS0010

SECKT2010

Tlc Shell Assembly With Planar Seating SECKT2005

Xpress Adjustable Contour Seating

Package

SECKT3005

SECKT3015 Xpress Shell Assembly With Contour

Seating

Xpress Shell Assembly With Planar

Seating

SECKT3010

Motion Concepts Power Tilt Only For Invacare, Quantum,

And Quickie Bases.

Otto Bock Kimba Neo Basic Seat - Size 2 -

Includes Elevating Legrests, Flip-Up

Footrest, Laterals,

Adjustable Hip Pads & Padding.

SECZG2005

SE0001159

Kimba Spring Multifunctional Seating SECOB3005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$500.00

$315.00

$1,568.00

$1,592.00

$315.00

$704.00

$260.00

$1,311.00

$1,311.00

$1,148.00

$916.00

$896.00

$896.00

$643.00

$5,250.00

$1,701.00

$1,516.00

Page: 22 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Complete Assembly

Headrest/Neckrest

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Otto Bock Unit - Size 1

Includes Elevating Legrests, Flip-Up

Footrest, Laterals,

Adjustable Hip Pads & Padding.

Kimba Spring Multifunctional Seating

Unit - Size 2

Includes Elevating Legrests, Flip-Up

Footrest, Laterals,

Adjustable Hip Pads & Padding.

Kimba Spring Plus Adjustable Seating

System - Size 1

Includes Armrests, Elevating Legrests,

Adjustable

Footplates & Recline.

Kimba Spring Plus Adjustable Seating

System - Size 2

Includes Armrests, Elevating Legrests,

Adjustable

Footplates & Recline.

Kimbo Neo Basic Seat - Size 1 -

Includes Elevating Legrests, Flip-Up

Footrest, Laterals,

Adjustable Hip Pads & Padding.

Mygo Seat Shell Size 1

Includes Seat Shell And Cushions

Mygo Seat Shell Size 2

Includes Seat Shell Cushions And

Shoulder Support

SECOB3010

SECOB4005

SECOB4010

SE0001158

SECOB4015

SECOB4020

OBSS Ortho-Shape

OBSS Ortho-Shape, greater than 20" wide and/or deep

OBSS Ortho-Shape, including additional liner for growth

Squiggle Seating System

SE0001046

SE0001047

SE0001048

Spenco

THOMASHILFEN EasyS or EasyS Modular

Toronto

Orthopedic Ltd.

Adaptive

Engineering Lab

Adaptive

Silicore Wheelchair Seat With Back and

Sides

Thevo Twist

SE0000701

SECSO0010

SE0001026

SE0001025

SECTP0005 Tops Seating System

Includes Butterfly Chest Strap,

Combination Head/Neckrest

Tilt Tray, Stroller Interface, Back And

Seat

Curved Headrest

Tri-Pad Headrest

SEHE10015

SEHE10005

Curved Hr Pad Or Contoured Hr Pad Or SEH2L0035

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$1,596.00

$1,456.00

$1,640.00

$1,616.00

$1,808.00

$2,079.00

$4,316.00

$4,676.00

$4,596.00

$1,712.00

$122.00

$1,596.00

$1,712.00

$1,562.00

$102.00

$315.00

$527.00

Page: 23 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Equipment

Systems (Aes)

Advanced

Mobility

Amysystems

Broda

Custom

Fabricated

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Bell Curved Hr Pad,

Cobra Headrest Bracket, Flip-Down.

Curved Hr Pad Or Contoured Hr Pad Or

Bell Curved Hr Pad,

Cobra Headrest Bracket.

SEH2L0030

SEH2L0015 Lateral-Posterior Head Support,

Adjustable Depth Bracket,

6-1/2"W X 7"H.

Lateral-Posterior Head Support,

Adjustable Depth Bracket,

Hinged.

Lateral-Posterior Head Support,

Adjustable Depth Bracket,

Paediatric 4" X 4" Or 5"X 5" Or 6"X 6".

Lateral-Posterior Head Support, Cobra

Headrest Bracket,

5" X 5"Or 6" X 6" Or 7" X 7"Or 8" X 8".

Lateral-Posterior Head Support, Cobra

Style Headrest

Bracket, Flip-Down 5" X 5"Or 6"X6" Or

7"X7" Or 8" X8".

Custom Headrest

Deep "U" Headrest

Large Padded Headrest

SEH2L0005

SEH2L0010

SEH2L0020

SEH2L0025

SEHAO0015

SEHAO0020

SEHAO0025

Macintosh Oxbow Headrest

So Soft Oval Headrest

Standard Curved Padded Headrest

Curved Headrest, All Sizes

Neckrest Cushion

Adjustable Headrest With Neckrest,

Vinyl Cover,

Without Hardware

Complex Headrest/Contoured Or

Molded, Vinyl Cover,

Without Hardware

SEHAO0010

SEHAO0030

SEHAO0005

SEH4P0010

SEHB-0010

SEHCF080L

SEHCF060L

Contoured Headrest/Curved Surface,

Vinyl Cover,

Without Hardware

Flat Headrest/Planar Head Support,

Vinyl Cover,

Without Hardware

Head Or Neckrest Incorporated With

Mobility Switches,

Vinyl Cover, Without Hardware

Neckrest With Vinyl Cover, Without

SEHCF050L

SEHCF040L

SEHCF090L

SEHCF070L

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$442.00

$412.00

$450.00

$391.00

$538.00

$622.00

$310.00

$200.00

$125.00

$310.00

$190.00

$200.00

$156.00

$116.00

$200.00

$156.00

$116.00

$187.00

$47.00

$420.00

Page: 24 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Custom

Fabricated

Daher Specialty

Foam Products

Hardware

Combination Headrest

Full Support Headrest

Large Headrest

MultiFit Headrest Dynamic Health

Care Solutions

Future Mobility

Handicare

Hoggi

Invacare

Jay Medical

SEHDH0010

SEHDH0015

SEHDH0005

SE0001131

Large Headrest With Multi-Axial

Hardware

Large Padded Headrest

Small Headrest With Multi-Axial

Hardware

Small Padded Headrest

Emineo Advanced Headrest

SEHFM0015

SEHFM0005

SEHFM0020

Emineo Basic Headrest

Large Headrest

Lateral Support Headrest

Offset Headrest Large

Offset Headrest Lateral

Offset Headrest Small

Sedeo Pro Flexible Headrest Pad

Sedeo Pro Large Headrest Pad

Sedeo Pro small headrest pad

Small Headrest Assesmbly

Ius Headrest

Basic Headrest - Adult

Basic Headrest - Child

Curved Adjustable Headrest System

Large Adjustable Headrest System

Small Adjustable Headrest System

SEHFM0010

SEHM90105

SEHM90100

SEHM90015

SEHM90010

SEHM90030

SEHM90025

SEHM90020

SE0000665

SE0000666

SE0000664

SEHM90005

SEHK20005

SEHNS1010

SEHNS1005

SEHNS1030

SEHNS1020

SEHNS1015

Two Step Adjustable Headrest System SEHNS1025

Jay Four Pad Headrest - Junior SEHJA0016

SEHJA0018 Jay Four Pad Rotational Headrest -

Junior

Jay Four Pad Rotational Headrest -

Standard

SEHJA0017

Jay Full Width Headrest

Jay Single Pad Headrest - Large

Jay Single Pad Headrest - Small

SEHJA0020

SEHJA0006

SEHJA0005

1

1

1

1

1

1

1

1

1

1

1

$58.00

$77.00

$58.00

$180.00

$284.00

$220.00

$280.00

$440.00

$147.00

$84.00

$84.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$216.00

$360.00

$236.00

$148.00

$140.00

$212.00

$204.00

$196.00

$108.00

$116.00

$80.00

$132.00

$288.00

$221.00

$221.00

$329.00

$354.00

$354.00

$329.00

$294.00

$440.00

Page: 25 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Effective From: February 01, 2015

Jay Medical

Kid Kart

Device

Jay Three Pad Headrest - Large SEHJA0011

Jay Three Pad Headrest - Large Junior SEHJA0013

Jay Three Pad Headrest - Small

Jay Three Pad Headrest - Small Junior SEHJA0012

Jay Three Pad Rotational Headrest -

Large

SEHJA0027

SEHJA0029 Jay Three Pad Rotational Headrest -

Large Junior

Jay Three Pad Rotational Headrest -

Small

Jay Three Pad Rotational Headrest -

Small Junior

SEHJA0026

SEHJA0028

Xpress Micro Adjustable Head Support SEHKT3010

Xpress Planar Head Support SEHKT3015

Xpress Tri-Wing Adjustable Head

Support

Lpa Medical Inc.

Cervical Support

Contour Headrest

ML Contour Maple Leaf

Wheelchair

Metalcraft

Industries

Contoured Headrest With Mounting

Hardware

Small, Large, Xlarge

Occipital Ring With Mounting Hardware

Small & Large Child Or Adult

Device Code

SEHJA0010

SEHKT3005

SEHO12005

SEHO12010

SE0001133

SEHNG0005

SEHNG0015

Motion Concepts Onyx Auto Style Headrest

Orthofab Padded Contour Support Without

Mounting Hardware,

Small, Medium, Or Large

Otto Bock

Occipital Ring, Add-On, With Mounting

Hardware

Small & Large Child Or Adult

Adjustable Wing Headrest (Size 1 & 2)

Contoured Headrest (Size 1 & 2)

SEHNG0020

SEHZG0005

SEHOF1005

SEHOB6020

SEHOB6010

Fixed Wing Headrest (Size 1 & 2)

Headrest - Combination

SEHOB6015

SEHOB0010

Headrest - Large/Small

Headrest - Lateral Control

Headrest Support (Size 1 & 2)

Neckrest - All Sizes

Soft Headrest - Large/Small

SEHOB0100

SEHOB0050

SEHOB6005

SEHOB0250

SEHOB0110

Max

Allowed

Qty.

1

1

1

1

1

Approved

Price

$210.00

$210.00

$210.00

$210.00

$352.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$352.00

$352.00

$352.00

$245.00

$160.00

$124.00

$42.00

$100.00

$208.00

$301.00

$345.00

$301.00

$187.00

$106.00

$562.00

$160.00

$396.00

$83.00

$84.00

$136.00

$286.00

$95.00

$120.00

Page: 26 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type

Headrest/Neckrest

Effective From: February 01, 2015

Manufacturer Device Device Code

Otto Bock

Performance

Health Products

X-Style Headrest/Neckrest

Combination, Adult &

Paediatric Sizes.

V-Trak Headrest, All Sizes, All

Configurations

SEHOB0015

SEHP00005

Permobil

Physipro

Headrest - For Ergo Back

Headrest

Contour Headrest Including Brackets

SEH1P0005

SE0001073

SEHWM0005 Power Plus

Mobility

Precision Rehab

Manufacturing

Pride Mobility

Products

Headreast - Large (14") Or Small (10")

Pad

SEHWB0010

Kids Up Including Mounting Hardware SE0001154

TRU-Comfort 2 Including Mounting

Hardware

SE0001153

Stealth Products Stealth Combo Headrest With Multi

Axis Hardware,

Large & Small Sizes

SEHNS2050

SEHNS3015 Stealth Comfort Plus Large 14" Comfort

Pad Only (With Ring)

Stealth Comfort Plus Medium 10"

Comfort Pad Only (With Ring)

Stealth Comfort Plus, Large 14"

Pad /Multi Axis Hardware

SEHNS3025

SEHNS3020

Stealth Comfort Plus, Large 14"

Pad/Standard Hardware

Stealth Comfort Plus, Medium 10"

Pad/Multi Axis Hardware

SEHNS3005

SEHNS3030

Stealth Comfort Plus, Medium 10"

Pad/Standard Hardware

Stealth Comfort Plus, Swingaway Both

Sides, Standard

Lateral Pad/Spot Pad/Long Lateral Pad

Stealth Comfort Plus, Swingaway Left

Side, Standard

Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3010

SEHNS3060

SEHNS3070

Stealth Comfort Plus, Swingaway Right

Side, Standard

Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3065

Stealth I2i Headrest System - All Sizes SEHNS2060

Stealth Occipital/Sub Occipital &

Laterals,

Adult & Paediatric Sizes (Specify

Swingaway)

SEHNS2005

Stealth Otto Bock Style, Swing Away

Both Sides, Standard

SEHNS3075

Max

Allowed

Qty.

1

Approved

Price

$125.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$360.00

$470.00

$170.00

$256.00

$120.00

$308.00

$282.00

$536.00

$165.00

$165.00

$338.00

$280.00

$338.00

$280.00

$494.00

$375.00

$375.00

$822.00

$1,133.00

$557.00

Page: 27 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Stealth Products Lateral Pad/Spot Pad/Long Lateral Pad

Stealth Otto Bock Style, Swingaway

Left Side, Standard

Lateral Pad/Spot Pad/Long Lateral Pad

Stealth Otto Bock Style, Swingaway

Right Side, Standard

Lateral Pad/Spot Pad/Long Lateral Pad

Stealth Ultra Channel With Ring, Large

& Small Sizes

Stealth Ultra Large Combo With Large

Sub Occipital

Stealth Ultra Occipital & Laterals,

Small & Large Sizes (Specify

Swingaway)

Stealth Ultra Occipital Large/Small

Stealth Ultra Small & Occipital/Sub

Occipital

SEHNS3085

SEHNS3080

SEHNS2020

SEHNS2007

SEHNS2015

SEHNS2030

SEHNS2010

Stealth Ultra Small Combo With Large

Sub Occipital

SEHNS2009

Stealth Ultra Sub Occipital Large/Small SEHNS2025

Stealth Ultra Swing Both Sides,

Standard Lateral

Pad/Spot Pad/Long Lateral Pad

SEHNS2035

SEHNS2045 Stealth Ultra Swingaway

Standard & Long Lateral Pad, Or Spot

Pad

Stealth Ultra-Ac Adjustable Channel

Headrest - Moldable, Includes Cover

SEHNS2040

SEH7C0015 The Comfort

Company

Vision

Wheelchair

Seating Systems

Inc.

SEHVC0005

SEHVC0010

Whitmyer

Biomechanix

Vector Head N Neck Support, 11"W X

8"D Pad

Vector Head N Neck Support, Custom

Pad

10" Plush Occipital Pad & Single Sub-

Occipital Pad

With Linx Vertical/Horizontal Mount

10" Plush Occipital Pad & Single Sub-

Occipital Pad

With Onyx Vertical/Horizontal Mount

10" Plush Occipital Pad & Single Sub-

Occipital Pad

With Pro Verticial/Horizontal Mount

14" Plush Pad With Linx

Vertical/Horizontal Mount

14" Plush Pad With Onyx

SEHWH7005

SEHWH7020

SEHWH7035

SEHWH5010

SEHWH5030

1

1

1

1

1

1

1

1

1

1

2

1

1

1

1

1

1

1

1

1

$426.00

$426.00

$647.00

$1,026.00

$803.00

$330.00

$659.00

$1,026.00

$330.00

$474.00

$375.00

$313.00

$218.00

$232.00

$328.00

$419.00

$393.00

$430.00

$228.00

$228.00

Page: 28 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Whitmyer

Biomechanix

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Vertical/Horizontal Mount

14" Plush Pad With Pro

Vertical/Horizontal Mount

19" Plush Pad With Link

Vertical/Horizontal Mount

19" Plush Pad With Onyx

Vertical/Horizontal Mount

19" Plush Pad With Pro

Vertical/Horizontal Mount

4"X6" Occipital Pad & Single Sub-

Occipital Pad

With Onyx Vertical/Horizontal Mount

4"X6" Occipital Pad & Single Sub-

Occipital Pad

With Pro Vertical/Horizontal Mount

4"X6"Occipital Pad & Single Sub-

Occipital Pad

With Lynx Vertical/Horizontal Mount

4"X6"Occipital Pad With Size 1/2 Sub-

Occipital Pads

With Lynx Vertical/Horizontal Mount

4"X6"Occipital Pad With Size 1/2 Sub-

Occipital Pads

With Onyx Vertical/Horizontal Mount

4"X6"Occipital Pad With Size 1/2 Sub-

Occipital Pads

With Pro Vertical/Horizontal Mount

8" Or 10" Plush Pad With Lightweight

Vertical/Horizontal Mount

8" Or 10" Plush Pad With Linx

Vertical/Horizontal Mount

8" Or 10" Plush Pad With Onyx

Vertical/Horizontal Mount

8" Or 10" Plush Pad With Pro

Vertical/Horizontal Mount

8"/10" Plush Occipital Pad With Size 1

Sub-Occipital Pads

With Pro Vertical/Horizontal Mount

8"/10" Plush Occipital Pad With Size

1sub-Occipital Pads

With Lynx Vertical/Horizontal Mount

8"/10" Plush Occipital Pad With Size

1sub-Occipital Pads

With Onyx Vertical/Horizontal Mount

Adjust-A-Plush Headrest System

SEHWH5040

SEHWH5015

SEHWH5032

SEHWH5045

SEHWH7025

SEHWH7040

SEHWH7010

SEHWH7050

SEHWH7065

SEHWH7080

SEHWH5020

SEHWH5005

SEHWH5025

SEHWH5035

SEHWH7085

SEHWH7055

SEHWH7070

SEHWH7260

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$244.00

$334.00

$302.00

$339.00

$334.00

$371.00

$366.00

$440.00

$344.00

$482.00

$218.00

$218.00

$218.00

$234.00

$541.00

$498.00

$525.00

$272.00

Page: 29 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Whitmyer

Biomechanix

Effective From: February 01, 2015

Device Device Code

Bilateral Lfc With Pads And Interface

Plate

For Plush & Contoured Cradle Systems

Heads Up Pad All Sizes -

Add On Occipital Pads Optional

Large Pad With Lightweight

Vertical/Horizontal Mount

Large Pad With Linx Vertical/Horizontal

Mount

Large Pad With Onyx

Vertical/Horizontal Mount

Large Pad With Pro Vertical/Horizontal

Mount

Lateral Facial Component With Pad

Medium Pad With Lightweight

Vertical/Horizontal Mount

Medium Pad With Lightweight

Vertical/Horizontal Mount

Medium Pad With Linx

Vertical/Horizontal Mount

Medium Pad With Pro

Vertical/Horizontal Mount

Occipital Pad With Size 3/4 Sub-

Occipital Pads

1"X4",4"X6",1"X4" With Lynx

Vertical/Horizontal Mount

Occipital Pad With Size 3/4 Sub-

Occipital Pads

1"X4",4"X6",1"X4" With Onyx

Vertical/Horizontal Mount

Occipital Pad With Size 3/4 Sub-

Occipital Pads

1"X4",4"X6",1"X4" With Pro

Vertical/Horizontal Mount

Single Pad Dynamic Forehead Strap

System All Sizes

SEHWH7235

SE0001099

SEHWH5075

SEHWH5060

SEHWH5090

SEHWH5110

SEHWH7250

SEHWH5070

SEHWH5085

SEHWH5055

SEHWH5105

SEHWH7105

SEHWH7115

SEHWH7125

SEHWH7200

Single Pad Static Forehead Strap

System All Sizes

Small Pad With Lightweight

Vertical/Horizontal Mount

Small Pad With Linx Vertical/Horizontal

Mount

SEHWH7205

SEHWH5065

SEHWH5050

Small Pad With Onyx

Vertical/Horizontal Mount

SEHWH5080

Small Pad With Pro Vertical/Horizontal SEHWH5095

Max

Allowed

Qty.

1

Approved

Price

$461.00

1

1

1

1

1

2

1

1

1

1

1

1

1

1

1

1

1

1

1

$240.00

$165.00

$165.00

$212.00

$228.00

$212.00

$154.00

$202.00

$154.00

$175.00

$440.00

$456.00

$482.00

$292.00

$308.00

$143.00

$143.00

$191.00

$165.00

Page: 30 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Headrest/Neckrest

Seat Cushion

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Whitmyer

Biomechanix

Mount

T-Bar Occipital Pads & Single Sub-

Occipital Pad

2.25"X7" & 2.25"X5" With Linx

Vertical/Horizontal Mount

T-Bar Occipital Pads & Single Sub-

Occipital Pad

2.25"X7" & 2.25"X5" With Onyx

Vertical/Horizontal Mount

T-Bar Occipital Pads & Single Sub-

Occipital Pad

2.25"X7" & 2.25"X5" With Pro

Vertical/Horizontal Mount

T-Bar Occipital Pads With Size 1 Sub-

Occipital Pads

2.25"X7" With Pro Vertical/Horizontal

Mount

T-Bar Occipital Pads With Size 1sub-

Occipital Pads

2.25"X7" With Linx Vertical/Horizontal

Mount

T-Bar Occipital Pads With Size 1sub-

Occipital Pads

2.25"X7" With Onyx Vertical/Horizontal

Mount

T-Bar Occipital Pads With Size 3 Single

Sub-Occipital Pads

2.25"X5" With Linx Vertical/Horizontal

Mount

T-Bar Occipital Pads With Size 3 Single

Sub-Occipital Pads

2.25"X5" With Onyx Vertical/Horizontal

Mount

T-Bar Occipital Pads With Size 3 Single

Sub-Occipital Pads

2.25"X5" With Pro Vertical/Horizontal

Mount

Unilateral Lfc With Pads And Interface

Plate

For Plush & Contoured Cradle Systems

Action Products ACTION XACT LP2

Action Xact LP2 SIZES XP: WIDTH:

16"/18"/20"/22" DEPTH: 16"/18"/20"

Action Xact LP2 XP: SIZES: XP 1818

TO 22X20

Centurian Cushion

16x16,16x81,18x16,18x18

SEHWH7015

SEHWH7030

SEHWH7045

SEHWH7090

SEHWH7060

SEHWH7075

SEHWH7110

SEHWH7120

SEHWH7130

SEHWH7230

SE0000329

SE0000570

SE0000571

SESAN2205

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$652.00

$620.00

$663.00

$737.00

$694.00

$710.00

$694.00

$710.00

$737.00

$250.00

$693.26

$695.00

$795.00

$265.00

Page: 31 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Action Products

Device

Centurian Cushion 18x20,20x18,20x20

Centurian Cushion Large Custom Sizes SESAN2225

Centurian Cushion Small Custom Sizes

Device Code

SESAN2210

SESAN2215

Centurian Cushion Xlarge Custom

Sizes

Commuter Cushion

16x16,16x18,18x16,18x18

SESAN2230

SESAN4405

Commuter Cushion 18x20,20x18,20x20 SESAN4410

Commuter Cushion Large Custom

Sizes

SESAN4425

SESAN4420 Commuter Cushion Medium Custom

Sizes

Commuter Cushion Small Sizes

Pilot Cushion

16x16,16x18,18x16,18x18

SESAN4415

SESAN3305

Pilot Cushion 18x20,20x18,20x20

Pilot Cushion Large Custom Sizes

Pilot Cushion Medium Custom Sizes

Pilot Cushion Small Custom Sizes

SESAN3310

SESAN3325

SESAN3320

SESAN3315

Pilot Cushion Xlarge Sizes

Pilot Cushion Xxxlarge Custom Sizes

Professional Cushion

16x16,16x18,18x16,18x18

Professional Cushion

18x20,20x18,20x20

Professional Cushion Large Custom

Sizes

Professional Cushion Medium Custom

Sizes

SESAN3330

SESAN3340

SESAN1105

SESAN1115

SESAN1130

SESAN1125

Shear Smart Pad

16x16,16x18,18x16,18x18

SESAN5505

Shear Smart Pad 18x20, 20x18, 20x20 SESAN5510

Xact Classic Cushion

10x10,16x14,17x17,16x20,18x20,20x20

SESAN9905

Xact Classic Cushion

16x16,16x18,18x16,18x18

Xact Individual Cushion All Custom

Sizes

SESAN9910

SESAN9915

Xact Individual Cushion Custom Sizes SESAN9920

Xact Integrated Cushion With Drop

Seat 16x20,18x20, 20x20

SESAN9010

Max

Allowed

Qty.

1

1

1

1

Approved

Price

$468.00

$491.00

$402.00

$625.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$240.00

$468.00

$459.00

$407.00

$370.00

$310.00

$431.00

$558.00

$482.00

$418.00

$647.00

$916.00

$410.00

$665.00

$698.00

$597.00

$210.00

$250.00

$695.00

$595.00

$1,195.00

$1,195.00

$750.00

Page: 32 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$695.00

Action Products Xact Integrated Drop Base Sizes 10x10

To 18x18

Xact Lite Cushion 16x16 - 18x18

Xact Lite Cushion 18x20 - 20x20

Xact Soft Foam Cushion 16x16, 16x18,

18x16, 18x18

Xact Soft Foam Cushion 16x20,18x20,

20x16, 20x18, 20x20

Xact Soft Foam Cushion With

Integrated Drop Seat, All Sizes

Adaptive

Engineering Lab

Adaptive

Equipment

Systems (Aes)

SESAN9005

SESAN9015

SESAN9020

SESAN9980

SESAN9985

SESAN9990

Drop-In Seat With 1.5" Sun-Mate Or

Pudgee Foam

SESE10030

Drop-In Seat With Contour One Foam SESE10035

Drop-In Seat With Poly Foam SESE10020

SESE10065 Full-Width Seat With 1.5" Sun-Mate Or

Pudgee Foam

Full-Width Seat With 1.5" Un-Mate Or

T-Foam

Full-Width Seat With Contour-One

Foam

SESE10055

SESE10070

SES2L0010 Full Width Solid Seat Package With J

Or Flush Or Drop Hooks

& Hold Downs.

Offset, T Style, I Style, Anti-Thrust Or

Medial Thigh

Support Solid Seat Insert, Includes T-

Nuts.

Oversize Upcharge For Seats Over 2o"

But Less Than 28".

Quick Fit Anti-Thrust Or Contour Solid

Seat Insert, Includes

T-Nuts.

Quick-Fit Contoured, Adjustable Split,

Or Foam Form Solid

Seat Insert, Incudes T-Nuts.

SES2L1015

SES2L1035

SES2L1020

SES2L1030

Sculptured Solid Set Insert, Includes T-

Nuts, Custom.

Sculpturefit Seat Package 2/Attaching

Hardware, Custom.

Solid Seat Insert Package, Li'L Kiddos,

14" Wide Or Less.

Solid Seat Insert Package, Li'L Kiddos,

Contoured, 14" Wide

Or Less.

SES2L1025

SES2L0015

SES2L0020

SES2L0025

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$425.00

$495.00

$595.00

$750.00

$845.00

$213.00

$303.00

$194.00

$376.00

$213.00

$303.00

$648.00

$269.00

$80.00

$491.00

$569.00

$999.00

$1,236.00

$635.00

$821.00

Page: 33 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$247.00

Adaptive

Equipment

Systems (Aes)

Advanced

Mobility

Solid Seat Insert, Includes T-Nuts, Li'L

Kiddos,

14" Wide Or Less.

Solid Seat Insert, Includes T-Nuts.

Solid Seat Package W/Universal Or E-Z

Mount Hardware.

All Star Cushion Custom Sizes Includes

Cover

All Star Cushion Includes

Cover And Sizes 16x16 16x18 16x18

17x17 18x16 18x18

SES2L1010

SES2L1005

SES2L0005

SESAO0080

SESAO0085

Amoena Medizin

Amysystems

All Star Drop Base, Includes

Cover, Base, 4 Drop Hooks

Comfort Contoured Cushion

Gel Flotation Pad

Pro Custom Cushion With Built In Drop

Base

Pro-Custom Cushion With Covers

Superstar Cushion Includes

Cover 16x16, 16x18, 18x16, 18x18

Superstar Drop Base, Size 17x17,

Includes

Cover, Base, 4 Drop Hooks

Upcharge For Custom Sizes Other

Than 17x17

Amovida Motion AV400

Amovida Motion Comfort + AV500

SESAO0090

SESAO0030

SESAO0110

SESAO0070

SESAO0075

SESAO0100

SESAO0105

SESAO0115

SE0000959

SE0000960

Contour Seat Cushion For Heavy Duty SES4P0020

Contour Seat Cushion, Non-Standard

Sizes

SES4P0015

Contour Seat Cushion, Standard Sizes SES4P0010

Bioform Reha

Blake Medical

Body Ryzm Life

Sciences /

Perspectis, Inc.

Foundation Cushion - All Sizes

Geomatrix Bronze

Geomatrix Gold, Gold+

Geomatrix Gold, Gold+ Custom Sizes

Geomatrix Hybrid Or Hybrid Deep

Geomatrix Platinum

Geomatrix Silver

Zentury, all sizes

SambaMD

SESZB0005

SESG00005

SESG00015

SESG00020

SESG00030

SESG00025

SESG00010

SE0000996

SE0001204

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$183.00

$542.00

$583.00

$516.00

$575.00

$140.00

$324.00

$615.00

$564.00

$600.00

$700.00

$79.00

$219.00

$266.00

$716.00

$607.00

$513.00

$484.00

$427.00

$613.00

$720.00

$652.00

$872.00

$560.00

$280.00

$173.00

Page: 34 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Broda

Clearview

Healthcare

Products

Custom

Fabricated

Dynamic Health

Care Solutions

Future Mobility

Device

Seat Pad

Debbonair Dynamics/Cushionair

Cushion

- Greater Than 20" Width Or Depth

Debbonair Dynamics/Cushionair

Cushion

- Standard Sizes

Debbonair Dynamics/Cushionair

Cushion

- Up To 20" Width Or Depth

Complex Indirect Molded Seat, Without

Cover

& Mounting Hardware

Contoured Seat, Includes Cover,

Without Hardware

Flat Seat/Rigid Base, Includes Cover,

Without Hardware

Sculptured Seat, Includes Cover,

Without Hardware

Wedged Seat (Thigh Bar), Includes

Cover, Without Hardware

Nxt BioFit Cushion, all sizes

Nxt KulFit Cushion, all sizes

Nxt NuFit Cushion, all sizes

Prism Elite Cushion 16x16-20x20

Prism Elite Cushion Custom Sizes

Prism Ideal Cushion All Sizes

Prism Supreme Air Cushion 18x18

Through 20x20

Prism Supreme Air Cushion 18x19

Through 20x19

Prism Supreme Air Cushion Custom

Sizes

Device Code

SESB-0010

SESGC0015

SESGC0005

SESGC0010

SESCF105L

SESCF103L

SESCF101L

SESCF104L

SESCF102L

SE0001037

SE0001039

SE0001038

SESFM0060

SESFM0065

SESFM0050

SESFM0030

SESFM0035

SESFM0040

Prism Supreme Cushion 14x14

Through 18x20

Prism Supreme Cushion 15x16

Through 20x20

SESFM0015

SESFM0020

Prism Supreme Cushion Custom Sizes SESFM0025

SESFM0110 Prism Supreme Gel Cushion 14x14

Through 18x20

Prism Supreme Gel Cushion 15x16

Through 20x20

Prism Supreme Gel Cushion Custom

SESFM0115

SESFM0120

Max

Allowed

Qty.

1

1

Approved

Price

$61.00

$676.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$546.00

$583.00

$1,460.00

$600.00

$300.00

$720.00

$450.00

$476.00

$436.00

$364.00

$300.00

$340.00

$184.00

$580.00

$600.00

$628.00

$460.00

$480.00

$548.00

$540.00

$560.00

$620.00

Page: 35 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Future Mobility

Handicare

Hoggi

Invacare

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Sizes

Prism Supreme Heavy Duty Cushion

Prism Supreme Ii Plus Cushion 14x14

Through 18x20

Prism Supreme Ii Plus Cushion 15x16

Through 20x20

Prism Supreme Ii Plus Cushion Custom

Sizes

Super Cushion For Kids 10x10 Through

16x16

SESFM0125

SESFM0070

SESFM0075

SESFM0080

SESFM0090

Super Cushion For Kids 10x12 Through

16x12

SESFM0095

Super Cushion For Kids Custom Sizes SESFM0100

Seat Cushion -Sellaskin

16x16,16x18,18x16,18x18

SESM90005

SE0000667 Sedeo Pro-comfort Cushion 16"w to

18"w (fits 16" w to 20" deep)

Sedeo Pro-comfort Cushion 20"w and

22"w (fits 16" to 20" deep)

Sedeo Pro-contour Cushion 16"w and

18"w (fits 16"w to 20" deep)

SE0000668

SE0000669

Sedeo Pro-contour Cushion 20"w and

22"w (fits 16" to 2-" deep)

Sedeo Pro-stability Cushion 20"w and

22"w (fits 16" to 20" deep)

Sedeo Pro-stability cushion 16" w and

18"w (fits 16"to 20" deep)

SE0000698

SE0000671

SE0000670

Support Seat Cushion

Non Standard Seat Width

Standard Seat Width

Swingbo Plus Seat Cushion

SESM90020

SE0000464

SE0000463

SE0000465

Xps Adaptive Seat Cushion

Absolute Fits 16" To 20" Wide W/C

SESK20050

SESNS0005

Airflo Cushion Custom Sizes SESNS2015

Airflo Cushion Fits 14 To 18" Wide W/C SESNS2005

SESNS2010 Airflo Cushion Fits 20" To 22" Wide

W/C

Comfort -Mate Extra - Special Size

Modifications

Comfort-Mate Extra - Fits 14" To 22"

Wide W/C

SESNS0039

SESNS0037

Contour U Seat Includes All SESNS0075

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$640.00

$460.00

$480.00

$548.00

$460.00

$480.00

$548.00

$156.00

$400.00

$440.00

$480.00

$520.00

$520.00

$480.00

$166.00

$166.00

$1,340.00

$300.00

$232.00

$153.00

$202.00

$312.00

$86.00

$647.00

$567.00

$574.00

Page: 36 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Invacare

Invacare - Matrx

Seating

Device Device Code Max

Allowed

Qty.

Approved

Price

Modifications & Vacuum/Vinyl

Upholstery

Invacare Matrx Flovair Cushion -

Gentle/Max Contour

Invacare Matrx Stabilite Cushion

MATRX PS POSTURE SEAT

Pediatric Sizes 1010/1012/1014

Matrx Libra - all sizes

Naked Contour U Seat, Includes All

Modifications

& Vacuum/Moisture Proof

Coating/Removable Cover

& Cover Pattern.

Silhouette Seat Cushion

Single Density Cushion, Non Standard

Size

SE0000967

SE0000966

SE0000131

SE0001212

SESNS0080

SESNS0070

SESNS0015

Ulti-mate Base Fits 10" To 14" Wide

W/C

Ulti-mate Base Special Adult Size &

Modifications

Ulti-mate Base Special Junior Size &

Modifications

Ulti-mate Cushion Fits 10" To 14" Wide

W/C

Ulti-mate Cushion Fits 16" To 20" Wide

W/C

Ulti-mate Cushion Special Adult Size &

Modifications

SESNS1040

SESNS1035

SESNS1045

SESNS0050

SESNS0040

SESNS0045

Ulti-mate Cushion Special Junior Size &

Modifications

Ulti-mate Fits 16" To 20" Wide W/C

Flo-Tech Cushion Fits W/C 16" - 19"

Width & 16" - 21" Depth

SESNS0055

SESNS1030

SES1M0030

SES1M0040 Flo-Tech Cushion Fits W/C 20" - 24

Width & 20" - 22" Depth

Flo-Tech Cushion Fits W/C 20" Width &

16" - 18" Depth

Kidabra Base Fits W/C 12"-14" Width &

12"-15" Depth

Kidabra Fits W/C 11"-14" Width &

12"-15" Depth

Matrx Posture Seat (PS Cushion)

23x30 Width To 21x30 Deep

Matrx Posture Seat(PS Cushion), All

SES1M0035

SES1M2005

SES1M0015

SES1M0066

SES1M0060

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$520.00

$368.00

$740.00

$596.00

$1,594.00

$632.00

$105.00

$482.00

$670.00

$670.00

$350.00

$433.00

$531.00

$449.00

$529.00

$639.00

$863.00

$733.00

$677.00

$509.00

$796.00

$444.00

Page: 37 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Invacare - Matrx

Seating

Jay Medical

Device Device Code Max

Allowed

Qty.

Approved

Price

Sizes

Matrx Vi Base Fits W/C 16"-20" Width &

16"-19" Depth

Matrx Vi Cushion Bariatric Sizes, Client

Weight

Exceeds 300lbs

Matrx Vi Cushion Fits W/C 14"-18"

Width & 15"-21" Depth

Matrx Vi Wide Cushion Fits W/C

19"-22" Width & 16"-21" Depth

SES1M1005

SES1M0011

SES1M0005

SES1M0010

Matrx Wide Cushion Fits W/C 20" Width

& 16"-19" Depth

PS Cushion with Visco Foam Upgrade

All Sizes

Posture Seat (PS Cushion) 11-12

Inches Wide To 20-21 Inches Deep

J-Gel Base

J-Gel Cushion 16" & 18" Deep

J-Gel Cushion 20" Deep

J2 Base Large Sizes

J2 Base Standard Sizes

J2 Plus Cushion Foam Base

J2 Plus Cushion, Ae Cover With

Custom Foam Kit

J2 Plus Cushion, Ae Cover With Fluid

Pad

SES1M1010

SES1M0070

SES1M0065

SESJA6830

SESJA0700

SESJA0705

SESJA6810

SESJA6800

SESJA6835

SESJA0755

SESJA0760

J2 Plus Cushion, Ae Cover With Foam

Kit

J2 Plus Cushion, Ls Inc. Cover With

Custom Foam Kit

J2 Plus Cushion, Ls Inc. Cover With

Fluid Pad

J2 Plus Cushion, Ls Inc. Cover With

Foam Kit

J3 Cushion

Jay 2 17x17

SESJA0750

SESJA0770

SESJA0775

SESJA0765

SESJA0800

SESJA0485

Jay 2 17x17 With Incontinent Cover SESJA0462

Jay 2 17x17 With Air Exchange Cover SESJA0442

SESJA0450 Jay 2 18x20, 15.5x20 With Air

Exchange Cover

Jay 2 18x20, 15.5x20 With Incontinent

Cover

SESJA0470

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$677.00

$742.00

$551.00

$602.00

$714.00

$524.00

$443.00

$216.00

$429.00

$429.00

$262.00

$207.00

$166.00

$690.00

$864.00

$656.00

$692.00

$864.00

$706.00

$700.00

$546.00

$550.00

$558.00

$640.00

$630.00

Page: 38 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Jay Medical

Effective From: February 01, 2015

Device

Jay 2 20x16

Jay 2 20x16, 20x18 With Air Exchange

Cover

Jay 2 20x16, 20x18 With Incontinent

Cover

Device Code

SESJA0480

SESJA0441

SESJA0461

Jay 2 20x18 SESJA0490

Jay 2 20x20 With Air Exchange Cover SESJA0445

Jay 2 20x20 With Incontinent Cover SESJA0465

Jay 2 24x20 With Air Exchange Cover SESJA0455

Jay 2 24x20 With Incontinent Cover

Jay 2 Cushion 14x16 With Standard

Cover

Jay 2 Cushion 15.5x 16, 15.5 X 18 With

Standard Cover

SESJA0475

SESJA0425

SESJA0420

Jay 2 Cushion 18x16, 18x18 With

Standard Cover

Jay 2 Cushion 20x20 With Standard

Cover

Jay 2 Cushion 24x20 With Standard

Cover

Jay 2 Cushion18x20, 15.5x20 With

Standard Cover

Jay 2 Deep Contour 20x16, 20x18,

16x20, 18x20

Jay 2 Deep Contour 20x20, 22x16,

22x18

SESJA0400

SESJA0405

SESJA0415

SESJA0410

SESJA0505

SESJA0507

Jay 2 Deep Contour 24x18

Jay 2 Deep Contour Standard Sizes

Jay 2 Deep Contourn with Solid Drop

Seat 20x16, 20x18, 16x20, 18x20, Solid

Drop Seat Attached

Jay 2 Deep Contourn with Solid Drop

Seat 20x20, 22x16, 22x18, Solid Drop

Seat Attached

Jay 2 Deep Contourn with Solid Drop

Seat Standard Sizes With Solid Drop

Seat

Jay 2 Standard Sizes With Air

Exchange Cover

Jay 2 Standard Sizes With Incontinent

Cover

Jay 3 Air Cushion - Dual Valve

Jay 3 Air Cushion - Single Valve

SESJA0510

SESJA0500

SESJA0605

SESJA0610

SESJA0600

SESJA0440

SESJA0460

SESJA9910

SESJA9905

Max

Allowed

Qty.

1

1

Approved

Price

$630.00

$640.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$630.00

$618.00

$737.00

$728.00

$789.00

$784.00

$546.00

$546.00

$546.00

$716.00

$794.00

$630.00

$620.00

$718.00

$758.00

$571.00

$666.00

$729.00

$598.00

$558.00

$550.00

$716.00

$704.00

Page: 39 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Jay Medical

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$872.00

Jay 3 Air Cushion -Width X Depth

Greater Than 21 Inches

Jay 3 Air Cushion- Dual Valve -Width X

Depth .gt.21 Inches

Jay Active Cushion 18x16, 16x16,

14x16

Jay Active Cushion 18x18, 16x18

Jay Active Cushion 20x18, 18x20,

16x20, With Adductor Wedges

Jay Active Foam Base 20" Deep

SESJA9915

SESJA9920

SESJA2010

SESJA2100

SESJA2200

Jay Basic Pro Cushion

Jay Care Cushion 18x16, 18x8, 16x16,

16x18

Jay Combi Base 18x16 To 15.5x20

SESJA6325

SE0001016

SESJA5500

SESJA6400

Jay Combi Base 20x18

Jay Combi Cushion 14x14/12x12 With

Back Support

SESJA6500

SESJA3200

Jay Combi Cushion 18x16 To 15.5x20

SESJA3010

Jay Combi Cushion 20x18 With Back

Support

SESJA3100

Jay Combi With Lumbar Support 14x14,

12x12

SESJA3326

Jay Combi With Lumbar Support 18x20,

16x20

SESJA3317

Jay Combi With Lumbar Support 20x18 SESJA3316

Jay Combi With Lumbar Support,

Narrow

Adult Soft 15.5x16

Jay Combi With Lumbar Support,

Regular

Adult Short 18x16

SESJA3320

SESJA3310

SESJA3315 Jay Combi With Lumbar Support,

Regular Adult

Jay Combi Without Lumbar Support

14x14, 12x12

Jay Combi Without Lumbar Support

16x20, 18x20

Jay Combi Without Lumbar Support

20x18

Jay Combi Without Lumbar Support,

Narrow

Adult Short 15.5x16

Jay Combi Without Lumbar Support,

SESJA3346

SESJA3337

SESJA3336

SESJA3340

SESJA3345

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$884.00

$606.00

$606.00

$666.00

$262.00

$140.00

$406.00

$43.00

$82.00

$225.00

$225.00

$212.00

$177.00

$208.00

$208.00

$212.00

$212.00

$212.00

$179.00

$179.00

$179.00

$179.00

$179.00

Page: 40 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Jay Medical

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Narrow Adult 15.5x18

Jay Combi Without Lumbar Support,

Regular

Adult Short 18x16

Jay Combi Without Lumbar Support,

Regular

Adult Soft 18x18

Jay Cushion 18x16, 15.5x16, 14x16

Jay Cushion 18x18, 15.5x18,

Jay Cushion 18x20, 15.5x20

Jay Cushion 20x20, 24x20

Jay Cushion Sizes 18x16 To 10x10

With Incontinent Cover

Jay Cusion Sizes 18x16 To 10x10 With

Air Exchange Cover

Jay Duo Cushion 16x16,16x18, 18x16,

18x18

Includes Solid Seat, 2 Covers &

Hardware

Jay Duo Cushion 17x16, 17x18

Includes Solid Seat, 2 Covers &

Hardware

SESJA3330

SESJA3335

SESJA0010

SESJA0100

SESJA0250

SESJA0200

SESJA0350

SESJA0325

SESJA8005

SESJA8017

Jay Duo Cushion 20x16 Includes Solid

Seat, 2 Covers & Hardware

Jay Duo Cushion Foam Cushion 16x16,

16x18, 18x16, 18x18

Jay Duo Cushion Foam Cushion 17x16,

17x18

SESJA8015

SESJA8040

SESJA8057

Jay Duo Cushion Foam Cushion 20x16 SESJA8055

Jay Duo Cushion Foam Cushion 20x18 SESJA8050

Jay Duo Cushion Large Adult 20x18

Includes Solid Seat, 2 Covers &

Hardware

SESJA8010

SESJA8020 Jay Duo Cushion Narrow Pan 16x16,

16x18, 18x16, 18x18

Includes Cushion, 2 Covers &

Hardware

Jay Duo Cushion Narrow Pan 17x16,

17x18

Includes Solid Seat, 2 Covers &

Hardware

Jay Duo Cushion Narrow Pan 20x16

Includes Solid Seat, 2 Covers &

Hardware

Jay Duo Cushion Narrow Pan 20x18

SESJA8027

SESJA8025

SESJA8030

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$179.00

$179.00

$612.00

$612.00

$678.00

$816.00

$626.00

$638.00

$410.00

$410.00

$464.00

$191.00

$191.00

$225.00

$225.00

$455.00

$402.00

$410.00

$455.00

$455.00

Page: 41 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Jay Medical

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Includes Cushion, 2 Covers &

Hardware

Jay Easy Cushion With Flat Or Curved

Bottom Sizes 14x16 Through 18x18

Jay Easy Cushion With Flat Or Curved

Bottom Sizes 18x20 Through 20x20

Jay Easy Foam Base With Flat Or

Curved Bottom Sizes 14x16

Through 18x18

Jay Easy Foam Base With Flat Or

Curved Bottom Sizes 18x20

Through 20x20

Jay Fit Cushion Adjustable Contour

Seat For 10" Or 12" Frame Width,

Various Seat Depths

Jay Fit Cushion Adjustable Contour

Seat For 14" Or 16" Frame Width,

Various Seat Depths

Jay Fit Cushion Adjustable Contour

Seat For 18" Frame Width,

Various Seat Depths

Jay Foam Base 20" Deep

Jay Fusion Air Single Valve Regular size

SESJA9805

SESJA9810

SESJA9815

SESJA9820

SESJA9700

SESJA9705

SESJA9710

SESJA6050

SE0000953

Jay Fusion Air Single Valve width of 22" or more OR Jay Fusion Air Single Valve depth of 22" or more

Jay Fusion Cushion AIR Dual Valve regular size

Jay Fusion Cushion AIr Dual Valve width of 22" or more OR Jay Fusion

Cushion AIr Dual Valve depth of 22" or more

Jay Fusion Cushion AIr Dual Valve with width AND depth greater than 22"

Jay Fusion Cushion Air Single Valve with width AND depth greater than 22"

SE0000954

SE0000956

SE0000957

SE0000958

SE0000955

Jay Fusion Cushion Fluid width and depth of 22" or more

Jay Fusion Cushion Fluid width of 22" or more OR Jay Fusion Cushion Fluid depth of 22" or more

Jay Fusion Cushion regular size

Jay GO

Jay GS

SE0000952

SE0000951

SE0000950

SE0000350

SESJA5000

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$449.00

$470.00

$118.00

$134.00

$357.00

$398.00

$442.00

$235.00

$700.00

$785.00

$712.00

$798.00

$884.00

$870.00

$870.00

$785.00

$700.00

$199.50

$594.00

Page: 42 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Jay Medical

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

10x13,12x15,14x17,16x19,18x20

Jay GS Cushion Pressure Relief Pad

With Air Exchange Cover

Jay GS Cushion Pressure Relief Pad

With Incontinent Cover

Jay Go - 19X15 to 24X24

Jay Go Cushion Adult and Paediatric

JGO14x14 to 18X24

Jay ION

Jay Lite Cushion - All Sizes

Jay Recline Cushion 20x20

Jay Recline Cushion 24x20

Jay Recline Cushion Large Sizes

SESJA5010

SESJA5005

SE0000324

SE0000323

SE0000348

SESJA4200

SESJA9505

SESJA9515

SESJA9510

Jay Recline Cushion Standard Sizes

Jay Recliner Cushion 18/15.5x20 With

Incontinent Cover

Jay Recliner Cushion 18x16 To 10x10

With Incontinent Cover

Jay Recliner Cushion 18x16, 18x18,

15.5x16, 15.5x18, 14x16

Jay Recliner Cushion 18x20, 15.5x20

Jay Recliner Cushion 20x20 With

Incontinent Cover

SESJA9500

SESJA1375

SESJA1350

SESJA1010

SESJA1100

SESJA1400

Jay Recliner Cushion 20x20,24x20 With

Quadrant Pads

SESJA1200

Jay Recliner Cushion 24x20 With

Incontinent Cover

Jay Solution With Solid Drop Seat,

Sizes 14 X 14 - 18 X 20,

Includes Cover

SESJA1425

SESJA0370

SESJA0375 Jay Solution With Solid Drop Seat,

Sizes 19 X 18 - 20 X 18,

Includes Cover

Jay Solution, Sizes 14 X 14 -17 X 18,

Includes Cover

Jay Solution, Sizes 18 X 16 - 20 X 18,

Includes Cover

Jay Triad Cushion 16x16, 16x18,

18x16,18x18,20x18 With Solid Drop

Base

Jay Triad Cushion 20x18

Jay Triad Cushion 20x18 With Solid

Drop Seat

SESJA0360

SESJA0365

SESJA9120

SESJA9106

SESJA9125

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$689.00

$702.00

$224.00

$200.00

$438.90

$560.00

$794.00

$841.00

$689.00

$602.00

$704.00

$640.00

$638.00

$718.00

$800.00

$855.00

$838.00

$636.00

$680.00

$479.00

$499.00

$347.00

$347.00

$453.00

Page: 43 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type

Seat Cushion

Effective From: February 01, 2015

Manufacturer Device Device Code

Jay Medical

Kid Kart

Jay Triad Cushion Standard Sizes

Jay Union Cushion 14X14 TO 18X18

Jay Union Cushion 18X19 TO 24X24

Jay Xtreme Cushion 16x20, 18x20 With

2 Covers

Jay Xtreme Cushion 20x20 With 2

Covers

Jay Zip Cushion, All Sizes

SESJA9105

SE0000352

SE0000353

Jay Union Cushion with additional cover size 14X14 TO 18X18

SE0000354

Jay Union Cushion with additional cover size 18X19 TO 24X24

SE0000355

Jay Xtreme Cushion 14x14 To 18x18

With 2 Covers

SESJA9020

SESJA9040

SESJA9030

Tlc Contoured Seat Cushion

Xpress Standard Seat Cushion -

Specify Short (900020/1) Or Long

(900022/3)

Xpress Contour Adjustable Cushion -

Specify Short (900312-28) Or Long

(900329-36)

SESJA5550

SESKT2010

SESKT2020

SESKT2030

SESKT2026 Xpress Ledge Seat Cushion -

Specify Short (900028/9) Or Long

(900030/1)

Xpress Wedge Seat Cushion -

Specify Short (900024/5) Or Long

(900026/7)

Lpa Medical Inc.

Contour Seat Cushion With Perineal

Abductor

Maple Leaf

Wheelchair

Pre-Cure Cushion

ML Bariatric

ML Cozy

ML Extreme Comfort

Nylon/Leatherette 2" Foam Cushion

Nylon/Leatherette 3" Foam Cushion

Motion Concepts Trx Onyx Seat 16-19" Width

Nighthawk

Trx Onyx Seat 20-22" Width

2" Standard Foam With Cover

3" Standard Foam With Cover

Aero Space Cushion, 18x16x3

Afg Cushion 16x16, 16x18, 18x16,

18x18

SESKT2025

SESO12005

SESO12010

SE0001092

SE0001090

SE0001091

SESWM0001

SESWM0005

SESZG0005

SESZG0010

SESNM2000

SESNM2010

SESNM9060

SESNM1010

Max

Allowed

Qty.

1

1

1

1

Approved

Price

$347.00

$510.72

$538.65

$550.62

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$578.55

$496.00

$424.00

$653.00

$476.00

$1,148.00

$200.00

$404.00

$370.00

$76.00

$108.00

$180.00

$627.00

$384.00

$500.00

$64.00

$72.00

$644.00

$695.00

$95.00

$55.00

$241.00

$347.00

Page: 44 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Nighthawk

Orthofab

Otto Bock

Permobil

Physipro

Effective From: February 01, 2015

Custom Sizes

Standard Sizes

Device

Cushion With Visco Foam Insert &

Contour Add Ons

14-20" Width & 15-20" Depth

Cushion With Visco Foam Insert &

Contour Add Ons

Non Standard Sizes & Options

Aerial Cushion 15"x16" to 20"x18"

All Sizes

Aquos Cushion 15"x18" to 20"x18"

Custom Sizes

Seat Finished With Spray

Coating,Cover,Sewing Pattern

Seat-Itemized Cushion (Unfinished)

Sizes 16x18,17x16,17x17,18 X16

Sizes 17x18,18x17,18x18,19 X16

Sizes 19x18,20x16,20x18

Standard Sizes Smaller Than 16x17

Terra Cushion 15"x16" to 20"x18"

Ergo Seat - All Sizes

C3S Cushion - All Sizes

LXA Cushion - All Sizes

Ultra Cushion - All Sizes

Ultra Cushion with Gel - All Sizes

Zero Pressure Cushion - All Sizes

Device Code

Bi-Sunmate Cushion & Base

Cumfy Plus Cushion With Cover

Gel Suspension Cushion

16x16,18x16,18x18

SESNM8070

SESNM4000

SESNM9045

Gel Suspension Cushion 20x16, 20x18 SESNM9050

Med Foam 1" Thru 4" With Cover SESNM0010

Superior Cumfy Cushion & Base

Superior Cushion With Cover

SESNM8000

SESNM2050

SESNM0000 Upcharge For Custom Sized Or

Oversized Cushions

Cushion With Contour Add Ons 15-18"

Width & 15-20" Depth

Cushion With Contour Add Ons Non

Standard Sizes & Options

SESOF1005

SESOF1010

SESOF1025

SESOF1030

SE0000691

SESOB704L

SE0000690

SESOB6045

SESOB8045

SESOB7100

SESOB7105

SESOB6020

SESOB6025

SESOB6030

SESOB8040

SESOB6015

SE0000689

SES1P0005

SE0001119

SE0001070

SE0001120

SE0001121

SE0001122

Max

Allowed

Qty.

1

1

1

Approved

Price

$455.00

$316.00

$298.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$251.00

$256.00

$550.00

$431.00

$49.00

$324.00

$384.00

$368.00

$448.00

$556.00

$444.00

$416.00

$641.00

$810.00

$1,983.00

$1,453.00

$503.00

$503.00

$517.00

$627.00

$489.00

$380.00

$407.00

$272.00

$370.00

$295.00

$504.00

$299.00

Page: 45 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Physipro

Power Plus

Mobility

Precision Rehab

Manufacturing

Pride Mobility

Products

Device Device Code

Zero Pressure Cushion with Gel - All

Sizes

SE0001123

Cozy Cushion Plus All Sizes SESWM0050

Max Comfort Bariatric Cushion All Sizes SESWM0040

Max Comfort Cushion All Sizes

Base Cushion Seat Sewn Cover

Waterproof Foam, Includes

Labour For Digitizing Or Plastering

Base Cushion Seat Vacuum Formed

Cover, Includes Labour

For Digitizing Or Plastering

Base Cushion Seat With All

Modifications, Includes

Labour For Digitizing Or Plastering

Comfort -Fit 12x12 to 20x20

Contoured-Fit (Moderate Positioning Air

Option)

12x12 to 20x20

Contoured-Fit (Moderate Positioning

Gel Option)

12x12 to 20x20

Contoured-Fit (Moderate Positioning

Visco-Foam)

12X12 20X20

Contoured-Fit Aggressive Positioning

Air Option 12x12 to 20x20

Contoured-Fit Agressive Positioning

Gel Option

12x12 to 20x20

SESWM0030

SESWB0010

SESWB0005

SESWB0015

SE0000754

SE0000757

SE0000756

SE0000755

SE0000760

SE0000759

Contoured-Fit Agressive Positioning

Visco-Foam

12x12 to 20x20

Precision-Fit Cushion Upcharge, Extra

Seat Depth 20"-24"

Precision-Fit Cushion Upcharge, Extra

Seat Width 20"-24"

SE0000758

SESWB0024

SESWB0022

Precision-Fit Cushion, Subtle, Moderate

Or Aggressive

Positioning. Includes Shape

Adjustments, Inner Cover, Outer

Cover And Cushion Rigidizer.

Contoured Seat Cushion - All Sizes

SESWB0020

SESK20005

Synergy Simplicity All Sizes

Synergy Solution 1 LTC Cushion

Synergy Solution Cushion

SESX10080

SE0000470

SESX10015

Max

Allowed

Qty.

1

Approved

Price

$492.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$480.00

$784.00

$624.00

$1,711.00

$1,439.00

$2,079.00

$213.00

$657.00

$517.00

$517.00

$657.00

$517.00

$517.00

$306.00

$306.00

$1,079.00

$312.00

$119.00

$420.00

$319.00

Page: 46 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Pride Mobility

Products

Quickie

Ride Designs

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Standard Sizes

Synergy Solution Cushion Custom

Sizes

Synergy Solution SG Cushion

Sizes 14" X 14" - 20" X 18"

SESX10020

SESX10100

Synergy Solution SG Cushion

Sizes 20" X 20" - 24" X 24"

Synergy Spectrum Air Contoured

Cushion Sizes 22" X 20" - 24" X 24"

Synergy Spectrum Air Cushion

Sizes 14" X 12" - 20" X 24"

Synergy Spectrum Air Cushion Sizes

22" X 20" - 24" X 24"

Synergy Spectrum Cushion

Viscoelastic Insert,Standard Sizes

Synergy Spectrum Cushion Twin Cell

Insert,Custom Sizes

SESX10105

SESX10135

SESX10120

SESX10125

SESX10025

SESX10040

Synergy Spectrum Cushion Twin Cell

Insert,Standard Sizes

Synergy Spectrum Cushion Viscoelastic

Insert,Custom Sizes

SESX10035

SESX10030

Synergy Sprectrum Air Contoured

Cushion

Sizes 14" X 12" - 20" X 24"

SESX10130

Synergy Tru Comfort/ Tru Comfort 2

Cushion Sizes 22" X 16" - 22" X 24"

Synergy Tru Comfort/ Tu Comfort 2

Cushion

Sizes 16" X 14" - 20" X 24"

SESX10095

SESX10090

SE0001050 Tru Comfort 2 non standard sizes, including air mesh cover

Tru Comfort 2 standard sizes, including air mesh cover

2", 3" Or 4" Cushion With Cover

BREEZY RELAX2 COMFORT

CUSHION

Contour Seat - Tilt Fx

JAY X2 with cover

Ride Custom Cushion: Standard

(12-20"), Extra Wide (21-22"), Custom

Sizes.

Ride Forward Cushion - All Sizes

Ride Java

SE0001049

SESQU0355

SE0000118

SESQU0400

SE0001155

SESR40005

SESR41020

SE0001223

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$359.00

$215.00

$255.00

$576.00

$464.00

$496.00

$439.00

$479.00

$439.00

$479.00

$544.00

$399.00

$319.00

$479.00

$399.00

$122.00

$1,996.00

$392.00

$672.00

$1,709.00

$472.00

$608.00

Page: 47 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Roho

Effective From: February 01, 2015

Device

Adaptor 9x13x1" (Maximum 5)

Airlite Cushion With Built In Cover All

Sizes

SESRO1105

SESRO9005

Contour Select Cushion Custom Sizes SESRO9025

Contour Select Cushion Standard Sizes SESRO9020

Custom (Made To Order) Cushion

W/Cover

SESRO030L

Enhancer, Custom Sizes,Dual

Valve,Cover

SESRO8010

SESRO8005 Enhancer, Standard Adult & Paediatric

Sizes, Dual Valve, With Cover

Harmony Cushion With Cover-Sizes

14x16, 20x18

High-Profile - LTC Cushion, Including

Cover

SESRO9050

SESRO3015

SESRO3005 High-Profile, All Standard Adult &

Paediatric Sizes Including Cover

High-Profile, Custom Sizes Including

Cover

Hybrid Elite/Hybrid Elite LTC Cushion,

Dual Valve, With Cover Sizes

14x14 ,20x20

Hybrid Elite/Hybrid Elite LTC Cushion,

Dual Valve, With Cover, Sizes 22x18,

24x20

Hybrid Elite/Hybrid Elite LTC Cushion,

Single Valve With Cover, Sizes 14x14 ,

20x20

Hybride Elite/Hybrid Elite LTC Cushion,

Single Valve With Cover, Sizes 22x18,

24x20

Low-Profile, All Standard Adult &

Pediatric Sizes Including Cover

Low-Profile, Custom Sizes Including

Cover

Low-Profile, LTC Cushion, Including

Cover

Mid-Profile, All Standard Adult &

Paediatric Sizes Including Cover

Mid-Profile, Custom Sizes Including

Cover

Mini-Max Cushion, Standard Sizes

(Does Not Include Cover)

Nexus Spirit Cushion With Cover,

Device Code

SESRO3010

SESRO9503

SESRO9504

SESRO9501

SESRO9502

SESRO3105

SESRO3110

SESRO3115

SESRO2005

SESRO2010

SESRO4005

SESRO6010

Max

Allowed

Qty.

5

1

Approved

Price

$209.00

$450.00

1

1

2

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$769.00

$719.00

$769.00

$725.00

$650.00

$499.00

$733.00

$650.00

$725.00

$789.00

$803.00

$742.00

$756.00

$650.00

$725.00

$733.00

$659.00

$739.00

$595.00

$585.00

Page: 48 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Roho

Solus Medical

Manufacturing

Inc

Star Cushion

Products Inc.

Supracor

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Standard Sizes

Nexus Spirit Cushion, Custom Sizes,

With Cover

Quatro Select LTC Cushion, Including

Cover

Quatro Select Low Or High Profile

Cushion, Custom Sizes With Cover

Quatro Select, Low Or High Profile

Cushion With Cover, Standard Sizes

EquaGel Pro Flex I

EquaGel Pro Flex II

EquaGel Pro Flex II Hybrid

EquaGel Pro Flex III Hybrid

EquaGel Pro Flex Ultra

All Sizes 12x12 Through 22x22

Custom Cell Height Cushion Standard

Sizes

Custom Sizes Over 22" In Two

Directions Width And Depth

Custom Sizes Over 22" One Direction

Width Or Depth

Galaxy Cushion - All Sizes

Mid Contour Cushion 3" Cells With

Cover

Short Contour Cushion 2" Cells With

Cover

Standard Contour Cushion 4" Cells

With Cover

Bariatric Cushion (Classic) Clb 20-24"

Bariatric Cushion (Classic) Clb 25-28"

Bariatric Cushion (Classic) Clb 29-31"

Bariatric Cushion (Classic) Clb 32-35"

Classic Cushion 14x16-20x20

Classic Sling Bottom Cushion

14x16-20x20

Contoured Cushion 14x16-20x20

Contoured Cushion, Standard Sizes

Contoured Sling Bottom Cushion

14x16-20x20

Corbee Cushion 10x10-14x14

Corbee Sling 10x10-14x14

SESRO6015

SESRO7055

SESRO7040

SESRO7035

SE0001113

SE0001114

SE0001115

SE0001116

SE0001117

SESTJ2005

SESTJ0115

SESTJ0110

SESTJ0105

SESTJ3005

SESTJ0015

SESTJ0010

SESTJ0005

SESRR0016

SESRR0017

SESRR0018

SESRR0019

SESRR0010

SESRR0015

SESRR0020

SESRR0060

SESRR0025

SESRR0100

SESRR0110

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$609.00

$797.00

$769.00

$719.00

$231.00

$543.00

$399.00

$455.00

$774.00

$532.00

$644.00

$716.00

$644.00

$520.00

$496.00

$496.00

$496.00

$756.00

$869.00

$1,040.00

$1,210.00

$545.00

$567.00

$665.00

$637.00

$658.00

$343.00

$371.00

Page: 49 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Supracor

The Comfort

Company

Toronto

Orthopedic Ltd.

Trulife

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$469.00

Paediatric Contoured Cushion, Custom

Sizes

Slimline Cushion 16x16-20x18

Slimline Sling Bottom Cushion

16x16-20x18

SESRR0065

SESRR0030

SESRR0035

Curve Cushion, Stretch Air Or Fusion

Cover, All Sizes

Curve Cushion, Stretch Air Or Fusion

Cover, Custom Sizes

SES7C0050

SES7C0055

Custom Embrace Anti Thrust Cushion SE0000127

SE0000130 Custom Embrace Anti Thrust Cushion

Hook and Loop non skid bottom

Custom Embrace Zero Elevation

Cushion

Custom Embrace Zero Elevation

Cushion

Hook and Loop non skid bottom

Embrace Anti-Thrust Cushion

Hook and loop non-skid bottom

Embrace Zero Elevation Cushion

Embrace Zero Elevation Cushion

Hook and Loop non-skid bottom

SE0000128

SE0000129

SE0000113

SE0000125

SE0000126

SES7C0030 Hyalite Cushion, Condura Knit Or

Stretch Air

Cover, All Sizes

Hyalite Cushion, Condura Knit Or

Stretch Air

Cover, Custom Sizes

Maxx Cushion, Round Or Flat Bottom,

Fusion

Or Stretch Air Cover, All Sizes

Maxx Cushion, Round Or Flat Bottom,

Fusion

Or Stretch Air Cover, Custom Sizes

Ridge Cushion, Stretch Air Or Fusion

Cover, All Sizes

Ridge Cushion, Stretch Air Or Fusion

Cover, Custom Sizes

Tops Seat Cushion (10" & 12" Width)

SES7C0035

SES7C0020

SES7C0025

SES7C0040

SES7C0045

SESTP0005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$441.00

$469.00

$134.00

$245.00

$685.00

$813.00

$685.00

$813.00

$428.00

$428.00

$508.00

$400.00

$716.00

$514.00

$907.00

$487.00

$894.00

$246.00

Gelcell Contour Cushion, All Sizes

Relax Duogel Contour Cushion, All

Sizes

Relax Easy Cushion All Sizes

SESCZ0080

SESCZ0040

SESCZ0070

1

1

1

$332.00

$233.00

$233.00

Page: 50 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Trulife

Varilite Medical

Products

Vicair

Vision

Wheelchair

Seating Systems

Inc.

Device

Academy Junior Adjuster

Academy Vector

Upcharge For Custom Sizes

Vicair Active: Sizes 12X12 - 18X18

Vicair Active: Sizes 18X20 - 20X20

Epic Cushion: custom sizes (up to

19x19)

Epic Cushion: standard sizes: 16x16

Device Code

Relax Gelcell, All Sizes

Relax Trio Cushion, All Sizes

Evolution Bariatric Cushion Standard Or

Psv, All Sizes,

Includes Cover And Pressure Setting

Valve

SESVP0408

Evolution Cushion Standard Or Psv, All

Sizes,

Includes Cover And Pressure Setting

Valve

Evolution Wave Bariatric Cushion

Includes,

Cover And Positioning Base

SESCZ0045

SESCZ0035

SESVP0406

SESVP0402

Evolution Wave, All Sizes, Includes

Cover And Positioning Base

Junior Cushion

Meridian Bariatric Cushion, All Sizes,

Includes Cover

SESVP0401

SE0001146

SESVP0605

Meridian Cushion, All Sizes, Includes

Cover

Meridian Wave Bariatric Cushion, All

Sizes, Includes Cover

Meridian Wave Cushion, All Sizes,

Includes Cover

Proform Nx Cushion, Single, Dual, All

Sizes

Includes Cover

Reflex Cushion, All Sizes, Includes

Cover

SESVP0600

SESVP0615

SESVP0610

SESVP0351

SESVP6020

Solo Cushion, Standard Or Psv, All

Sizes, Includes Cover

Stratus Cushion, All Sizes, Includes

Cover

SESVP0200

SESVP0410

Zoid Cushion, All Sizes, Includes Cover SESVP0500

Academy Adjuster SESV10020

SESV10010

SESV10025

SESV11005

SE0001102

SE0001103

SE0000673

SE0000672

Max

Allowed

Qty.

1

1

1

Approved

Price

$319.00

$105.00

$714.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$672.00

$817.00

$700.00

$652.00

$756.00

$630.00

$859.00

$737.00

$667.00

$397.00

$485.00

$369.00

$555.00

$630.00

$541.00

$677.00

$80.00

$580.00

$636.00

$485.00

$432.00

Page: 51 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

Device Type Manufacturer

Seat Cushion

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Vision

Wheelchair

Seating Systems

Inc.

1/2 to 18x18

Epic Drop Seat: Custom Sizes (up to

19x19)

Epic Drop Seat: standard sizes: 16x16

1/2 to 18x18

SE0000675

SE0000674

Epic Plus Cushion Standard Sizes

16x20 to 20x18

Epic Plus Cushion: Bariatric Custom sizes

Epic Plus Drop Seat: Bariatric Custom sizes

Epic Plus Drop Seat: Standard Sizes

16x20 to 20x18

Upcharge for custom Cushions 20"X20

- 24"X24"

Upcharge for custom Cushions Up To

20" X 19", Inclusive

SE0000676

SE0000677

SE0000679

SE0000678

SESVC4510

SESVC4500

Upcharge for custom Drop-Seat up to

20"X19", Inclusive

Upcharge for custom Drop-Seats

20"X20 - 24"X24"

VIVE -Deep Leg Trough -Drop Seat;

Standard Sizes 16x16 1/2 to 20x18

SESVC4520

SESVC4530

SESVC4180

VIVE -Deep Leg Trough Cushion;

Standard Sizes 16x16 1/2 to 20x18

VIVE -Drop Seat; Standard Sizes 16x16

1/2 to 20x18

SESVC4170

SESVC4160

SESVC4150 VIVE Cushion; Standard Sizes 16x16

1/2 to 20x18

Very Soft Drop-Seat; Standard Sizes

16x16 1/2 to 20x18

VerySOFT -Deep Leg Trough Cushion;

Standard Sizes 16x16 1/2 to 20x18

VerySOFT Cushion, Standard Sizes

16x16 1/2 to 20x18

VerySOFT- Deep Leg Trough -Drop

Seat; Standard Sizes 16x16 1/2 to

20x18

SESVC4030

SESVC4100

SESVC4000

SESVC4120

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$631.00

$562.00

$485.00

$582.00

$782.00

$632.00

$196.00

$135.00

$153.00

$216.00

$995.00

$763.00

$950.00

$727.00

$872.00

$678.00

$684.00

$919.00

Page: 52 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Arm Support Hardware

Arm Support Options

Arm Support(s)

Back Cover

Back Hardware

Effective From: February 01, 2015

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Custom

Fabricated

Approved ADP

Manufacturers

Only

Device Device Code Max

Allowed

Qty.

2

Approved

Price

$160.00

Non Standard Modular Mounting

Hardware

Required For Positioning (Maximum 2)

SEAND0025

Swivel Armrest Hardware (Maximum 2) SEICF301L 2 $70.00

Add Modular Pressure Relief To

Armrest -

Specialty Foam/Gel (Maximum 2)

Rigid Side Panel For Custom Arm

Support

(Maximum 2)

Side Panel Pad For Custom Arm

Support

(Maximum 2)

SEAND0030

SEMCF601L

SEMCF602L

Extra Wide &/Or Extended Length For

Modular Arm Supports -

Includes Mounting Hardware (Maximum

2)

Modular Arm Support - Includes

Mounting Hardware (Maximum 2)

SEAND0010

SEAND0005

Modular Hand Support - Flat/Cone -

Includes Mounting Hardware (Maximum

2)

Complex Arm Support, Multi

Component,

Includes Hardware (Maximum 2)

Fixed Arm Support, One Piece,

Includes Hardware (Maximum 2)

SEAND0015

SEACF102L

SEACF101L

SEACF104L Full Sling Arm Support,

Includes Hardware (Maximum 2)

Heavy Duty Solid Padded Armrest

Support,

Replaces Padded W/C Armpad,

Includes Hardware (Maximum 2)

Removable Cover For Back With

Laterals

Removable Cover For

Contoured/Custom Contoured Back

Removable Cover For Flat Back

SEACF103L

SEMCF103L

SEMCF102L

SEMCF101L

SEMCF104L Removable Cover For Sculptured Or

Molded Back

Complex Specialized Mounting

Hardware - Including

Hardware For Custom Molded Modular

SEBND0010

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

$75.00

$60.00

$40.00

$105.00

$275.00

$75.00

$250.00

$150.00

$300.00

$75.00

$230.00

$180.00

$120.00

$270.00

$400.00

Page: 53 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Back Hardware

Back Support Options

Foot/Leg Support Hardware

Foot/Leg Support Options

Foot/Leg Support(s)

Effective From: February 01, 2015

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Device Device Code Max

Allowed

Qty.

Approved

Price

Systems

Simple Back Interface Mounts Back To

Wheelchair Frame

Additional Pressure Relief - Gel/Air

Inserts/Pads Etc.

(Maximum 6)

Custom Modifications And Sizing -

Including Custom Sizes,

Additional Postural Support - Lumbar

Pad, Foam Pads Etc.

(Maximum 6)

Back Channeling - Upgrade For Slots

For Lateral Adjustments

SEICF160L

SEBND0020

SEBND0015

SEMCF201L

Back Plaster Molding/Vacuum Form, for

Custom Fabricated Device Only

Back Reinforcement - Heavy Duty

Upgrade

Modify Or Refurbish Existing Custom

Fabricated Back,

Includes Parts, Hardware & Labour

Complex Specialized Mounting

Hardware

SEUCF003L

SEMCF202L

SEMCF200L

SEFND0030

1

6

6

1

1

1

1

2

$195.00

$134.00

$55.00

$150.00

$160.00

$100.00

$225.00

$100.00

Mount Footrest To Seating System

Extra Padding For Specific Pressure

Relief - (Maximum 2)

SEICF501L

SEFND0035

2

2

$120.00

$50.00

Footrest Discrepancy Upcharge -

Accommodates Differences Between

Left & Right Leg

Footrest Extension, Not Padded

(Maximum 2)

Footrest Padding (Maximum2)

Footrest Reinforcement Upcharge -

Heavy Duty

Upgrade To Reinforce Footrest

1 Piece Foot Board - Includes Mounting

Hardware & Padding

Amputee Board/Stump Support -

Includes Mounting Hardware & Padding

Calf Panel - Includes Mounting

Hardware & Padding

SEMCF801L

SE0000322

SEMCF803L

SEMCF802L

SEFND0015

SEFND0005

SEFND0010

1

2

2

2

1

1

2

$80.00

$75.00

$60.00

$140.00

$110.00

$285.00

$50.00

Page: 54 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Foot/Leg Support(s)

Headrest/Neckrest Hardware

Headrest/Neckrest Options

Effective From: February 01, 2015

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Custom

Fabricated

Device Device Code Max

Allowed

Qty.

2

Approved

Price

$240.00

Foot Box - Includes Mounting Hardware

& Padding -

Foot Box May Be 1 Piece Or 2 Piece

(Each Foot)

SEFND0020

Calf Support, Padded And Removable SEFCF107L

Complex Foot Rest (One Or Two

Piece),

Includes Parts, Hardware, And Labour

SEFCF102L

Footpocket, Not Padded ( Maximum 2) SEFCF106L

One Piece Double Footbox, Not

Padded

SEFCF103L

One Piece Fixed Footrest,

Not Padded

SEFCF101L

SEHND0020 Bracket To Mount Headrest To Seating

System/Back

Support Or Wheelchair

Complex Specialized Mounting

Hardware

Non Standard Mounting Hardware Not

Included In Base Device -

Removable, Allows Multi Axis

Adjustments

Standard Mounting Hardware Not

Included In Base Device -

Removable, Allows Height, Anterior &

Posterior Adjustments

SEHND0015

SEHND0010

SEHND0005

Complex Headrest Hardware, Allows

For Removability

& Height And Forward Adjustment

Multi-Axis Headrest Hardware, Allows

For Removability

And Multi Adjustments

Simple Headrest Hardware, Allows For

Removability

& Height Adjustment

Wheelchair Mounting Bracket For

Headrest Hardware

Complex Extension Pad, Mounted

(Maximum 2)

SEICF007L

SEICF008L

SEICF006L

SEICF009L

SEMCF006L

Removable Cover For Complex

Headrests, Use For Complex

Headrest & Headrest/Neckrest

Combinations

SEMCF002L

Removable Headrest/Neckrest Cover, SEMCF001L

2

1

2

1

1

1

1

1

1

1

1

1

1

2

2

2

$195.00

$440.00

$200.00

$297.00

$150.00

$100.00

$300.00

$160.00

$140.00

$155.00

$261.00

$70.00

$220.00

$300.00

$180.00

$120.00

Page: 55 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Headrest/Neckrest Options

Lateral Support Hardware

Lateral Support Options

Lateral Support(s)

Pommel Hardware

Pommel/Adductors

Effective From: February 01, 2015

Custom

Fabricated

Quickie

Custom

Fabricated

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Device Device Code Max

Allowed

Qty.

Approved

Price

Any Fabric, Use

For Flat/Contoured Headrest &

Neckrest

Simple Extension Pad, Mounted

(Maximum 2)

RELAX HEADREST PAD

Fixed Lateral Hardware, Non-

Adjustable (Maximum 2)

Hinged Swingaway Lateral Hardware,

Height& Width Adjustable (Maximum 2)

Removable Lateral Hardware,

Height & Width Adjustable (Maximum 2)

Extra Padding (Maximum 2)

SEMCF005L

SE0000119

SEICF201L

SEICF202L

SEICF203L

SEMCF651L

2

1

2

2

2

2

$200.00

$272.00

$60.00

$200.00

$100.00

$60.00

4 $192.50

Complex Shape Lateral Supports, Each

-

Includes Padding & Mounting Hardware

(Maximum 4)

Fixed Lateral Supports, Each -

Includes Padding & Mounting Hardware

(Maximum 4)

Shoulder Wings, Each - Includes

Padding & Mounting Hardware

(Maximum 2)

Swingaway Lateral Supports, Each -

Includes Padding & Mounting Hardware

(Maximum 4)

Complex Shaped Thoracolumbar

Supports, Non Adjustable,

Includes Cover (Maximum 2)

Shoulder Wings, Non Adjustable,

Includes Cover

Thoracolumbar Supports, Rigid & Non

Adjustable,

Includes Cover (Maximum 2)

Hardware For Fixed Pommel

Hardware For Flip-Down Pommel

Hardware For Removable Pommel

Pommel, Flip Down, All Components

Including Hardware

SELND0015

SELND0005

SELND0020

SELND0010

SELCF102L

SELCF103L

SELCF101L

SEICF401L

SEICF403L

SEICF402L

SESND1043

Custom Pommel Without Hardware SEMCF701L

4

2

4

2

2

2

1

1

1

1

1

$120.00

$55.00

$180.00

$175.00

$95.00

$80.00

$85.00

$300.00

$175.00

$300.00

$160.00

Page: 56 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Pommel/Adductors

Positioning Belts

Positioning Belts Options

SE - Custom Modifications

Effective From: February 01, 2015

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Custom

Fabricated

Approved ADP

Manufacturers

Only

Device Device Code Max

Allowed

Qty.

2

Approved

Price

$120.00

Fixed Padded Adductor Includes Cover

(Maximum 2)

Removable Padded Adductor Includes

Cover

(Maximum 2)

Any 2 Point Strap For Positioning Only -

Any Closure -

Includes Padding & Mounting

Hardware -Chest, Hip,

Thigh, Calf, Ankle, Foot (Maximum 6)

Any 4 Point Strap For Positioning Only -

Any Closure -

Includes Padding & Mounting Hardware

-

Pelvic "Y" Strap, "H" Leg Strap

(Maximum 2)

Chest Harness For Positioning Only -

Any Closure -

Includes Padding & Mounting Hardware

Non Standard Chest Or Shoulder

Harness Required For

Positioning Support Only

SEMCF702L

SEMCF703L

SERND0030

SERND0020

SERND0001

SERND0035

Shoulder Straps For Positioning Only -

Any Closure -

Includes Padding & Mounting Hardware

(Maximum 2)

Custom Chest Support, Includes

Attachments

Custom Positioning Belt, Includes

Attachments.

Specify Upper &/Or Lower Extremity

&/Or Chest

(Maximum 12)

SERND0010

SERCF103L

SERCF105L

Custom Shoulder Harness, Includes

Padding & Attachments

Pelvic "Y" Belt Or Groin Strap, Includes

Attachments

SERCF104L

SERCF101L

Complex Control Pads (Maximum 4) SEMCF503L

Positioning Control Pads (Maximum 12) SEMCF502L

Positioning Support Pads (Maximum

12)

SEMCF501L

Custom Modifications Required To Adp

Listed Wheelchair To

Facilitate Installation Of Custom

Fabricated Positioning

SEMCF990L

2

6

2

1

1

2

1

12

1

1

4

12

12

1

$190.00

$65.00

$150.00

$140.00

$460.00

$60.00

$150.00

$55.00

$210.00

$60.00

$165.00

$55.00

$55.00

Page: 57 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

SE - Custom Modifications

Seat Cushion Cover(s)

Seat Hardware

Effective From: February 01, 2015

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Device Device Code Max

Allowed

Qty.

Approved

Price

Devices (Seating). Authorizer Must

Provide Clinical Rational

To Support Request. Clinic Must

Provide A Breakdown

Of The Cost Of Parts And Labour (Not

To Exceed $40.00/Hour).

Custom Modifications To An Adp Listed

Modular Seating Device

& No Adp Code With Assigned Funding

Is Available -

Authorizer Must Provide Clinical

Rationale To Support

Request - Vendor Must Provide

Breakdown Of Cost Of Parts

& Labour (Not To Exceed $40.00/Hour)

Transfer Existing Adp Approved

Modular Seating System

Into New Or Modified Adp Approved

Wheelchair -

Labour Only, When No Parts Required

Transfer Existing Adp Approved

Custom Seating System

Into A New Or Modified Adp Approved

Wheelchair.

Labour Only, No Parts Required.

Extra Cover Bariatric Sizes

Extra Cover Non Standard Sizes

Extra Cover Standard Sizes

Removable Cover For Flat Seat, For

Incontinence

(Maximum 2)

Removable Cover For Sculptured Or

Molded Seat,

For Incontinence (Maximum 2)

Removable Cover For Wedged Or

Contoured Seat,

For Incontinence (Maximum 2)

Complex Specialized Mounting

Hardware - Including

Hardware For Custom Molded Modular

Systems

Complex Interface Mounts Seat & Back

To Wheelchair Frame

Hardware To Mount Positioning Device

Into

Paediatric Stroller

SEMND2005

SEMND1005

SEUCF200L

SESND1060

SESND1055

SESND1050

SEMCF105L

SEMCF107L

SEMCF106L

SESND1010

SEICF170L

SEICF190L

1

1

1

2

2

2

2

2

2

1

1

1

$80.00

$80.00

$155.00

$115.00

$75.00

$125.00

$250.00

$180.00

$300.00

$350.00

$100.00

Page: 58 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Seat Hardware

Seat Options

Effective From: February 01, 2015

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$570.00

Hardware To Mount Seat & Back Into

Dynamic Tilt Wheelchair

Seat Rigidizer - Flat Rigid Insert

Securing Hardware That Mounts

Hardware To Mobility Device

(Maximum 8)

Simple Seat Interface Mounts Seat To

Wheelchair Frame

Strap Interface (2) Mounts Seat To

Wheelchair

Additional Pressure Relief - Specialty

Foam, Air, Gel

Custom Modifications And Sizing -

Including Custom Sizes,

Static Adductors & Pommels, Wedges

& Anti-Thrust

Devices, Leg Length Discrepancy

Allowance (Maximum 6).

Drop Base And Hooks (4)

SEICF180L

SEICF192L

SEICF191L

SEICF150L

SEICF140L

SESND1045

SESND1040

Roho Bolster

Solid Seat Insert

Subasis Bar, Complete, Including

Hardware

2" Convolute Foam Cut To Size

(Maximum 2)

SESND1020

SESND1035

SESND1015

SESND1041

SEMCF403L

2" Polyfoam Cut To Size

(Maximum 2)

3" Convolute Foam Cut To Size

(Maximum 2)

3" Polyfoam Cut To Size

(Maximum 2)

4" Convolute Foam Cut To Size

(Maximum 2)

Add Waterproof Skin On Complex

Indirect Molded Seat

Complex Pelvic Stabilizers, Each

(Maximum 2)

SEMCF406L

SEMCF404L

SEMCF407L

SEMCF405L

SEMCF210L

SEMCF206L

Contoured Cushion With Troughing

Secured In Front Of A Roho

Cushion, Not Including Roho Cushion,

Includes Cover

SEMCF209L

Heavy Duty Upgrade To Reinforce Seat SEMCF207L

1

8

2

2

1

6

1

1

1

1

2

2

2

2

2

2

2

1

1

$60.00

$25.00

$195.00

$100.00

$415.00

$80.00

$250.00

$180.00

$80.00

$200.00

$40.00

$30.00

$45.00

$35.00

$50.00

$100.00

$225.00

$380.00

$75.00

Page: 59 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Seat Options

Tray

Effective From: February 01, 2015

Custom

Fabricated

Approved ADP

Manufacturers

Only

Custom

Fabricated

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$225.00

Modify Or Refurbish Existing Custom

Fabricated Seat,

Includes Parts, Hardware & Labour

Pelvic Stabilizer (Maximum 2)

Polymer Supplement Pad

(Maximum 2)

Seat Plaster Molding/Vacuum Form, for

Custom Fabricated Device Only

Simple Cushion Secured In Front Of A

Roho Cushion,

Not Including Roho Cushion, Includes

Cover

Single Complex Pelvic Stabilizer For

Seat Or Back

Upgrade To Provide Extra Pressure

Relief,

Gel/Foam/Air/Liquid Etc. (Maximum 2)

Viscoelastic Foam Or Pudgee 1"

Thick/1 Square Foot

(Maximum 2)

SEMCF212L

SEMCF204L

SEMCF402L

SEUCF005L

SEMCF208L

SEMCF205L

SEMCF203L

SEMCF401L

Full Tray For Positioning Support Only -

Standard

Adult & Paediatric Sizes, Includes

Mounting Hardware

Full Tray Non Standard Size For

Positioning Support Only -

Adult & Paediatric Sizes, Includes

Mounting Hardware

Plastic Tray, Includes Mounting

Hardware

Wood/Arborite Tray, Includes Mounting

Hardware

SETND0005

SETND0010

Half Tray For Positioning Support Only -

Non Standard

Adult & Paediatric Sizes, Includes

Mounting Hardware

SETND0020

Half Tray For Positioning Support Only -

Standard

Adult & Paediatric Sizes, Includes

Mounting Hardware

SETND0015

Customized Lexan Tray, Includes

Mounting Hardware

Kydex Tray, Includes Mounting

Hardware

SETCF103L

SETCF104L

SETCF101L

SETCF102L

2

2

1

1

1

2

2

1

1

2

2

1

1

1

1

$214.00

$150.00

$160.00

$200.00

$300.00

$150.00

$60.00

$190.00

$325.00

$315.00

$235.00

$420.00

$360.00

$350.00

$255.00

Page: 60 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Seating

OPTIONS:

Device Type Manufacturer

Tray Options

Effective From: February 01, 2015

Approved ADP

Manufacturers

Only

Custom

Fabricated

Device Device Code

SETND0030

Max

Allowed

Qty.

4

Approved

Price

$65.00

Add Modular Elbow Or Hip Blocks To

Any Modular Tray -

(Maximum 4)

Add Padding To Any Tray

Clear Tray Cover, Removable

Elbow Block Padding Including Cover

(Maximum 2)

Elbow Blocks (Maximum 2)

Large/Full Tray Pad (Maximum 2)

Small Tray Pad (Maximum 2)

SETND0035

SEMCF301L

SEMCF306L

SEMCF305L

SEMCF304L

SEMCF303L

2

1

2

2

2

2

$75.00

$80.00

$60.00

$85.00

$145.00

$80.00

Page: 61 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer

Effective From: February 01, 2015

Device

Adult High Performance Rigid Manual

Wheelchair

Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 18"wide x

18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Adult Lightweight Performance

Manual Wheelchair

Wheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x

18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Invacare

Ki Mobility

LEVO AG

A-4

Crossfire T6/Ti

Crossfire T7a

Terminator

Rogue

Tsunami

LEVO compact-easy LCEV with battery powered stand-up feature

Motion Composites Veloce

Otto Bock Ventus

Pantera AB

Voyager Evo

Panthera S2

Panthera U2

Elevation Product Design

Group

Quickie Quickie Gp/Gpv

Quickie Gt

Rgk Wheelchairs

TiLite iCON

Future Mobility

Quickie Q7

Quickie QRi

Hi-Lite

Maxima

Tilite Aero Z

Tilite Yr/Tr,Yra/Tra,Trc,Zra

Icon A1

Galaxy Lite

Handicare

Invacare

Northern Lite

Legend 2 Exigo/Exigo

Compass Xe (Allegro)

Mvp

Myon Active

Prospin X4

Xtra

Catalyst 5, 5ti Ki Mobility

Maple Leaf

Wheelchair

Catalyst 5vx

EZ Ride

Motion Composites Helio A7

Helio C2

Device Code

WMA4IN015

WMA4IN110

WMA4IN130

WMA4IN105

WM0001043

WMA4KI015

WM0000471

Max

Allowed

Qty.

1

1

1

1

1

1

1

Approved

Price

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

WM0001029

WM0001104

WM0001190

WM0000972

WM0000973

WM0001203

WMA4QU005

WMA4QU030

WMA4QU040

WM0000991

WMA4RZ005

WM0000696

WMA4TZ010

WMA4TZ005

WM0000945

WMA3FM010

WMA3FM005

WMA3M9015

WMA3IN030

WMA3IN060

WMA3IN065

WMA3IN035

WMA3IN005

WMA3KI010

WMA3KI015

WMA3WM005

WM0001020

WM0000964

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$2,655.00

$2,655.00

Page: 62 of 80

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$3,592.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer Device

Adult Lightweight Performance

Manual Wheelchair

Wheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x

18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Adult Lightweight Standard Manual

Wheelchair

Wheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Orthofab

Otto Bock

Prima

Motus

Start M5 Comfort/ M5XXL

Permobil

Physipro

TiLite AERO X

XL-5/XL-5 ci

Power Plus Mobility Glyder

Pride Mobility

Products

Litestream Xf

Product Design

Group

Quickie

Eclipse 600

Quickie 2

Quickie 2 Hp

Quickie 2 Lite

Rgk Wheelchairs

TiLite

Drive Medical

Design &

Manufacturing

Future Mobility

Quickie Gtx

Quickie Lxi

Quickie M6

Quickie QXi

Quickie Revolution

Quickie Xenon

Maxima

Tilite X, Sx, Tx

Viper Plus GT

Invacare

Stellato

Stellato II

9000 SL

9000 Topaz

9000 Xt

Myon Manual Wheelchair

Ki Mobility

Maple Leaf

Wheelchair

Patriot

Catalyst 4, 4c

NRG+

NRG+ Gold

Swift

Motion Composites Move

Orthofab

Otto Bock

Ch+

Start M2 Effect

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code

WMA3OF010

WMA3OB010

WMA3OB005

WM0001169

WM0001132

WM0001061

WMA3X1010

Max

Allowed

Qty.

1

1

1

1

1

1

1

Approved

Price

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

WMA3MV005

WMA3QU005

WMA3QU010

WMA3QU020

WMA3QU040

WMA3QU405

WMA3QU420

WM0000562

WMA3QU410

WM0001156

WMA3RZ005

WMA3TZ005

WM0000317

1

1

1

1

1

1

1

1

1

1

1

1

1

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,655.00

$2,665.00

$2,655.00

$2,655.00

$1,680.00

WMA2FM005

WM0001188

WMA2IN030

WMA2IN055

WMA2IN025

WMA2IN060

WMA2IN050

WMA2KI010

WMA2WM005

WM0001134

WMA2WM010

WM0001196

WMA2OF005

WMA2OB005

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

Page: 63 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer

Effective From: February 01, 2015

Device Device Code

Adult Lightweight Standard Manual

Wheelchair

Wheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Adult Manual Dynamic Tilt Wheelchair

Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Power Plus Mobility Magic Plus

Voyager Plus

Pride Mobility

Products

Litestream Xf Ltd

Stylus 400

Quickie Breezy 600

Breezy RubiX2

Breezy Ultra 4

Advanced Mobility

Broda

Future Mobility

Handicare

Invacare

Ki Mobility

Lpa Medical Inc

Maple Leaf

Wheelchair

Orthofab

Quickie Lx

Ams Itilt2

Tilt Recline/ I Tilt

Comfort Tilt 587V3

Elite 785

Models 80 & 48

Models 85 & 35 & 75

Capella, Capella 45

Orion 500

Orion III

Orion Ii

Emineo

Ibis

Concept 45

Htr

Solara 2g

Solara 3g

Focus CR

Comp-Position

Dyn-Ergo

Evolution

Optimum Posturo-Pedic

Lowrider

MLT 700 A/B

MLTR 500/600

Supertilt Oval Frame (maximum tilt

45 deg)

Supertilt Square Frame (maximum tilt 35 deg)

Tango

WM0001062

WM0001063

WMA2X1010

WMA2X1005

WMA2QU001

WM0000567

WMA2QU010

WMA2QU105

WMA5AO020

WMA5AO015

WMA5B-025

WMA5B-020

WMA5B-005

WMA5B-010

WM0000559

WMA5FM010

WM0001195

WMA5FM005

WMA5M9010

WMA5M9005

WMA5IN020

WMA5IN025

WMA5IN035

WMA5IN040

WM0001160

WMA5LQ010

WMA5LQ020

WMA5LQ015

WMA5LQ005

WM0001080

WMA5WM015

WMA5WM010

WM0001111

WM0001166

WMA5OF005

Approved

Price

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$1,680.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$1,680.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Max

Allowed

Qty.

1

1

1

1

1

1

$2,446.00

$2,446.00

Page: 64 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer

Effective From: February 01, 2015

Device

Adult Manual Dynamic Tilt Wheelchair

Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Power Plus Mobility Extreme

NV Tilt

Supertilt Plus

Pride Mobility

Products

Product Design

Group

Litestream Traverse

Bentley

Fuze T20

Fuze T50

Quickie

Seating Matters

Limited

Amg Medical

Stellar, Stellar GL, Stellar HD

Breezy Relax2

Quickie Iris

Quickie SR-45

Quickie Ts

Tilt Fx

Pheonix

Sorrento

Airgo

Adult Standard Manual Wheelchair

Wheelchair type most suitable for user who is not consistently independently mobile and requires minimal adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Paediatric High Performance Rigid

Manual Wheelchair

Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x

16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Everest & Jennings Traveler

Invacare

Quickie

Hoggi

Invacare

Ki Mobility

LEVO AG

Otto Bock

900

Tracer

Easy Care 2000 & 4000

Pantera AB

Permobil

Quickie

Supra

Crossfire T6a

Rogue

Tsunami

LEVO compact-easy LCEV with battery operated Stand-up feature

Ventus

Voyager Evo

Bambino

TiLite Twist

Quickie Gp

Quickie Gt

Quickie Q7

Device Code

WM0001041

WM0001076

WM0001040

WM0001030

Max

Allowed

Qty.

1

1

1

1

Approved

Price

$2,446.00

$2,446.00

$2,446.00

$2,446.00

WMA5MV005

WMA5MV025

WMA5MV020

WMA5MV010

WM0000454

WMA5QU015

WM0000474

WMA5QU005

WMA5QU020

WM0000974

WM0000975

WMA1GM005

WMA1EJ005

WMA1IN015

WMA1IN005

WMA1QU015

WM0000462

WMK4IN130

WM0001044

WMK4KI005

WM0000472

WM0001105

WM0001191

WM0000976

WM0001187

WMK4QU010

WMK4QU030

WMK4QU035

1

1

1

1

1

1

1

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$2,446.00

$1,424.00

$1,424.00

$1,424.00

$1,424.00

$1,424.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

Page: 65 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer Device

Paediatric High Performance Rigid

Manual Wheelchair

Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x

16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Paediatric Lightweight Performance

Manual Wheelchair

Wheelchair type offers maximum adjustments and options. Suitable for the active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Quickie

Rgk Wheelchairs

TiLite

Quickie QRi

Quickie Ti

Zippie

Zippie Zone

Hi-Lite

Maxima

Tilite Aero Z iCON

Invacare

Tilite Yr/Tr,Yra/Tra,Trc,Zra

Icon A1

Compass Xe (Allegro)

Mvp Junior

Myon Jr Manual Wheelchair

Prospin X4

Ki Mobility Catalyst Spark

Motion Composites Helio Kids

Otto Bock

Permobil

Quickie

Motus

TILite AERO X

Quickie 2

Quickie 2 Hp

Quickie 2 Lite

Quickie Gtx

Quickie Lxi

Quickie Xenon

Zippie 2

Rgk Wheelchairs

TiLite

Handicare

Zippie Gs

Maxima

Tilite X, Sx, Tx

Legend 2 Exigo/Exigo

Paediatric Lightweight Standard

Manual Wheelchair

Wheelchair type most suitable for user who requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Paediatric Manual Dynamic Tilt

Wheelchair

Invacare

Otto Bock

Pride Mobility

Products

Quickie

Convaid

Future Mobility

9000 Jymni

Start M2 Junior

Litestream Xf

Quickie Lx

Safari Tilt

Super Chair For Kids

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code

WMK3OB005

WM0001170

WMK3QU010

WMK3QU015

WMK3QU020

WMK3QU040

WMK3QU030

WM0001157

WMK3QU005

WMK3QU035

WMK3RZ005

WMK3TZ005

WMK2M9020

WM0000992

WMK4QU025

WMK4QU005

WMK4QU040

WMK4RZ005

WM0000697

WMK4TZ010

WMK4TZ005

WM0000946

WMK3IN020

WMK3IN030

WMK3IN040

WMK3IN035

WM0000695

WM0000563

Approved

Price

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$1,850.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$3,889.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

$2,678.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Max

Allowed

Qty.

1

1

1

1

1

1

1

WMK2IN010

WM0001079

WMK2X1010

1

1

1

$1,850.00

$1,850.00

$1,850.00

WMK2QU020

WMK5CO040

WMK5FM010

1

1

1

$1,850.00

$3,251.00

$3,251.00

Page: 66 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

Device Type Manufacturer

Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual

Wheelchair Options Chart for other basic components funded by ADP.

Hoggi

Invacare

Ki Mobility

Kid Kart

Otto Bock

Pride Mobility

Products

Product Design

Group

Quickie

THOMASHILFEN

Paediatric Specific Specialty Stroller

ADP price includes stroller frame and upholstery, foot support, seat and back supports, headrest, chest and pelvic positioning straps (harness), abductor, and wheels. See

Manual Wheelchair Options Chart for additional basic components funded by ADP.

Alvema

Convaid

Maclaren

Otto Bock

Quickie

THOMASHILFEN

Effective From: February 01, 2015

Device Device Code

Bingo/Bingo Evolution

Swingbo Plus

Orbit/Tiger

Spree 3g

Spree Gt

Spree Xt

Focus CR

WMK5K2010

WM0000461

WMK5IN010

WMK5IN030

WMK5IN025

WMK5IN020

WM0001161

Kid Kart Xpress

Kid-Tlc

WMK5KT020

WMK5KT010

Discovery Tmax WM0001192

Kimba Spring & Kimba Spring Plus WMK5OB010

F.A.S.T

Kids Rock

Fuze T20

Fuze T50

WMK5K2015

WMK5K2005

WMK5MV025

WMK5MV020

Quickie SR-45

Zippie Iris

Zippie Ts

Easy S

Thevo Twist

Series 100/Pix1

Cruiser Cx

Ez Rider

Metro

Rodeo Tilt

Buggy

Eco-Buggy

Kimba Neo

Zippie Voyage

Swifty Stroller - Paediatric specific specialty stroller type 6

Thevo Swifty Stroller WM0000316

WM0000473

WMK5QU010

WMK5QU005

WM0000326

WM0000325

WMK6AL005

WMK6CO005

WMK6CO050

WMK6CO030

WMK6CO060

WMK6AM005

WMK6OB005

WM0001100

WM0001083

WM0000318

Approved

Price

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$1,511.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

$3,251.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Max

Allowed

Qty.

1

1

1

1

1

1

1

1 $1,511.00

Page: 67 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

OPTIONS:

Device Type Manufacturer

Amputee Axle Plates (pair)

Caster Pin Locks (pair)

Clothing Guards

Elevating Legrests (pair)

Grade Aids (pair)

Heavy Duty Cross Braces &

Upholstery

Hub-Eez Easy Push Wheel

MW - Adjustable Tension Back

Upholstery over 18" Frame Width

MW - Adjustable Tension Back

Upholstery up to 18" Frame Width

MW - Angle Adjustable Footplates

(pair)

MW - Custom Modifications

MW - Heavy Duty Model, Client

Weight Exceeds 250 Lbs

Heavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements.

MW - Heavy Duty Model, Client

Weight Exceeds 350 Lbs

Heavy duty model required, client weight exceeds 350lbs. Authorizer must document client weight. Selected device must meet weight requirements.

MW - Heavy Duty Model, Client

Weight Exceeds 400 Lbs

Heavy duty model required, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements.

MW - Oxygen Tank Holder

MW - Seat Depth Required is Greater

Than 18"

Device

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

WAMT

WAMS

WAMV

WAMK

WAMR

WAMC

Device Code

1

1

1

1

Max

Allowed

Qty.

1

1

Approved

Price

$113.00

$171.00

$126.00

$404.00

$116.00

$680.00

WAMM

WAME

WAMD

1

1

1

$716.00

$240.00

$140.00

WAMJ

MWCM

WAMF

1

1

1

$130.00

$730.00

WAMG

WAMH

WAMX

WAMB

1 $992.00

1 $1,110.00

1

1

$195.00

$265.00

Page: 68 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Manual)

OPTIONS:

Device Type Manufacturer

MW - Seat Width Required is Greater

Than 18"

MW - Ventilator Tray

One Arm/Lever Drive

Plastic Coated Handrims

Power Add-On Device

Device is added onto a manual wheelchair to assist the user meet their long term basic and essential mobility requirements. User must be able to operate the manual wheelchair independently. This code may be used only when it is not anticipated that the user will require the use of a power wheelchair to meet their long term basic and essential mobility requirements. ADP funding assistance is not provided for a power add on device and a power wheelchair.

Projected Handrims (pair)

Quick Release Axles (pair)

Recliner Option

Spoke Protectors (pair)

Standard Manual Wheelchair Frame with Manual Dynamic Tilt *

Standard manual wheelchair with manual dynamic tilt. Frame offers ongoing adjustability and facilitates independent mobility. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Stroller Handles/Paediatric

Titanium Frame *

Titanium frame manual wheelchair. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Uni-Lateral Wheel Lock

Dolomite

Magicwheels

Max Mobility

Quickie

Alber E.Motion

Magicwheels

Smart Drive

Quickie Xtender

Device

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code

WAMA

Max

Allowed

Qty.

1

Approved

Price

$399.00

WAMY

WAML

WAMO

WPS1DO005

WPS1WS005

WM0001081

WPS1QU005

WAMQ

WAMU

WAMI

WAMP

WANA

1

1

1

1

1

1

1

1

1

1

1

1

$425.00

$1,046.00

$134.00

$6,135.00

$6,135.00

$6,135.00

$6,135.00

$224.00

$110.00

$527.00

$116.00

$1,200.00

WAMW

WAMZ

WAMN

1

1

$147.00

$1,500.00

1 $149.00

Page: 69 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

Device Type Manufacturer Device

Adult Power Base Type 1

Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x 18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair

Options Chart for other basic components funded by ADP.

Invacare

Power Plus

Mobility

Pride Mobility

Products

Shoprider/

Pihsiang

Adult Power Base Type 2

Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x

18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, and wheels. See Power Wheelchair

Options Chart for other basic components funded by ADP.

Adult Power Base Type 3

Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See

Power Wheelchair Options Chart for other basic components funded by ADP.

Invacare

Power Plus

Mobility

Pride Mobility

Products

Future Mobility

Handicare

Invacare

LEVO AG

Orthofab

Permobil

Nutron Series R51lxp

Pronto M51

Mp1

J6 Jazzy

Jazzy Elite ES Portable

Jazzy Select 6

Shoprider P424l

Shoprider P424m

3g Ranger X Storm Series

Mp2

Jazzy 600

Orion Explorer Magellan

Orion Explorer Viking

Alex Power Wheelchair

PUMA 40

Action Torque Storm

Arrow Storm Rwd

Fdx

Pronto M91

Pronto M94

Tdx Sp/Sr

Tdx-Sc

LEVO C3

Oasis

C300

C350

C400

C500

Chairman Hd3

M300

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code

WPA1IN065

WPA1IN075

WPA1WN005

Max

Allowed

Qty.

1

1

1

Approved

Price

$5,092.00

$5,092.00

$5,092.00

WP0000564

WP0001224

WPA1X1230

WPA1S7015

WPA1S7010

WPA2IN040

1

1

1

1

1

1

$5,092.00

$5,092.00

$5,092.00

$5,092.00

$5,092.00

$6,738.00

WPA2WN005 1 $6,738.00

WPA2X1220 1 $6,738.00

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

WPA3FM005

WPA3FM010

WPA3M9005

WP0000647

WPA3IN015

WPA3IN020

WPA3IN080

WPA3IN050

WPA3IN052

WPA3IN070

WPA3IN075

WP0001140

WPA3OF110

WPA31P010

WPA31P030

WPA31P015

WPA31P020

WPA31P025

WP0000455

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

Page: 70 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

Device Type Manufacturer Device

Adult Power Base Type 3

Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See

Power Wheelchair Options Chart for other basic components funded by ADP.

Permobil

Power Plus

Mobility

Pride Mobility

Products

Quickie

M300 Corpus HD R-Net

Street

Mp5

Jazzy/Quantum 1113

Jazzy/Quantum 1121

Jazzy/Quantum 1170

Jazzy/Quantum 1402 & 1420

Jazzy/Quantum 1650

Q6 Edge HD

Quantum 1450

Quantum 600

Quantum 6000

Quantum 6000z

Quantum 610

Quantum 614

Quantum Q6 Edge Adult

Quantum R4000

Quantum Rival

Quickie P-222

Quickie Pulse 6

Quickie QM-710, 715, 720

Quickie S-646 (S-626)

Quickie X2

Quickie Xcel

Quickie Xperience

Quickie Xplore

Express

Nutron Series R51lxp

Paediatric Power Base Type 1

Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair

Options Chart for other basic components funded by ADP.

Ranger

Wheelchairs

Invacare

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code

WP0001165

WPA31P005

WPA3WM005

Max

Allowed

Qty.

1

1

1

Approved

Price

$7,101.00

$7,101.00

$7,101.00

WPA3X1100

WPA3X1110

WPA3X1010

WPA3X1020

WPA3X1230

WP0001058

WP0001021

WPA3X1220

WPA3X1240

WPA3X1245

WPA3X1225

WPA3X1255

WP0000108

WPA3X1250

WP0000968

WPA3QU240

WP0000637

WP0000686

WPA3QU230

WPA3QU290

WPA3QU300

WPA3QU280

WPA3QU270

WP0001023

WPK1IN015

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$7,101.00

$5,424.00

Page: 71 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

Device Type Manufacturer

Effective From: February 01, 2015

Device Device Code

WPK2IN015

Max

Allowed

Qty.

1

Approved

Price

$6,385.00

Paediatric Power Base Type 2

Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x

16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair

Options Chart for other basic components funded by ADP.

Paediatric Power Base Type 3

Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure, and standard joystick control. See

Power Wheelchair Options Chart for other basic components funded by ADP.

Invacare

Handicare

Invacare

LEVO AG

Permobil

Tiger

Pride Mobility

Products

Quickie

Alex Power Wheelchair

Arrow Storm

Fdx

Storm Torque

Tdx Sp/Sr

Tdx Spree

LEVO C3

C300 Corpus Junior / K300

C400 Corpus Junior

M300

Q6 Edge HD

Quantum 600

Quantum 6000

Quantum 6000z

Quantum 610

Quantum Q6 Edge Paediatric Power

Base Type 3 Wheelchair

Quantum Rival

Quickie P-222

Quickie Pulse 6 with SPOT Tilt

Quickie QM-710, 715, 720

Quickie Xperience

Quickie Xplore

Tdx Spree

WPK3M9005

WPK3IN010

WPK3IN080

WPK3IN015

WPK3IN070

WPK3IN075

WP0001141

WPK31P010

WPK31P015

WP0000987

WP0001059

WPK3X1220

WPK3X1240

WPK3X1245

WPK3X1225

WP0000109

WP0000969

WPK3QU020

WP0000638

WP0000687

WPK3QU080

WPK3QU070

WPK4IN075

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Paediatric Power Base with Manual

Dynamic Tilt

Wheelchair type offers manual dynamic tilt required by the user who can not maintain a functional posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away

Invacare

Tiger WPK4IN005 1 $6,505.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,843.00

$6,505.00

Page: 72 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

Device Type Manufacturer Device detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair

Options Chart for other basic components funded by ADP.

Power Scooter

Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat.

ADP funding for positioning devices (seating) is not available for scooters. See Power

Wheelchair Options Chart when heavy duty models are required.

Invacare

AMIGO

MOBILITY

INTERNATIONAL

AMIGO RD310000 - 3 WHEEL

SCOOTER

Activelite Mobility Easy Travel -3 Wh.

Advanced Vehicle

Concepts

Quingo Classic

Fortress 1700fs -3 Wh.

1700fs -4 Wh.

Winner -3 Wh.

Winner -4 Wh.

Invacare

Power Plus

Mobility

COMET 4 WHEEL SCOOTER

Comet HD 4 Wheel Scooter

Leo Scooter 3 Wheel

Leo Scooter 4 Wheel

PEGASUS 3 WHEEL SCOOTER

PEGASUS 4 WHEEL SCOOTER

Mp3 -3 Wh.

Mp4 -4 Wh.

Pride Mobility

Products

Shoprider/

Pihsiang

Celebrity LR

Celebrity Xl - 4 Wh.

Go Go LX 4 Wheel

Go Go Sport - 4 Wheel

Gogo Elite Traveller Plus - 3 Wh.

Gogo Elite Traveller Plus - 4 Wh.

Maxima -3 Wh.

Maxima -4 Wh.

Victory 10 - 3 Wh, 3 Wh Twin

Victory 10 - 4 Wh

Victory 10 DX

Victory Twin DX

Chameleon Gkb - 3 Wh

Chameleon Gkb - 4 Wh

Cobra 778el -3 Wh.

Cobra 778el -4 Wh.

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code Max

Allowed

Qty.

Approved

Price

WP0000333 1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

WS16A0005

WS15V0005

WS1X10100

WS1X10105

WS1X10060

WS1X10065

WS1X10110

WS1X10115

WP0000688

WP0000699

WS1S7005

WS1S7010

WS1S70020

WS1S70025

WS1FS0015

WS1FS0020

WS1FS0070

WS1FS0075

WP0000121

WP0000546

WP0001019

WS1IN0085

WP0000122

WP0000123

WS1WN0005

WS1WN0010

WP0000965

WS1X10017

WP0001142

WP0001075

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

Page: 73 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

Device Type Manufacturer Device

Power Scooter

Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat.

ADP funding for positioning devices (seating) is not available for scooters. See Power

Wheelchair Options Chart when heavy duty models are required.

Shoprider/

Pihsiang

Yelle &

Associates Ltd.

ZHE JIANY

BISWIFT

ENTERPRISE

Landcruiser 889-3wh.

Landcruiser 889xls 4wh.

Sovereign 888 -4 Wh.

Trailblazer 889sel 4wh.

Voyager 778s -3 Wh.

Voyager 888sel -4 Wh.

Safari/Ltd-3 Wh.

Solo Ltd-4 Wh.

Solo/Ltd-3 Wh.

Solo/Xt550-4 Wh.

Boomer Buggy (3 or 4 Wheel)

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

WS1S70035

WS1S70036

WS1S70032

WS1S70045

WS1S70037

WS1S70040

WS1YE0020

WS1YE0007

WS1YE0005

WS1YE0010

WP0000561

Device Code Max

Allowed

Qty.

1

1

1

1

1

1

1

1

1

1

1

Approved

Price

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

$3,041.00

Page: 74 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$1,500.00

Auto Correction System*

Specialized electronics for power wheelchairs -

Offers increased driving control through specific auto-correction system; for client with limited trunk and/or upper extremity control. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Manual Elevating Legrests (pair)

Manual Recline Option

Midline Control

Multi-function Control Box

WEPQ

WEPK

WEPI

WE3D

Amysystems Multi-Function Control Box, For Use

On

Systems With Multiple Functions

Including Tilt And Power

Legs, Tilt, Recline And Power Legs

Etc.

Handicare

Invacare multi-function control box - for use on systems with multiple functions including tilt and power legs, tilt and power legs, etc

Multi-Function Control Box For Use

On

Systems With Multiple Functions.

Including Tilt

And Power Legs, Tilt, Recline And

Power Legs Etc.

Motion Concepts Trx Helix Multi-Function Control Box

(Thmc)

For Use On Systems With Multiple

Functions,

Including Tilt And Power Legs, Tilt,

Recline, Power Legs,

Etc. Includes Reduced Drive With

Elevate.

Permobil Multi-Function Control Box - For Use

On Systems

With Multiple Functions Including, Tilt

And

Power Legs, Tilt, Recline And Power

Legs, Etc.

Pride Mobility

Products

Quickie

Multi-Function Control Box -

Advanced Acutator Module (Aam)

Multi-Function Control Box For Use

On Systems With Multiple

SEC4P5005

WP0000654

SECIN5005

SECZG5005

SEC1P1005

SECX15005

SECQU4005

1

1

1

1

1

1

1

1

1

1

$391.00

$749.00

$340.00

$2,048.00

$467.00

$1,841.00

$1,820.00

$2,142.00

$596.00

$2,786.00

Page: 75 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Multi-function Control Box

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price

Functions, Including Tilt And Power

Legrest, Tilt, Recline,

Power Legrests Etc.

WEPL

WEPE

1

1

$213.00

$240.00

One Piece 90/90 Front Riggings

PW - Adjustable Tension Back

Upholstery over 18" Frame Width

PW - Adjustable Tension Back

Upholstery up to 18" Frame Width

PW - Angle Adjustable Footplates

(pair)

PW - Custom Modifications

PW - Heavy Duty Model, Client

Weight Exceeds 250 Lbs

Heavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements.

PW - Heavy Duty Model, Client

Weight Exceeds 350 Lbs

Heavy duty model required, client weight exceeds 350lbs. Authorizer must document client weight. Selected device must meet weight requirements.

PW - Heavy Duty Model, Client

Weight Exceeds 400 Lbs

Heavy duty model required, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements.

PW - Oxygen Tank

PW - Seat Depth Required is Greater

Than 18"

PW - Seat Width Required is Greater

Than 18"

PW - Ventilator Tray

Power Elevating Footrests

Amysystems

Handicare

Power Elevating & Articulating

Legrests or Center mount foot platform

Power elevating and articulating

WEPD

WEPJ

PWCM

WEPF

WEPG

WEPH

WEPX

WEPB

WEPA

WEPY

SEF4P0005

WP0000653

1

1

1

1

1

1

1

1

1

1

1

1

$140.00

$117.00

$556.00

$667.00

$979.00

$135.00

$292.00

$430.00

$1,690.00

$2,609.00

$2,800.00

Page: 76 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Power Elevating Footrests

Power Recline Only

Power Tilt Only

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

Approved

Price legrests

Motion Concepts Power Elevating At5544 Legrest

Package For Invacare

And Quickie Bases. Includes

Legrests And Actuators.

Permobil

Power Elevating Legrests For

Invacare, Quantum, And

Quickie Bases. Includes Legrests

And Actuators.

Power Elevating Articulating Leg

Rests

Articulating Foot Platform Pride Mobility

Products

Quickie

Power Elevating Articulating Leg

Rests

Power Elevating/Articulating Leg

Rests

Tarsys (Invacare) Power Elevating Legrests

Amysystems Power Recline With Integrated Shear

Reduction (Isr)

Handicare

Invacare

QLASS power recline

Sedeo Pro recline

Formula CG 12" 20" Recline Only

Formula CG 21" - 24" Recline Only

SEFZG0010

SEFZG0005

SEF1P0005

SEFX13010

SEFX13005

SEFQU0005

SEFTY0005

SEC4P0045

WP0000995

WP0000652

SECIN1010

SECIN1015

SECZG0015 Motion Concepts Power Recline Only With Power

Sliding Back (Psb) For

Invacare, Quantum, And Quickie

Bases.

Power Recline System With Esr For

Invacare,

Quickie, And Quantum Bases

Permobil

Power Recline System With

Extended Shear Reduction (Esr) For

Invacare, Quantum, And Quickie

Bases.

Corpus Power Positioning System

With Power Recline Only

Pride Mobility

Products

Quickie

Amysystems

SECZG1010

SECZG0010

SEC1P0010

Quantum TRU-Balance 3

Tru-Balance 2 Power Recline

WP0001163

SECX12055

Recline with Power Shear Reduction WP0001149

Bariatric CG Power Tilt SEC4P0060

Cg Power Tilt SEC4P0040

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

$2,567.00

$2,567.00

$2,637.00

$2,795.00

$2,543.00

$2,609.00

$2,746.00

$7,462.00

$7,933.00

$7,933.00

$9,286.00

$10,041.00

$8,698.00

$9,534.00

$8,138.00

$6,958.00

$6,298.00

$6,300.00

$7,609.00

$7,462.00

$6,062.00

Page: 77 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Power Tilt Only

Power Tilt and Recline

Effective From: February 01, 2015

Quickie

Amysystems

Handicare

Invacare

Device Device Code

Handicare

Invacare

QLASS centre of gravity power tilt WP0000993

Sedeo Pro centre of gravity power tilt WP0000650

Formula CG 12" - 20" Tilt Only

Formula CG 21" - 24" Tilt Only

SECIN1000

SECIN1005

WP0001151

SECZG0005

LEVO AG C3 Power Tilt Only

Motion Concepts Power Tilt Only For Invacare,

Quantum, And Quickie Bases.

Permobil

Power Tilt Only For Invacare,

Quantum, And Quickie Bases.

Corpus Hd Power Positioning System

With 30 Deg.

Power Tilt Only

Corpus Power Positioning System

With 45 Deg. Power Tilt Only

Ps Power Positioning System With 45

Deg. Power Tilt Only

SECZG1005

SEC1P0105

SEC1P0005

SEC1P0205

Pride Mobility

Products

Quantum TRU-Balance 3 Power

Positioning

Tru-Balance 2 Power Tilt

Tru-Balance Bariatric Power Tilt

Tru-Balance Power Tilt

WP0001162

SECX12050

WP0001022

SECX12005

Power C.G. Tilt For Quickie G-424 &

S-525

SECQU1005

Power C.G. Tilt For Quickie P-222se SECQU1015

Power C.G. Tilt For Quickie Rhythm SECQU3005

Power C.G. Tilt For Quickie S-626 SECQU1010

SPOT TILT

Spot Tilt II

Bariatric CG Power Tilt and Power

Recline With Integrated Shear

Reduction (Isr)

WP0000639

WP0001148

SEC4P0070

Cg Power Tilt & Power Recline With

Integrated Shear

Reduction (Isr)

QLASS centre of gravity power tilt and recline

SEC4P0050

WP0000994

Sedeo Pro centre of gravity power tilt plus recline

WP0000651

Formula CG 16" 20" Tilt And Recline SECIN1020

Max

Allowed

Qty.

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Approved

Price

$6,066.00

$6,067.00

$6,249.00

$7,003.00

$5,907.00

$6,067.00

$7,462.00

$10,635.00

$6,155.00

$5,222.00

$6,042.00

$5,595.00

$6,528.00

$5,320.00

$5,431.00

$5,479.00

$5,502.00

$5,431.00

$4,018.00

$6,182.00

$12,128.00

$10,728.00

$10,546.00

$10,546.00

$10,382.00

Page: 78 of 80

Assistive Devices Program

Product Manual

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Power Tilt and Recline

Effective From: February 01, 2015

Device Device Code Max

Allowed

Qty.

1

Approved

Price

$11,136.00

Invacare Formula CG 21" - 24" Tilt And

Recline

Motion Concepts Power Tilt And Power Recline For

Invacare,

Quickie, And Quantum Bases.

Power Tilt And Power Recline For

Invacare, Quantum, And

Quickie Bases.

Power Tilt And Power Recline With

Esr For

Invacare, Quantum, And Quickie

Bases

Power Tilt And Power Recline With

Esr For Invacare,

Quantum, And Quickie Bases.

Power Tilt And Power Recline With

Esr For Invacare,

Quickie, And Quantum Bases.

Power Tilt And Power Recline With

Psb For

Invacare, Quantum, And Quickie

Bases.

Permobil

Pride Mobility

Products

Quickie

SECIN1025

SECZG0018

SECZG2010

SECZG0020

SECZG2015

SECZG1015

SECZG0025

Power Tilt And Power Recline With

Psb For Invacare,

Quantum, And Quickie Bases.

Corpus Power Positioning System

With 45 Deg. Power Tilt

And Power Recline

SECZG2020

SEC1P0015

Quantum TRU-Balance 3 WP0001164

Tru-Balance 2 Power Tilt And Recline SECX12060

Smart Seat Tilt & Recline System

Tilt & Recline with Power Shear

Reduction

SECQU2005

WP0001150

WEPN

1

1

1

1

1

1

1

1

1

1

1

1

1

$9,683.00

$8,866.00

$10,210.00

$9,394.00

$10,775.00

$10,770.00

$9,954.00

$10,262.00

$10,497.00

$10,500.00

$10,733.00

$10,945.00

$842.00

Seat Package 1 for Power Bases

Seat package 1 for power bases (includes frame, sling upholstery, armrests, footrests.)

Seat Package 2 for Power Bases

Seat package 2 for power bases (includes deluxe seat and back, armrests, footrests.) No positioning devices (seating) allowed with this code.

Specialty Controls 1 Non Standard

Joystick*

WEPO

WEX1

1

1

$866.00

$1,400.00

Page: 79 of 80

Ministry of Health and Long-Term Care

Mobility Devices

Wheelchairs (Power)

OPTIONS:

Device Type Manufacturer

Specialty controls 1 - Simple Non-Standard

Joystick (includes mounting hardware, upgraded electronics & labour). Authorizer must provide clinical rationale to support the request.

Selected device must meet clinical requirements.

Specialty Controls 2 Chin/Rim

Control*

Specialty controls 2 - Complex Non-Standard

Joystick (includes upgraded electronics, mounting hardware, display, joystick modifications & labour). For chin/rim control etc.

Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 3 Simple Touch*

Specialty controls 3 - Simple Touch (includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). For footplate/headrest/tray switches etc. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 4 Proximity

Control*

Specialty controls 4 - Proximity Control

(includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 5 Breath Control*

Specialty Controls 5 - Breath Control -

Sip'N'Puff (includes mounting hardware, upgraded electronics, display, cables & labour).

Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 6 Scanners*

Specialty Controls 6 - Scanners (includes mounting hardware, upgraded electronics, display, cables, scanner & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Swingaway Mounting Bracket

Device

Assistive Devices Program

Product Manual

Effective From: February 01, 2015

Device Code Max

Allowed

Qty.

Approved

Price

WEX2

WEX3

WEX4

WEX5

WEX6

1 $3,000.00

1 $6,700.00

1 $7,500.00

1 $3,000.00

1 $5,000.00

WEPM 1 $294.00

Page: 80 of 80