Reimbursement Schedule for Prosthetic and Orthotic Services and Supplies

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To determine the PharmaCare maximum reimbursement amount for a specific procedure, consult the list below.

Claim the appropriate reimbursement amount for the labour and small component costs using the relevant prosthetic or orthotic Product Identification Number (PIN).

Notes:

  • Maximum reimbursement amounts are based on a health care provider’s usual and customary price up to the PharmaCare maximum reimbursement specified below.
  • PharmaCare coverage is limited to one check, test, dynamic or diagnostic socket per laminated definitive socket.
  • An immediate post-operative prosthesis can be billed separately, or it can be included with the first Application for Financial Assistance form completed for the client’s first prosthetic device.
Procedure  PIN Maximum Reimbursement
Hourly rate— for repairs and adjustments (can be calculated at amounts less than a full hour) - $163
Cosmesis, endoskeletal finish—transtibial (TT)
Note: the cosmesis can be billed under a definitive socket PIN, if included in a pre-approval for a full prosthesis; if being billed separately use this PIN
77123532 $600
Cosmesis, endoskeletal finish—transfemoral (TF)
Note: the cosmesis can be billed under a definitive socket PIN, if included in a pre-approval for a full prosthesis; if being billed separately use this PIN
77123532 $1380 (full cosmesis)
$600 (lower portion only - NEW)
Immediate post-operative prosthesis (IPOP)
*Provided in the operating room, not post-surgery
- $1,820
Liner, fit and trim (pair)—only when replacing liners, without replacing the definitive socket - $82
Liner—pelite - $440
Liner—pelite and leather - $550
Liner—pelite, leather and PPT - $665
Liner—transfemoral (TF), thermolyn with valve - $720
Loaner—foot - $165
Loaner—knee - $220
Ocular polishing 77123531 by approval
Ocular polishing/repairs—use if pre-approval is not required 77123165 reimbursement is based on actual fee but cannot exceed $399.99
Orthotic repairs/adjustments—use if pre-approval is not required 77123504 by approval
Orthotic repairs/adjustments—use if pre-approval is required 77123528 reimbursement is based on actual costs but cannot exceed $399.99
Prosthetic glove, install - $82
Prosthetic repairs/adjustments—use if pre-aproval is not required 77123244 reimbursement is based on actual costs but cannot exceed $399.99
Prosthetic repairs/adjustments—use if pre-aproval is required 77123529 by approval
Prosthetic supplies—use if pre-aproval is not required 77123232 reimbursement is based on actual costs but cannot exceed $399.99
Prosthetic supplies—use if pre-aproval is required 77123530 by approval
Shuttle lock procedure (during fabrication of definitive socket) - $300
Strap, patellar tendon bearing (PTB) - $200
Suction procedure (TF—skin fit only) - $360
Test socket—diagnostic, dynamic, transfemoral (TF) - $825
Test socket—diagnostic, dynamic, transtibial (TT) - $700
Test socket—diagnostic, static, transfemoral (TF) - $600
Test socket—diagnostic, static, transtibial (TT) - $500
Test socket—diagnostic, static, transtibial (TR) - $500
Test socket—diagnostic, static, transtibial (TH) - $500

Note: The maximum reimbursement amounts above often include the cost of certain small components. The cost of shop supplies is NOT eligible for reimbursement.