Reimbursement schedule for prosthetic and orthotic services and supplies
Last updated on January 31, 2024To print this page, press CTRL+P
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 | reimbursement is based on actual costs but cannot exceed $399.99 |
| Orthotic repairs/adjustments—use if pre-approval is required | 77123528 |
by approval |
| 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.