Prosthetic & Orthotic Product Identification Numbers

Mastectomy PINs
Ocular PINs
Orthotic PINs
Prosthetic PINs

PharmaCare requires health care providers to apply for pre-approvals for their patients for all benefits valued at $400 or more.
PharmaCare will not cover any item at or above that value unless pre-approval was granted.
Pre-approval is valid for 6 months from the date on the approval letter/form returned to the health care provider.

Mastectomy PINs

PharmaCare provides coverage for mastectomy prostheses and supplies for eligible individuals who have undergone a mastectomy.

	Mastectomy Products	PIN	Limits
	Breast Prosthesis – Left	77123116	1 every 2 years; maximum $350
	Breast Prosthesis – Right	77123104	1 every 2 years; maximum $350
NEW	Breast Prosthesis (Lumpectomy) – Left	77123117	1 every 2 years; maximum $300
NEW	Breast Prosthesis (Lumpectomy) – Right	77123118	1 every 2 years; maximum $300
NEW	Unattached off-the-shelf glove/gauntlet	77123533	2 per year, per mastectomy; maximum $150 each
NEW	Unattached custom-fit glove/gauntlet	77123534	2 per year, per mastectomy; maximum $300 each
	Lymphedema Arm Sleeve	77123130	2 sleeves per year, per mastectomy
	Post Mastectomy Brassiere	77123128	2 per mastectomy within 6 months of surgery

Ocular PINs

Claims to PharmaCare should include labour and material costs associated with the device, as included on the pre-approval. These costs should be claimed under the appropriate PIN based on the side that is being fitted.

Prosthetic devices may be replaced:

no sooner than three years from the date on the PharmaCare approval letter/form; and
only if it is demonstrated that the existing device no longer meets the patient’s basic functionality needs.

Ocular Products	PIN	Limits
Ocular Polishing/Repairs – Use ONLY if No Pre-Approval is Required	77123165	Maximum $400
Ocular Polishing/Repairs – Use if Pre‑Approval is Required	77123531
Ocular Prosthesis – Left	77123153
Ocular Prosthesis – Right	77123141

Orthotic PINs

Claims to PharmaCare should include clinical labour, material and component costs associated with the device, as included on the pre-approval. These costs should be claimed under the appropriate PIN based on the type of orthosis being fitted.

Orthoses for children and youth may be replaced:

no sooner than one year from the date on the approval letter/form; and
only if it is demonstrated that the existing device no longer meets the basic functionality needs for the patient.

Orthotic Products	PIN	Limits
Supramalleolar Orthosis – Child Brace	77123507
Ankle Foot Orthosis – Rigid – Child Brace	77123508
Ankle Foot Orthosis – Articulated – Child Brace	77123509
Ankle Foot Orthosis with Supramalleolar Orthosis – Child Brace	77123510
Ankle Foot Orthosis, Patella Tendon Bearing/Ground Reaction – Child Brace	77123511
Hip Abduction Orthosis – Child’s Brace	77123512
Knee Ankle Foot Orthosis, Rigid Ankle – Child Brace	77123513
Knee Ankle Foot Orthosis, Articulated Ankle – Child Brace	77123514
Hip Knee Ankle Foot Orthosis – Child Brace	77123515
Reciprocating Gait Orthosis – Child Brace	77123516
Spinal Orthosis – Child’s Brace	77123517
Plagiocephaly Orthosis – Child’s Helmet	77123499
Orthotic Repairs and Adjustments – Use ONLY if No Pre-approval Required	77123504	Maximum $400
Orthotic Repairs and Adjustments – Use if Pre‑Approval Required	77123528

Prosthetic PINs

Prosthetic devices may be replaced:

no sooner than three years from the date on the PharmaCare approval letter/form; and
only if it is demonstrated that the existing device no longer meets the patient’s basic functionality needs.

Prosthetic Products	PIN	Limits
Cosmesis	77123532
Ear Prosthesis – Left	77123177
Ear Prosthesis – Right	77123189
Elbow Disarticulation – Left – Prosthesis	77123520
Elbow Disarticulation – Right – Prosthesis	77123521
Finger Prosthesis	77123500
Hand Prosthesis – Partial	77123505
Hemipelvectomy – Left – Prosthesis	77123522
Hemipelvectomy – Right – Prosthesis	77123523
Hip Disarticulation – Left – Prosthesis	77123440
Hip Disarticulation – Right – Prosthesis	77123438
Knee Disarticulation – Left – Prosthesis	77123487
Knee Disarticulation – Right – Prosthesis	77123475
Nose Prosthesis	77123501
Prosthetic Repairs/Adjustments – Use ONLY if No Pre-Approval Required	77123244	Maximum $400
Prosthetic Repairs/Adjustments – Use if Pre‑Approval Required	77123529
Prosthetic Supplies – Use ONLY if No Pre‑Approval Required	77123232	Maximum $400
Prosthetic Supplies – Use if Pre‑Approval Required	77123530
Proximal Femoral Focal Deficiency – Left – Prosthesis	77123524
Proximal Femoral Focal Deficiency – Right – Prosthesis	77123525
Rotation Plasty – Left – Prosthesis	77123526
Rotation Plasty – Right – Prosthesis	77123527
Shoulder Disarticulation – Left – Prosthesis	77123463
Shoulder Disarticulation – Right – Prosthesis	77123451
Symes Prosthesis – Left – Prosthesis	77123384
Symes Prosthesis – Right – Prosthesis	77123372
Trans-femoral (Above Knee) – Left – Prosthesis	77123359
Trans-femoral (Above Knee) – Right – Prosthesis	77123335
Trans-humeral (Above Elbow) – Left – Prosthesis	77123270
Trans-humeral (Above Elbow) – Right – Prosthesis	77123256
Trans-metatarsal – Left – Prosthesis	77123207
Trans-metatarsal – Right – Prosthesis	77123190
Trans-radial (Below Elbow) – Left – Prosthesis	77123281
Trans-radial (Below Elbow) – Right – Prosthesis	77123268
Trans-tibial (Below Knee) – Left – Prosthesis	77123360
Trans-tibial (Below Knee) – Right – Prosthesis	77123347
Trans-tarsal – Left – Prosthesis	77123402
Trans-tarsal – Right – Prosthesis	77123396
Wrist Disarticulation – Left – Prosthesis	77123518
Wrist Disarticulation – Right – Prosthesis	77123519