Prosthetic & Orthotic Product Identification Numbers

Mastectomy PINs
Ocular PINs
Orthotic PINs
Prosthetic PINs

 


  • PharmaCare requires pre-approval for all eligible prostheses and orthoses except the following exempted items:
    • prosthetic supplies under $400.00
    • lymphedema arm sleeves, and gloves / gauntlets
    • plagiocephaly helmets for patients who meet the criteria set forth on page 2 of the PharmaCare Orthotic Benefits – Plagiocephaly Helmet form (HLTH 5450)
    • regular benefit breast prostheses and post-mastectomy brassieres (unless requesting an exception to policy, such as replacing a breast prosthesis before the two-year limit; in that case, pre-approval is required)
    • prosthetic and orthotic repairs or adjustments under $400.00
  • PharmaCare will not cover any non-exempt item unless pre-approval was granted.

  • Pre-approval is valid for 6 months from the date on the approval letter 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 $399.99

 

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; 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
(Use when pre-approval IS required)

77123499

Maximum $2,850.00

 

Plagiocephaly Orthosis – Child’s Helmet
(Use only when pre-approval is NOT required)

77123535

Maximum $2,850.00

 

Orthotic Repairs and Adjustments – Use ONLY if No Pre-approval required

77123504

Maximum $399.99

 

Orthotic Repairs and Adjustments – Use if Pre‑approval required

77123528

 

 

Prosthetic 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 level of amputation, and 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.

 

Prosthetic Products

PIN

Limits

 

Cosmesis

77123532

 

 

Ear Prosthesis – Left

77123177

 

 

Ear Prosthesis – Right

77123189

 

 

Elbow Disarticulation – Left – Prosthesis

77123520

 

 

Elbow Disarticulation – Right – Prosthesis

77123521

 

 

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 $399.99

 

Prosthetic Repairs/Adjustments – Use if Pre‑Approval Required

77123529

 

 

Prosthetic Supplies – Use ONLY if No Pre‑Approval Required

77123232

Maximum $399.99

 

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