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PINs and reimbursement schedule for mastectomy supplies
Last updated on January 31, 2024To print this page, press CTRL+P
Breast prostheses
- One prosthesis (each side) every 2 years or at the end of the manufacturer’s warranty
- Maximum $450 for mastectomy, $350 for lumpectomy
Note: For breast prostheses, exceptions may be made to the 2-year limit. PharmaCare pre-approval is required.
Lymphedema arm sleeves
- Two sleeves per mastectomy, per year
Gloves or gauntlets for lymphedema arm sleeves
- Two gloves or gauntlets per mastectomy, per year
- Maximum $150 for off-the-shelf products, $300 for custom-fit products
Use the relevant PIN on all applications and invoices.
PIN |
Description |
Maximum reimbursement |
|---|---|---|
| 77123116 | breast prosthesis (left) | $450 |
| 77123104 | breast prosthesis (right) | $450 |
| 77123117 | lumpectomy (left) | $350 |
| 77123118 | lumpectomy (right) | $350 |
| 77123533 | off-shelf glove or gauntlet | $150 |
| 77123534 | custom glove or gauntlet | $300 |
| 77123130 | lymphedema arm sleeve | regular retail price |