PINs and Reimbursement Schedule for Mastectomy Supplies

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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