Prosthetic & Orthotic Product Identification Numbers (PINs)

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About Coverage of Prosthetic and Orthotic Products

The Prosthetic and Orthotic Program helps patients to achieve or maintain basic functionality. PharmaCare helps eligible patients pay for the costs of eligible prostheses and orthoses, subject to the rules of their PharmaCare plan, including any annual deductible requirement.
Full details of the Prosthetic and Orthotic Program and associated policies are provided in:

Please note: Health Canada’s Non-Insured Health Benefits (NIHB) covers prosthetic, orthotic, mastectomy, and ostomy benefits for First Nations Health Authority clients. These are not currently covered for FNHA clients under PharmaCare Plan W.

Pre-Approval Requirements

  • PharmaCare requires pre-approval for all eligible prostheses and orthoses except the following:
    • 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) (PDF, 529KB)
    • regular benefit breast prostheses (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 does not cover any non-exempt item unless pre-approval has been 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 $450

 *

Breast Prosthesis – Right

77123104

1 every 2 years;
maximum $450

 *

Breast Prosthesis (Lumpectomy) – Left

77123117

1 every 2 years;
maximum $350

 *

Breast Prosthesis (Lumpectomy) – Right

77123118

1 every 2 years;
maximum $350

 

Unattached off-the-shelf glove/gauntlet

77123533

2 per year,
per mastectomy;
maximum $150 each

 

Unattached custom-fit glove/gauntlet

77123534

2 per year,
per mastectomy;
maximum $300 each

 

Lymphedema Arm Sleeve

77123130

2 sleeves per year,
per mastectomy

       

* Maximum coverage updated June 24, 2015

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