The Surgeon General recommends that mothers exclusively breastfeed for six months (no formula), and continue to breastfeed after the introduction of solid food for a year, or longer if desired. The Affordable Care Act requires most health insurance plans to cover the cost of a breast pump as part of women’s preventative health services. To help you successfully breastfeed, EmblemHealth has made breast pumps available to you through participating vendors.
This benefit does not apply to members enrolled in limited benefits coverage plans. See exclusions.
How can I get a manual or electric breast pump?
- Call the Customer Service number on the back of your member ID card to confirm coverage.
- Get a prescription from your provider (physician, midwife, nurse practitioner or physician assistant) during your third trimester of pregnancy.
- Contact a participating Durable Medical Equipment (DME) vendor from the list below and arrange to mail, fax or email your actual prescription or a scanned copy. The DME vendor will arrange for delivery of your pump to you.
You can keep your manual or electric breast pump. All necessary supplies for double pumping such as bottles, caps, tubing and shields are covered and should be included in the breast pump kit. Only one breast pump will be issued in a 12-month period.
Hospital Grade Breast Pumps
Hospital grade breast pumps are often recommended when a baby is in the neonatal intensive care unit (NICU), is unable to latch, or a medical issue presents. Your provider (physician, midwife, nurse practitioner or physician assistant) can prescribe a hospital grade breast pump rental.
EmblemHealth requires prior authorization for a hospital grade breast pump rental. Once authorized, the rental is effective for 90 days. If needed for longer than 90 days, additional pre-authorization and a prescription are needed every 90 days thereafter for continued rental.
How can I get a hospital grade breast pump?
- Your provider will need to provide a prescription stating the specific reason for medical necessity for the hospital grade breast pump.
- Contact EmblemHealth and request prior authorization for the rental of your hospital grade breast pump and submit the prescription of medical necessity from your provider.
- Contact a participating DME vendor from the list above for your pump.
- When authorized, the DME vendor will arrange to deliver your pump and supply kit to you.
- All necessary basic breast pump supplies for double pumping, as well as receptacle bottles with flanges, caps, and tubing, are included in the breast pump kit with the rental.
Breast Pump Supplies
Can I get reimbursed for breast pump supplies?
- Breast pump supplies (CPT A4281 through 4286) purchased through an EmblemHealth DME vendor listed above will be reimbursed with proof of purchase/receipt only; no prescription is required for breast pump supplies for participating plans.
Exclusions: Breast pump adaptors and battery packs, regular baby bottles not specific to the breast pump, travel bags, breast pump cleaning supplies, hands-free bras, baby weigh scales, ice packs/coolers, nursing bras, breast shells, nursing pads, nipple shields, and over-the-counter breastfeeding creams or ointments.
A prescription is required for reimbursement for all covered plan members who have purchased either an (E0602) - Breast Pump: Manual - any type or an (E0603) - Breast Pump: Electric (AC and/or DC) through our DME vendors. Reimbursement may be requested in writing with proof of purchase/receipt and a prescription from your provider.
If you need assistance, call Healthy Beginnings PATH at 1-888-447-0337. Representatives are available Monday through Friday from 8:30 am to 5 pm (TTY/TDD: 711).
Meet With a Lactation Consultant
Hospital maternity units have lactation consultants on staff. While you’re in the hospital after delivery, ask to have the lactation consultant come to see you while you are breastfeeding. She can offer suggestions and encouragement to make breastfeeding the special experience it should be.
All members are covered for lactation consultant visits* at home or in the doctor’s office after delivery. For more information about lactation consultant visits, go to www.emblemhealth.com/breastfeeding or call the Healthy Beginnings PATH program at 1-888-447-0337, Monday through Friday from 8:30 am to 5 pm (TTY/TTD: 711).
Note: This benefit does not apply to members enrolled in limited benefits coverage plans, such as dental only and vision only, or grandfathered plans, such as certain Healthy New York plans and certain standard HMO individual direct payment plans. Also, HIP City of New York accounts, HMO, and Vytra, are not covered under the Women’s Preventive Services (WPS) Mandate, unless they have a durable medical equipment rider with EmblemHealth. For more information regarding Grandfathered plans and the WPS, please visit https://www.healthcare.gov/coverage/breast-feeding-benefits/.
Medicare does not cover breast pumps or breast pump supplies.
*Lactation consultant must be an International Board Certified Lactation Consultant (IBCLC) who is also a nurse, midwife, physician assistant, nurse practitioner or physician.