2019 New Tricare Breast Pump Policy

FAQ’s for New Tricare Policy The Tricare policy for Breast pumps has been updated as of March 12, 2019.

However, the effective date of the policy changes was made retroactive to July 5, 2018. This means that any claims that have not processed or are under appeal will be subjected to the new policy guidelines.

Section 3.2 defines the coverage extended to all pregnant Tricare Beneficiaries beginning at the 27th week of pregnancy (third trimester) or birth of the child if prior to 27 weeks.

  • • E0603 standard electric breast pump will NOT be covered if the date of service is prior to the 27th week of pregnancy. The Due date of the baby will be the determining factor.
  • No E0603 should be shipped any sooner than 91 days prior to the due date.
  • NO SUPPLIES will be covered before the birth event Section

4.2.4 changes the coverage of Breast Pump Kits from two per birth event to ONE PER BIRTH event. It also states that it may not be separately reimbursed. Section 5.5 goes on further to explain that the “KIT” or all items packaged with the E0603 Breast Pump may not be separately reimbursable.

  • While one “Kit” per birth event is covered, it is not an item that can be billed. It is considered included with the reimbursement for the E0603 Standard Electric Breast Pump.

Section 4.2.5 states that a prescription from a TRICARE-authorized physician, physician assistant, nurse practitioner, or nurse midwife is required for coverage of the breast pump. In addition, the prescription must, at a minimum, indicate the type of breast pump prescribed (manual or standard electric).

  • The initial E0603 Standard Electric Breast Pump order must be signed by only the listed and credentialed providers.
  • NO LPN, RN, office staff, Medical assistant etc. may sign the prescription
  • Because the supplies are included with the pump the initial prescription does not have to state “Supplies” or “Accessories”

4.2.7 Effective for dates of service on or after July 5, 2018, only the following replacement supplies are available without an additional prescription:

  • Bottles: Two bottles and caps/locking rings every 12 months following a birth event;
  • Power Adapters: One replacement power adapter per birth event, and not within the first 12 months following purchase;
  • Valves: Twelve valves/membranes for each 12 months period following a birth event;
  • One set (2) of flanges/breast shields per birth event;
  • One set of tubing per birth event;
  • Ninety breast milk bags every 30 days following the birth event.

4.2.9 Effective July 5, 2018, additional replacement supplies, in addition to those detailed in paragraphs 4.2.7 and 4.2.8, may be covered when a new prescription from an authorized individual professional provider is obtained, describing the specific supplies required. Only those replacement supplies in excess of the limits described in paragraphs 4.2.7 and 4.2.8, which are essential for breast feeding and are accompanied by a new prescription from a TRICARE-authorized individual professional provider, shall be reimbursed.

  • Following the initial E0603 Standard Electric Breast Pump order and the birth of the baby Supplies may be ordered.
  • 4.2.7 outlines the quantity and time frame for REPLACEMENT supplies that may be provided with no prescription
  • If a customer has already received a replacement item then subsequent orders would require a prescription with quantity.
  • This only a replacement order and can not exceed the quantity of the items listed in 4.2.7

Example; Pump ordered with compliant RX (signed, dated by authorized provider, includes customer name, includes description of electric breast pump and is legible) Due date is within 91 days.

The following items can be ordered with out a prescription after the birth event;

  • Bottles: Two bottles and caps/locking rings every 12 months following a birth event;
  • Power Adapters: One replacement power adapter per birth event, and not within the first 12 months following purchase;
  • Valves: Twelve valves/membranes for each 12 months period following a birth event;
  • One set (2) of flanges/breast shields per birth event;
  • One set of tubing per birth event;
  • Ninety breast milk bags every 30 days following the birth event.

Customer has received two bottles in previous order;

  • We need to have a detailed RX specifying 2 bottles, caps and locking rings
  • Can not exceed 2 bottles because we are only replacing used/non-functional items
  • RX must be within 30 days of new order of bottles. We cannot have an old RX for new order. i.e., cannot have an rx from November for order being placed in January even if the customer has never received any items associated with November RX

E0603 – Standard Electric Breast Pump Can only be ordered on or after 27 weeks of Pregnancy (91 days prior to due date) Requires RX always RX must include “Electric Breast Pump” at a minimum RX must be from authorized provider (Physician, Physician’s assistant, Nurse Practitioner or Nurse Mid-wife – No other signers permitted) RX must include order date RX must have patients name at a minimum

A4281 – Replacement tubing One set of tubing may be provided per “birth event” without an RX If additional tubing is required after the initial set has been billed, we need to have an RX specifying “Replacement Tubing” (Reference RX requirements in E0603) We can only supply one set of tubing per order/per prescription (this is intended only as a replacement for damaged/non-functional items.

A4282 – Replacement Power adaptor Can only be provided 12 months after initial E0603 date of service No RX is required

A4285 – Bottle   A4283 – Cap   A4286 – Locking Rings

Two Bottles with Caps and Locking Rings may be provided per “birth event” without an RX

If additional Bottles are required after the initial set has been billed, we need to have an RX specifying “Replacement Bottle with Caps and Locking Rings” (Reference RX requirements in E0603)

We can only supply one set of Bottles per order/per prescription (this is intended only as a replacement for damaged/non-functional items.

A9900 – Breast Milk Storage Bags 90 bags per 30 day period may be provided without an RX following the Birth Event NO MORE than 90 bags will be covered regardless of circumstances Can not bill more than 90 bags within a 30 day period

A9999 – Valve / Membranes 12 valve/membranes are covered for each 12 months period following the birth event without an RX 12 valves/membranes are covered after 12 months from initial E0603 date of service without a prescription

Place your order for a breast pump covered 100% through Tricare bellow :

 

Click Here for a PDF download of the new 2019 Tricare Breast Pump Policy