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Insurance Order Form
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1
Are you located in one of the following States: Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont or Maine?
YES
NO
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2
At this time we do not offer Breast Pump's through insurance for the state you are in.
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3
Patient Information
*
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First Name
Last Name
Date of Birth
Phone Number
Street Address
City
State
Zip Code
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4
Email
example@example.com
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5
Due Date
*
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-
Date
Year
Month
Day
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6
Prescription
*
This field is required.
I have a prescription for an electric breast pump
I do not have a prescription for an electric breast pump
I have a prescription for an electric breast pump
I do not have a prescription for an electric breast pump
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7
Prescription Upload
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Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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8
OBGYN/Midwife Information
OBGYN/Midwife Name
OBGYN/Midwife Phone Number
OBGYN/Midwife Facility Name
OBGYN/Midwife Office Address
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9
Insurance Information
Aetna
Allways
Anthem BC/CT
BCBS MA
BCBS of RI
Blue Benefits of Mass
BMC Healthnet/Northwood
Cigna
Harvard Pilgrim
Masshealth
Tufts - Commercial
Tufts - Medicaid
My Insurance Isn't Listed
Aetna
Allways
Anthem BC/CT
BCBS MA
BCBS of RI
Blue Benefits of Mass
BMC Healthnet/Northwood
Cigna
Harvard Pilgrim
Masshealth
Tufts - Commercial
Tufts - Medicaid
My Insurance Isn't Listed
Primary Insurance Name
Primary Insurance ID#
I am the policy holder
I am the spouse of the policy holder
I am the child of the policy holder
I am the policy holder
I am the spouse of the policy holder
I am the child of the policy holder
Relationship to Policy Holder
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10
Do you have secondary insurance?
*
This field is required.
YES
NO
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11
Secondary Insurance Information
*
This field is required.
Secondary Insurance Name
Secondary Insurance ID#
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12
Products - Aetna
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
$50 - Elvie Stride
$75 - Spectra S1 Plus
$80 - Pump In Style® with MaxFlow™
$105 - Medela Swing Maxi
$195 - Freestyle Flex™
$355 - Elvie Double
The Breast Pump I'm interested in is not listed.
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13
Products - Allways
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
$15 - Elvie Stride
$15 - Pump In Style® with MaxFlow™
$25 - Spectra S1 Plus
$55 - Medela Swing Maxi
$140 - Freestyle Flex™
$300 - Elvie Double
The Breast Pump I'm interested in is not listed.
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14
Products - Anthem BC/CT
*
This field is required.
$0 - Ameda Mya Joy
$20 - Ameda Mya Rechargeable
$50 - Spectra S2 Plus
$50 - Pump In Style® with MaxFlow™ Insurance
$130 - Elvie Stride
$130 - Spectra S1 Plus
$155 - Pump In Style® with MaxFlow™
$185 - Medela Swing Maxi
$265 - Freestyle Flex™
$430 - Elvie Double
The Breast Pump I'm interested in is not listed.
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15
Products - BCBS of MA
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
$75 - Elvie Stride
$85 - Spectra S1 Plus
$100 - Pump In Style® with MaxFlow™
$125 - Medela Swing Maxi
$210 - Freestyle Flex™
$375 - Elvie Double
The Breast Pump I'm interested in is not listed.
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16
Products - BCBS of RI
*
This field is required.
$0 - Ameda Mya Joy
$50 - Ameda Mya Rechargeable
$60 - Spectra S2 Plus
$75 - Pump In Style® with MaxFlow™ Insurance
$120 - Elvie Stride
$120 - Spectra S1 Plus
$145 - Pump In Style® with MaxFlow™
$175 - Medela Swing Maxi
$255 - Freestyle Flex™
$420 - Elvie Double
The Breast Pump I'm interested in is not listed.
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17
Products - Blue Benefits of Mass
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
$75 - Elvie Stride
$85 - Spectra S1 Plus
$100 - Pump In Style® with MaxFlow™
$125 - Medela Swing Maxi
$210 - Freestyle Flex™
$375 - Elvie Double
The Breast Pump I'm interested in is not listed.
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18
Products - BMC Healthnet/Northwood
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
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19
Products - Cigna
*
This field is required.
$0 - Ameda Mya Joy
$50 - Ameda Mya Rechargeable
$50 - Pump In Style® with MaxFlow™ Insurance
$65 - Spectra S2 Plus
$120 - Elvie Stride
$130 - Spectra S1 Plus
$155 - Pump In Style® with MaxFlow™
$185 - Medela Swing Maxi
$265 - Freestyle Flex™
The Breast Pump I'm interested in is not listed.
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20
Products - Harvard Pilgrim
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
$15 - Elvie Stride
$25 - Spectra S1 Plus
$25 - Pump In Style® with MaxFlow™
$55 - Medela Swing Maxi
$140 - Freestyle Flex™
$300 - Elvie Double
The Breast Pump I'm interested in is not listed.
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21
Products - Masshealth
*
This field is required.
$0 - Spectra S2 Plus
$0 - Pump In Style® with MaxFlow™ Insurance
$0 - Ameda Mya Joy
$0 - Ameda Mya Rechargeable
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22
Products - Tufts - Commercial
*
This field is required.
$0 - Spectra S2 Plus Electric Breast Pump
$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump
$0 - Ameda Mya Joy Double Electric Breast Pump
$0 - Ameda Mya Rechargeable
$25 - Spectra S1 Plus Electric Breast Pump
$50 - Pump In Style® with MaxFlow™ Breast Pump
$100 - Freestyle Flex™ Double Electric Breast Pump
The Breast Pump I'm interested in is not listed.
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23
Products - Tufts - Medicaid r
*
This field is required.
$0 - Spectra S2 Plus Electric Breast Pump
$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump
$0 - Ameda Mya Joy Double Electric Breast Pump
$0 - Ameda Mya Rechargeable
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24
Please select any additional supplies you'd like to purchase.
Please note, these items would be an out of pocket expense.
$34.99 *Elvie Catch* A set of breast milk collection cups with slip-proof security. Stay leak-free and save your milk.
$49.99 *Elvie Curve* A wearable, silicone breast pump for easy, hands-free expression. Uses natural suction for low-effort expression.
$199.00 *Elvie Trainer* Smart Kegel trainer to strengthen your pelvic floor. Fun, expert-designed workouts and fast results. Your most personal trainer.
No thanks. I'd only like to order the breast pump.
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25
Terms and Conditions Acknowledgment
*
This field is required.
I acknowledge that if I have coverage under more than insurance policy, I have listed both insurances in the proper Primary and Secondary insurance sections. If I do not, I may be responsible for payment in full if my claim is denied by the listed Primary insurer. I certify that I have reviewed, understand, and accept the terms and conditions disclosed
here
.
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