Breast Pump Insurance Order Form

1

Are you located in one of the following States: Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont or Maine?

YESNO

2

At this time we do not offer Breast Pump's through insurance for the state you are in.

3

Patient Information* This field is required.

First Name

Last Name

Date of Birth

Phone Number

Street Address

City

State

Zip Code

4

Prescription* This field is required.

5

Prescription Upload* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

6

OBGYN/Midwife Information

OBGYN/Midwife Name

OBGYN/Midwife Phone Number

OBGYN/Midwife Facility Name

OBGYN/Midwife Office Address

7

Insurance Information

Primary Insurance Name

Primary Insurance ID#

Relationship to Policy Holder

8

Do you have secondary insurance?* This field is required.

YESNO

9

Secondary Insurance Information* This field is required.

Secondary Insurance Name

Secondary Insurance ID#

10

Products - Aetna* This field is required.

$75 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$80 - Pump In Style® with MaxFlow™ Breast Pump

$195 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

11

Products - Allways* This field is required.

$25 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$15 - Pump In Style® with MaxFlow™ Breast Pump

$140 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

12

Products - Anthem BC/CT* This field is required.

$130 - Spectra S1 Plus Electric Breast Pump

$70 - Spectra S2 Plus Electric Breast Pump

$49 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$155 - Pump In Style® with MaxFlow™ Breast Pump

$265 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$60 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

13

Products - BCBS of MA* This field is required.

$85 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$100 - Pump In Style® with MaxFlow™ Breast Pump

$210 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

14

Products - BCBS of RI* This field is required.

$120 - Spectra S1 Plus Electric Breast Pump

$60 - Spectra S2 Plus Electric Breast Pump

$49 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$145 - Pump In Style® with MaxFlow™ Breast Pump

$255 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$50 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

15

Products - Blue Benefits of Mass* This field is required.

$85 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$100 - Pump In Style® with MaxFlow™ Breast Pump

$210 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

16

Products - BMC Healthnet/Northwood* 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

17

Products - Cigna* This field is required.

$130 - Spectra S1 Plus Electric Breast Pump

$65 - Spectra S2 Plus Electric Breast Pump

$49 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$155 - Pump In Style® with MaxFlow™ Breast Pump

$265 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$60 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

18

Products - Harvard Pilgrim* This field is required.

$25 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$25 - Pump In Style® with MaxFlow™ Breast Pump

$140 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

19

Products - Masshealth* 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

20

Products - Tufts* This field is required.

$25 - Spectra S1 Plus Electric Breast Pump

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$50 - Pump In Style® with MaxFlow™ Breast Pump

$100 - Freestyle Flex™ Double Electric Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

The Breast Pump I'm interested in is not listed.

21

Products - Tufts Health Together* 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

22

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.

YESNO