Breast pump prescription forms
Insurance needs a prescription from your doctor. Pick your form, fill it in online, and bring it to your appointment ready to sign.
Breast pump
Pregnant or just had your baby? This covers your double electric breast pump and milk storage bags.
Pump supplies
Already have a pump? This covers replacement flanges, bottles, tubing, valves and membranes.
Maternity support
Support bands, braces, compression socks and more, for during pregnancy and after birth.
What is a breast pump prescription?
A breast pump prescription is a short, signed order from your doctor or midwife for a double electric breast pump. Your insurance needs one before it covers your pump.
It isn’t the kind you take to a pharmacy. It comes to us, your medical supply company, and we bill your plan. The example here is our form, filled in the way your doctor will see it.
What’s on the prescription
- Your details
- Name, date of birth, phone and due date. Your insurance helps us match it to your order.
- The pump
- A double electric breast pump, code E0603, with a length of need of 99 months.
- Milk storage bags
- Code A4287, with how many bags your plan covers every 30 days.
- Diagnosis
- Z39.1, the code for lactation care.
- Your doctor
- Their printed name, NPI number and phone, so we can reach the office.
- Signature and date
- Signed by that provider, by hand or electronically. The date is required.
Who can sign it
An MD, DO, PA, CRNP, DNP, CNMW or ARNP. That’s usually your OB, midwife, family doctor or nurse practitioner.
- No stamped signatures.
- A nurse (RN or LPN) or medical assistant can’t sign for the provider.
- On a state Medicaid plan, a Medicaid credentialed provider signs.
How to get your prescription signed
Bring it to your doctor
- Pick your form at the top of this page and fill it in online.
- Bring it to your next appointment, or send it to the office.
- Your doctor faxes it to (866) 430-7882 or emails RX@thebreastfeedingshop.com.
- Or you upload the signed form when you order.
Or let us ask for it
- Start your order and add your doctor’s name.
- We request the prescription from their office.
- We check your coverage while we wait.
When to get your prescription
Any time during pregnancy. Most plans let you receive your pump about 30 days before your due date, and some allow it earlier. TRICARE covers the pump from 27 weeks.
Getting it signed at a prenatal visit means it’s ready the day your plan is. Not sure of your date? Try our due date calculator.
Breast pump prescription questions
Do I need a prescription for a breast pump?
Yes, to get it through insurance. You don’t need it in hand to order, though. Give us your doctor’s details when you order and we request the prescription for you.
What does a breast pump prescription look like?
It’s a one-page order with your details, the pump and its code (E0603), a diagnosis (Z39.1), and your doctor’s name, NPI, signature and the date. The example on this page is our form, filled in.
I have a prescription for a breast pump. Now what?
Order online and upload it there. Or have your doctor’s office fax it to (866) 430-7882 or email it to RX@thebreastfeedingshop.com. We check your coverage and ship as soon as your plan allows.
Can my midwife or nurse practitioner sign it?
Yes. An MD, DO, PA, CRNP, DNP, CNMW or ARNP can sign. A nurse (RN or LPN) or a medical assistant can’t sign on the provider’s behalf.
When should I get my breast pump prescription?
Any time during pregnancy. Most plans let you receive your pump about 30 days before your due date, and some allow it earlier. TRICARE covers the pump from 27 weeks of pregnancy.
Does Medicaid need anything different?
Yes. If your plan is run by your state’s Medicaid program, the prescription has to be signed by a Medicaid credentialed provider.
Do I need a prescription for pump parts or compression socks?
To use your insurance for them, yes. Pick the pump supplies or maternity support form at the top of this page and have your doctor sign it.
Is what I type on the fill-in form sent to you?
No. Your prescription is made on your phone or computer, and nothing you type is sent to us or saved. You send us the signed form when you’re ready.
Ready to order your pump?
Start your order with or without a prescription. We check your coverage and handle the paperwork with your doctor.
Questions? Call (866) 255-6779.