Your Top 20 TRICARE Lactation Policy Questions Answered

TRICARE Lactation Policy breastpumpIf you are in the military or know someone in the military, you’ve probably heard the rumors swirling around about TRICARE finally offering breast pumps, supplies and lactation counseling.  The rumors are true and last week I wrote a post about the Updated TRICARE Lactation Policy and was immediately inundated with numerous questions and comments on the BFinCB Facebook Page, this Blog and via my email about how it all works.

I won’t rehash the policy here. You can read the actual policy at the TRICARE website and take a look at the announcement that they posted. My aim here is to do my best to provide clarification on the new policy below (with updates as I find out more in the coming days and weeks).

Here are the Top 20 Questions:

1. I’ve called TRICARE and the reps are saying breast pumps, supplies and counseling are NOT covered, or that I need a referral, or that there is a cap on the reimbursement.  Why is that?

It takes time for the new policies to be put in place and training to occur so that the reps CAN answer your questions.  The policy will be implemented as of July 1st and then the Regional Contractors will start giving out information regarding coverage of breast pumps, breastfeeding supplies and counseling.  It seems that different regions are also implementing the policy differently depending on how they interpret it (which is very unfortunate, it should be the same across the board). 

2. What exactly is a “birth event”?

A “birth event” includes a TRICARE-eligible pregnant beneficiary or female beneficiary who legally adopts an infant and intends to breastfeed the infant. In other words, if you are TRICARE-eligible and are pregnant, have had a baby, or are planning to adopt or have adopted an infant (and plan to or are breastfeeding), it all counts as a “birth event”.

3. How do I get a prescription for the breast pump and supplies?

Easy-peasy, ask your HCP to write one. It can be your PCM, OB, Family Practice, Pediatrician, pretty much anyone with prescribing authority. The prescription must state what kind of pump you need: hospital-grade, electric or manual. Wondering which pump to get? You can read this FAQ “Choosing a Breast Pump” (and download the handout) or even better, you can see an IBCLC who can go over your options in person. You can ask your doctor, but he or she may not have a clue unless they also happen to be an IBCLC or have read up on all the differences in types of pumps and what is suitable for your individual situation.

4. Does it matter what type of doctor I get my prescription from?  

No. There is no requirement that the prescription be from a specific type of physician or physician specialty, only that they are TRICARE-authorized.  CNMs and NPs can write prescriptions for breast pumps as well.

5. What brands of pumps are covered? 

Any brand of pump is covered. It just has to match the type on your prescription (i.e. hospital-grade, electric or manual). But here is a hint for you: get the best pump you can, for YOUR situation.  Don’t settle for a cheap-o pump from Walmart that will kill your milk supply in less than a week. Opt to get one of the best pumps on the market by well-known leaders in the breast pump business (it helps if they are WHO-code compliant as well). Wondering what the differences are in breast pumps? See the handout “Types of Breast Pumps“.  For all of you active duty moms returning to work, please do yourselves a favor and get a personal use electric pump. You might do fine with a manual pump, but most moms can’t maintain a good supply with a manual pump alone.

6. Is there a cap on the price of the pump? There are different styles of breast pumps, some more advanced than others.  Will I get reimbursed if I choose a more expensive breast pump?  

As of July 1st 2015 TRICARE has not YET set a dollar limit for the purchase of one basic manual pump or one standard electric pump. Use your best judgement when purchasing your breast pump, keeping in mind ‘basic’ and ‘standard’.  Rumor has it that reimbursement will not cover “deluxe or luxury features that make the pump more expensive then others on the market without those features” and ” We are going to monitor claims and adjust the fee schedule over the next 6 months”.  This means the backpacks and totes the pumps come in, that are not essential to the operation of the pump, are considered luxury items. If you want that you will need to pay the difference or realize you won’t be reimbursed for that part of the pump. Also caps are being put in place regarding the price of the pump and it is based on what STATE you live in (i.e. – Virginia and North Carolina reimbursement cap is $252, Washington is $160 for a Standard Electric pump). This is NOT official information from TRICARE, only what I am hearing from the DMEs I am in contact with. 

7. Where can I buy my pump?

Anywhere they are sold! They need to be purchased from a TRICARE-authorized provider, supplier or vendor.  That includes:

  • Any firm, supplier or provider that is authorized under Medicare
  • Any commissary that is part of DeCA
  • Any PX, BX, NEX, CGX or Military Exchange operated by AAFES
  • Any civilian retail store (Target, Walmart, Babies R ‘Us, etc.)
  • Any online store (Amazon, etc.)

The easiest way to get your pump is through a TRICARE-approved pharmacy, TRICARE-approved pump dealer, or DME (Durable Medical Equipment) provider. There all you have to do is hand over your prescription and they hand you a pump with no money out-of-pocket. If that is not doable for you, you can buy your pump and then fill out the claim form and submit it with your receipt and prescription for reimbursement. You can find instructions and the claim form (DD2642) here. **IT CAN TAKE UP TO 60 DAYS FOR THE CLAIM TO BE PROCESSED**

Short list of DME providers (I will add to this as I learn of more-contact me if you want your business added):

8. What types of breastfeeding supplies are covered and do I need a separate prescription for them?                

Up to 2 pump kits, tubing, flanges, power adaptors, storage bags and bottles (for that particular pump) are covered for up to 36 months post birth event. Nothing else is covered.

You do NOT need a prescription for the supplies, only for the breast pump itself.  However to avoid claims processing delays, it would be a good idea to submit a copy of your prescription when you file your claim (and include all your expenses on the claim) just in case.  If you buy more supplies in the future (you have a 36 month window after all) you can send in another copy of the prescription if needed with your new claim.  

9. I’m on Active Duty or in the Reserves/Guard and use TRICARE Reserve (Select, etc.) do I still qualify for a pump?

Yes. Any type of TRICARE coverage qualifies you for a pump, supplies and lactation counseling. Prime, Standard, Reserve, you-name-it.  If it’s TRICARE you are covered.  So active duty moms, dependents, Reserve and Guard members all qualify under the policy. The exception here are Veterans, but they have the option of obtaining breast pumps and supplies through the VA.

10. I’m stationed overseas, can I still get a pump?

Yes, it works the same as being CONUS. You need a prescription and then you can buy the pump anywhere, including online, and file your claim for reimbursement.

11. The policy is retroactive to December 19th, what does that mean?

The policy was signed into law as part of the National Defense Authorization Act 2015 that the President signed on December 19th, 2014. So that is when the policy took effect and any pumps, supplies, and counseling obtained AFTER that date is covered. It will be implemented on July 1st and that’s when you can start submitting your claims.

12. I’m pregnant, can I get a pump now?

Yes. Although the policy doesn’t specifically address this, you can buy a pump and supplies, while you are pregnant.

13. My baby was born before Dec 19, 2014, can I still get a pump?

Yes. Coverage is based on when you purchased the breast pump and supplies, NOT when the baby was born.  As long as you bought the pump after December 19th, you will be reimbursed.

14. My baby is almost one, can I still get a pump, supplies or see a lactation consultant?

Yes. You can get a pump as long as the purchase is made after Dec 19, 2014.  If you need breastfeeding supplies, you are covered according to the policy for up to 36 months after the birth of your baby. You can also receive your 6 counseling sessions if needed as long as they are after Dec 19, 2014.

15. I purchased a pump earlier this year, but didn’t have a prescription.  If I get a prescription now and submit it with my claim, will get reimbursed?  

Yes. There is no requirement for the date of the prescription to be before the date of the purchase.  All that is needed is a valid prescription. As long as you bought the pump on or after December 19, 2014 you will be reimbursed for the pump.

16. If I have another baby in a few years will I be able to receive another pump?

Yes. The policy states that pumps, supplies and lactation counseling are to be given to moms “per birth event”, so you can get all of the above for each child that you choose to bring into this world or adopt.

17.  I had two children born 14 months apart, can I receive a breast pump and supplies for each child? 

Yes, you are eligible for a breast pump for each child (or “birth event”). And the 36 month coverage for breastfeeding supplies begins again with each ‘birth event”.

18. I need a hospital-grade pump for my baby that is in the NICU/has a cleft palate/etc. Is that covered and how do I get reimbursed? 

Hospital-grade pumps are covered under this new policy when required to support the initiation of breastfeeding due to medical complications that prevent feeding at the breast, including inducing lactation for an adopted infant.  Continued use after infant is discharged from the hospital requires documentation of medical need from a physician. Reimbursement is the same as for a standard electric pump, you need a prescription from your provider, and then you can pick one up at your local DME or TRICARE authorized provider, supplier or vendor.

19. Can I still get a regular electric pump when I no longer need the hospital-grade pump I am using now?

Yes. After the hospital-grade pump is no longer deemed medically necessary, you can then get a standard electric pump at no cost.

20. I live in a remote area that doesn’t have a MTF nearby with Lactation Consultants on staff. I need to be seen by Private Practice Lactation Consultant out in town. Will I be able to have my vists covered? 

Per the policy, outpatient lactation counseling sessions performed by an individual professional provider, hospital or clinic that is not TRICARE authorized will not be reimbursed. Since many private practice lactation consultants are not TRICARE authorized, the answer is NO at this time. See the answer below for why this is a problem.

BONUS question: Why doesn’t the policy specify or even mention International Board Certified Lactation Consultants (IBCLC) or Certified Lactation Consultants (CLC) as Providers under Lactation Support?

That is a very good question!  Overall this is a fantastic policy and one that is long overdue. But it is sorely lacking when it comes to the lactation counseling portion. My best guess is that IBCLCs are not yet licensed, and like Medicaid and a few other insurance companies, TRICARE simply won’t recognize IBCLCs as Providers until such time as they do become licensed (yes, I am in favor of licensure, it will fix a multitude of problems). But licensure is a long ways off unfortunately and in the meantime TRICARE needs to fix this so that the experts in lactation, International Board Certified Lactation Consultants, as well as Certified Lactation Consultants are recognized (and paid) for their time and expertise, and mothers do get the qualified care that they deserve.

Why is this important? As noted in the question above, not all MTF’s have IBCLCs on staff, especially the smaller hospitals and clinics so mothers will have to go out in town and see a private practice IBCLC or CLC, many of whom are not RNs, but are fully qualified to manage breastfeeding issues. And second, leaving the counseling to MD’s, CNMs, RNs, PAs and NPs who very often have no more than at best a single day of lactation training (and often more like just a few HOURS), is ludicrous and frankly dangerous to mom and baby’s health. There is a reason why CLCs and especially IBCLCs have so much education that is specific to lactation, as well as thousands of hours of experience in BREASTFEEDING counseling and management.  By not including CLCs and IBCLCs as providers, mothers who need to be seen are either left seeing a provider that doesn’t know much about breastfeeding (and will probably resort to telling her to supplement with formula), seeing a PPLC and paying out-of-pocket with no reimbursement, or not being seen at all and weaning as a result.

In addition, TRICARE needs to understand the differences between CLCs and IBCLCs and require that in order to receive reimbursement, mothers see a a qualified and trained professional in breastfeeding management such as a CLC or IBCLC.  Each level of breastfeeding helper is wonderful for the work that she does, and each has it’s place in the team, and each should know when to refer up to the next level when out of their scope of practice (or experience). CLCs are fully qualified for basic breastfeeding management (which most ‘problems’ new mothers face have) and IBCLCs are the Gold Standard in breastfeeding care for more involved issues.  If you are a mom and want to know more about the differences in breastfeeding helpers and why its important that you see a CLC or IBCLC depending on your situation (and that TRICARE recognizes and pays for you to see one) please read “Choosing Your Breastfeeding Helper“.

I hope that this clarifies some of the most common questions about the new policy. If you need more Resources about the new policy check out the TRICARE Lactation Policy for links to policy, claims form, handouts, DME providers and more!

If you have any further questions I urge you to call your Regional TRICARE Contractor for more info.

Questions, comments, thoughts?  Leave them below!

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