Breast Pump Coverage - Passport Health Plan

Breast Pump Coverage - Passport Health Plan

Breast Pump Coverage Sent: To: April 30, 2015 Passport Hospitals, OB/GYNs, and DME/Home Health/Home Infusion Providers Background: At Passport, we ...

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Breast Pump Coverage Sent: To:

April 30, 2015 Passport Hospitals, OB/GYNs, and DME/Home Health/Home Infusion Providers


At Passport, we recognize the importance of breastfeeding and want to enable our moms to be as successful as possible through education and the coverage of lactation supplies. Passport continues to cover the rentals of Hospital Grade Breast Pumps (code EO604), but now coverage also includes the purchase of one Manual Breast Pump (code E0602) OR one Personal Use Electric Breast Pump (code E0603) for lactating women (V24.1) per calendar year. No prior authorization is required.

Provider Action Needed: To qualify for breast pump coverage, members must meet the following conditions: 1. Passport is primary insurance. 2. Baby has been born. 3. Breast pump must be obtained from a Medicaid certified and Passport participating Durable Medical Equipment (DME) provider. 4. Medical indication for rental to be included on prescription along with member’s name, date of birth, MD signature and NPI and date written. (Hospital Grade Only) 5. Breast pump is to be utilized for detained babies, or separation of mom and baby (i.e., mom discharged, baby stays inpatient). (Hospital Grade Only) Please include the following on the prescription for billing purposes: • Member’s name • Date of Delivery • “Personal use breast pump for lactating mother” • MD signature and NPI • Date Written

Please note: Code E0604 Hospital Grade Breast Pump is rental only. Codes E0602 Manual Breast Pump and E0603 Personal Use Electric Breast Pump are purchase only. Member may not have a rental and a purchase at the same time.


If you have any questions regarding these additions to our plan coverage, please call Passport Provider Services, (800) 578-0775 or contact your Provider Relations Specialist. ©2015 Passport Health Plan (HLTH51269)