In the chart below (page 8 of the SPD), under “Preventive Care Benefits”, you will see the description of the Health Plan breast pump benefits. Though it may not be immediately obvious from the technical nature of the language, the Health Plan covers breast pumps as follows:
- A breast pump is covered in-network only, in conjunction with each birth.
- A prescription is required from the referring MD (OB/GYN) and/or a registered Nurse/Midwife.
- A prescription can be written up to a month prior to delivery, but not to exceed one year after birth.
- The breast pump is covered at 100%, with no Participant cost share, as regulated by the Affordable Care Act, under Preventive care benefits for women.
OTHER MEDICAL SERVICES
LOW OPTION PLAN
(COBRA and Extended Coverage Participants only)
|In-Network Provider||Out-of-Network Provider||Out-of-Area||In-Network Provider||Out-of-Network Provider|
|Contracted rate applies||Allowed Charge applies||For participants 25+ miles from two in-network providers – contact Plan office to confirm eligibility. Allowed Charge applies.||Contracted rate applies||Allowed Charge applies|
|Hospice Care||Preauthorization Required – 85%||Preauthorization Required – 60%||Preauthorization Required – 80%||Preauthorization Required – 70%||Preauthorization Required – 60%|
|Infertility Treatment||Not covered||Not covered||Not covered||Not covered||Not covered|
Preventive Care Benefits
For services covered under Wellness Benefits, see pages 107-108 of the SPD.
|100% of certain preventive charges as identified by federal law||Not available||Not available||100% of certain preventive charges identified by federal law||Not available|
Preventive Care Benefits as relates to breast pumps are found on page 101 of the Summary Plan Document (SPD):
WOMEN’S PREVENTIVE CARE SERVICES
Well woman visit, annually
Breast Cancer Testing
Breast cancer preventive medication (“chemoprevention”) counseling for women at risk for breast cancer
Breast feeding interventions for the duration of breast feeding (includes counseling, instruction and supplies)
Cervical Cancer Testing
As per the ACA, breast pumps are covered at no cost to the Participant IF the breast pump is obtained from an in-network supplier. You can locate an in-network provider by using Anthem’s Find Care page. Once there, under “Use Member ID for Basic Search”, enter WRX in the input field and press “Continue”.
You can also call the PWGA, ask for Participant Services, and a Participant Service agent will supply you with contact information of providers the Health Plan has confirmed are in-network DME suppliers, who carry breast pumps.
By way of example, with the caveat that these providers change ownership frequently, here are three currently in-network providers:
- American Medical Enterprises: (562) 698-0266
- Supercare: (800) 206-4880
- Life Care solutions: (866) 260-2192