Blog by: Michael Sheeran, CFP

When our family had a baby, we were trying to figure out the coverage for breast pumps with our Horizon BCBS Omnia plan. I work in the business and had a difficult time getting the answers, so I’m sharing the information I learned here to help other Blue Cross members in NJ.

So are breast pumps covered by Horizon BCBS? Yes! Breast pumps are covered without pre-authorization as long as the cost is below $250.00, and they are ordered through one of the durable medical providers that I will list below. They can be ordered no sooner than fifteen days prior to your expected delivery date.

The process with Horizon BCBS was extremely easy and pain free. Most expecting moms have already done a lot of research on which pump they prefer, and you will be pleased that you can get the top models like:

• Spectra S2Plus
• Medela Pump In Style
• Ameda Finesse
• Lansinoh Signature Pro

Choosing your Durable Medical Provider (DME)

We had trouble finding the list of providers that we could order the pump from, but I was able to come up with this list through a lot of searching. It may not be all of providers available as of this writing, but hopefully you will find one that works for you.

We used Edgepark, and the experience was fantastic. They also have a good website showing the models they have available.

How to order the breast pump?

I will focus in on the process we went through using Edgepark, since it’s the only one we have used.

During one of my wife’s visits to the doctor, he provided a prescription to order the pump. I called Edgepark and they took my information including my health plan and also the expected delivery date. The pump can be ordered fifteen days before the expected date so I was asked to call back then.

Fast forward to fifteen days out, I called again to order the pump and there were no issues at all. I had a prescription ready to send over, but the office at Edgepark coordinated directly with our doctor and Horizon BCBS to make the process seamless for us. A few days after the call, we had the pump at our doorstep and the Horizon BCBS Omnia Silver plan covered it.

On their website, Edgepark states you can order the pump earlier on in the pregnancy and they will hold the order from you until the fifteen day out mark.

Does it matter which Horizon BCBS plan I have?

From my research, the coverage is the same on all of the plans. This includes the Horizon Small Group Plans, Individual Plans, and Midsize plans. Your card might say:

• Horizon Omnia
• Horizon Omnia Bronze H.S.A
• Horizon Omnia Silver
• Horizon Omnia Silver H.S.A
• Horizon Omnia Gold
• Horizon Omnia Platinum
• Horizon Advantage Silver

And so on. The good news is that the providers(at least Edgepark), will call Horizon for you and confirm benefits. I don’t recommend calling the 800 number with Horizon as the reps you get unfortunately don’t understand some nuances of each of the plans.

How much does the breast pump cost with Horizon BCBS insurance?

From what I have read and experienced, there is no copay involved to order the pump. The coverage guidelines state that they will pay up to $250.00 before an authorization is required so my best guess is that if you exceed that amount, you will be paying out of pocket.

The plan summaries in many cases say that durable medical equipment is covered at 50% coinsurance, meaning you pay 50%. Fortunately, it doesn’t seem to apply to the pumps. If you have had other experiences, please let me know and I will update my post.

Related Questions

How do I claim a breast pump on insurance? You won’t have to. As long as you order directly through the durable medical provider, they will handle the claims process. In my experience in working with Horizon, they don’t usually like it when you purchase something on your own and then try to be reimbursed.

Does insurance cover breast milk bags? No. Based on my research and by reviewing the Horizon BCBS Medical Policy Manual, they will cover the pump, tubing for the breast pump, adaptor for the breast pump, breast shield and splash protector.

Do you get a free breast pump with each pregnancy? Yes. Horizon states they will cover a pump for each subsequent delivery.

What do I need to do to add coverage for my newborn? This is a pretty straightforward process and an enrollment form needs to be submitted to Horizon BCBS within 60 days of birth. I don’t suggest waiting that long and personally, I added my children within a week of delivery. Some parents want to wait until they get their child’s Social Security Number, but the enrollment form can be submitted without it, and then the information can be updated later. Horizon will use a placeholder for the SSN until one is received.

You can speak with your broker ahead of time to get the enrollment form or download it directly from the website. Adding the baby sooner prevents any mistakes with possibly forgetting altogether and your pediatrician also wants to see that they have been named the primary care provider for your child. Believe it not, many new parents have forgotten to do this more often than you would expect.

For more information or to get a quote please contact Glenn Insurance at 888-OK-Glenn or by clicking here.