To order a breast pump through Anthem insurance, confirm your plan’s coverage details, get a prescription from your OB-GYN or midwife in your third trimester, and place the order through an in-network durable medical equipment supplier that will bill Anthem directly. For most non-grandfathered plans, the pump itself costs you nothing, because federal law requires preventive coverage of breastfeeding equipment at no cost-sharing.1Office of the Law Revision Counsel. 42 USC 300gg-13 – Coverage of Preventive Health Services The work is mostly paperwork, and starting early is what keeps it painless.
Confirm What Your Plan Covers
Anthem plans vary in the specifics even though the federal floor is the same. Some plans fully cover a double electric pump for you to keep. Others cover only a manual pump at no cost, or provide a rental for a limited period. Your Summary of Benefits and Coverage document spells out what falls under durable medical equipment, including any restrictions on pump type or timing.2CMS. Summary of Benefits and Coverage and Uniform Glossary
The fastest check is Anthem’s member portal or mobile app. Log in, look under your benefits for “durable medical equipment” or “breast pump,” and note whether prior authorization is required. Or call the number on the back of your card. Ask these questions:
- Does my plan cover a breast pump at no cost?
- Which models or brands are fully covered?
- Do I need prior authorization?
- Am I required to use a specific supplier?
One boundary worth checking upfront: grandfathered health plans, meaning plans that existed before the ACA took effect in March 2010 and haven’t made certain significant changes since, are not required to cover breast pumps at all. Your SBC or a call to member services will confirm whether yours is grandfathered.3HealthCare.gov. Breastfeeding Benefits
Get a Prescription From Your Provider
Anthem requires a prescription before it will approve a pump. Your OB-GYN, midwife, or primary care doctor can write one at a routine prenatal visit. The prescription should include your name, expected delivery date, and the type of pump recommended. Many suppliers also want the ICD-10 code Z39.1, which indicates lactation support, so the claim processes cleanly.
Ask for the prescription early in your third trimester. Some Anthem plans only accept prescriptions dated within a set window, and a date outside that window can trigger a rejection. A prenatal appointment around 30 weeks gives you room to order, resolve any snags, and have the pump in hand before delivery.
Choose an In-Network Supplier
Anthem expects you to order through an approved durable medical equipment supplier. Going out of network can mean higher costs or a denial. Use Anthem’s online provider directory and search for “durable medical equipment” or “breast pump” in your area.
Several national DME companies specialize in insurance-covered pumps: Aeroflow, Edgepark, and Byram Healthcare are the ones members most often use. You enter your insurance details online, upload the prescription, and they handle the rest. They verify benefits, tell you which pumps are fully covered under your plan, ship to your door, and bill Anthem directly so you never pay out of pocket for the covered pump.
Before you commit to a supplier, confirm two things. First, that they participate in Anthem’s network for your specific plan, because network participation varies by state and plan type. Second, that the pump model you want is one Anthem covers at zero cost through that supplier. Good suppliers show you exactly which models are fully covered and which carry an upgrade fee.
Pick Your Pump
The pump most members receive at no cost is a standard personal-use electric pump, covered when there’s documentation of ongoing breastfeeding.4Anthem. Electric Breast Pumps Anthem can apply “reasonable medical management” to limit which specific models are fully covered while still meeting the federal requirement.5CMS. Affordable Care Act Implementation FAQs – Set 12
If you want a model that costs more than what your plan fully covers, most in-network suppliers let you pay the difference out of pocket. That gap payment is how many members end up with a higher-end pump like the Spectra S1 or Elvie Stride. Some suppliers bundle accessories such as extra bottles, storage bags, and carrying cases into upgrade packages. Compare the fully covered options first though. The no-cost models have improved a lot, and one of them may cover your needs without any extra spending.
Hospital-Grade Pumps Are a Separate Category
Hospital-grade pumps are heavier, more powerful units approved for multi-user use, and Anthem treats them differently. They’re considered medically necessary only when one of these applies:4Anthem. Electric Breast Pumps
- The infant is hospitalized, such as a NICU stay.
- The baby has a medical or congenital condition, such as cleft palate or a respiratory or cardiac problem, that interferes with direct breastfeeding.
- You’ve been unable to express enough milk after trying a manual, battery-powered, or standard electric pump.
Without one of those, Anthem will deny a hospital-grade pump as not medically necessary. When they are covered, it’s typically as a rental rather than a purchase, and your provider needs to document the specific medical reason in the prescription. If your baby ends up in the NICU unexpectedly, the prescription can be written after delivery.
Time the Order Right
Some Anthem plans allow prenatal ordering; others make you wait until after delivery. Plans that permit prenatal ordering often ship the pump about 30 days before your estimated due date.3HealthCare.gov. Breastfeeding Benefits
The sweet spot for most members is 30 to 34 weeks of pregnancy. That gives the supplier time to verify insurance, process the prescription, and ship before your due date. Waiting until after delivery means chasing paperwork while caring for a newborn, and some suppliers have multi-week processing times. An early start also creates a buffer if Anthem requires prior authorization, which can add a few days.
If You Paid Out of Pocket, File for Reimbursement
When you order through an in-network supplier that bills Anthem directly, there’s nothing to file. If you paid out of pocket first, whether because you used an out-of-network supplier or bought the pump before confirming coverage, you’ll need to submit a reimbursement claim yourself.
Gather an itemized receipt showing the pump’s make, model, purchase date, and total cost, together with your prescription. Submit through Anthem’s member portal, mobile app, or the mailing address on your plan documents. Keep copies of everything.
Claims must be filed within Anthem’s specified timeframe, which varies by plan but is often around 365 days from the date of purchase. Late filing is one of the most common reasons for denial, and Anthem won’t make exceptions once the window closes. Check your specific deadline through member services or your plan documents, and file as soon as you can within the window.
If Anthem Denies the Claim
Denials happen, and they aren’t always final. Anthem’s denial letter explains the reason: missing documentation, a policy exclusion, a coding error, or a medical necessity dispute. Read it carefully, because the reason dictates the next move.
For simple problems like a missing prescription or wrong code, resubmitting with corrected paperwork often resolves things without a formal appeal. For substantive denials where Anthem says the pump or service isn’t covered, you have the right to appeal.
Anthem’s internal appeal process involves a written request with supporting documentation: your prescription, medical records, and a letter from your provider explaining medical necessity. Filing timelines vary by plan, but Anthem’s provider-facing guidelines reference windows ranging from 30 days for claim payment appeals to 180 days for clinical appeals.6Anthem. Anthem Provider Claims Dispute Process Your denial letter will spell out your exact deadline.
If Anthem upholds the denial after internal appeal, federal law gives you the right to external review by an independent third party. Under 45 CFR ยง 147.136, you have at least four months from receiving the denial notice to request external review, and Anthem pays the cost of the independent review organization. Some states allow a small filing fee of up to $25, refunded if the decision is reversed in your favor.7eCFR. 45 CFR 147.136 – Internal Claims and Appeals and External Review Processes External review decisions bind Anthem, so this step carries real weight. Save every document you submit and every response you receive.