Tricare Breast Pump Coverage for Providers
If a patient requests a prescription for a breast pump:
1. Hand written prescription (We are ordering a stamper for the prescription forms so it will not
have to be written out each time)
2. Made out for mother not baby
3. Need to specify manual breast pump E0602 or Standard Electric Breast Pump E0603
4. Most patients want/need the Standard Electric Breast Pump
5. Need the diagnosis code V 24.1
6. Prescription may be signed by a TRICARE-authorized physician, physician’s assistant, nurse
practitioner or nurse midwife
7. Questions not answered by information sheet may be referred to Lactation Consultant
Examples
Standard Electric Breast Pump
Manual Breast Pump
E0603
E0602
Dx: V24.1
OR
DX: V24.1
DISP: 1
DISP: 1
SIG: use as directed
SIG: use as directed
Medical necessity when baby not able to nurse at breast
A Hospital grade pump for medical necessity needs the TICARE Service Request/Notification form for
Durable Medical Equipment form submitted. This can only be signed by a physician.
The order for DME can be entered electronically in CHCS/AHLTA as DME
The order will be processed and the pump mailed to the patient
After the hospital grade pump is no longer medically necessary, patient is still eligible for a personal
breast pump as above.