Breast Pump Insurance form for Illinois

1
Patient's Name* This field is required.Expecting Mother's Name
First Name
Last Name
2
Expected Due DateBreast Pumps can be dispensed starting at the 28th week of pregnancy
Date
Month
Day
Year
3
Shipping Address* This field is required.Illinois only
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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eSwatini
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Other
Country
4
Phone Number* This field is required.Mobile number
We will text you updates
5
Email* This field is required.Internal use only
example@example.com
6
Date of Birth* This field is required.MM-DD-YYYY
Date
Month
Day
Year
7
Emergency ContactYou can always put yourself
Contact Name
Contact's mobile number
Contact's Relationship to you
8
Insurance Policy Name* This field is required.Select from drop down
Aetna Medicaid of Illinois
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield-Medicaid
County Care
Illinois Public Aid
Meridian Health
9
Policy Number* This field is required.
Member ID
10
Group NoNot applicable to medicaid insurance
Required for BCBS commercial policy
11
Prescribing Provider* This field is required.Doctor or Midwife Information Who is writing the Prescription?
Full Name
Office ☎️
Office Fax
12
Do you have a prescription already?* This field is required.If No, don't worry a fax request will be sent
YESNO
13
Upload prescription image 📷Skip to next, if you don't have an RX
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Insurance forgets to tell you its required for us to bill
Cancelof
14
Insurance Card Front image
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Make sure it's legible
Cancelof
15
Government ID* This field is required.Driver's license/ Passport/State license
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Your photo is better than mine required
Cancelof
16
Enter the COUPON CODE according to your insurance carrier policy:

1. BCBSPPO- Blue Cross Blue Shield PPO (max coverage is $150)

2. MEDICAID -Medicaid, Aetna Better Health Medicaid, Blue Cross Blue Shield MMCP, County Care, Meridian Health Plan MMCP, Molina Health Care (max coverage is $139.00)

The field will appear at the bottom of the breast pump list in the next section.

If you have MEDICAID you are NOT eligible to pay the difference between an upgraded model
17
Breast Pump Options* This field is required.Enter Coupon Code: BCBSPPO or MEDICAID accordingly
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
ShippingUSD
SubtotalUSD
Total costUSD
Zomee Z2 with Tote
Default option for Medicaid policies. AAMS FAVORITE
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Tote included
Tote included
No Tote needed
Bag option
Medela Pump in Style with Max Flow
Covered under BCBS PPO
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S1 Plus Portable & Rechargeable
Upgrade Model for BCBS PPO
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S1Plus with Deluxe Tote
*Most popular upgraded item for BCBS PPO* Spectra S1 soft blue electric breast pump TOTEl, ZGrey, Cooler Bag Pink .Max Suction Strength: 270 mmHgPump Noise Level: 45 dB
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S2 Plus by Spectra
Covered under BCBS PPO
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S9 Plus by Spectra
Covered under BCBS PPO
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Baby Buddha
Upgrade Model for BCBS PPO
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Zomee Fit Wearable Double Electric
Worn inside your bra. Silent. Hands-Free. Comfortable.Now you can have it all – a Zomee hospital-grade strength motor in a wearable pump! Thoughtfully designed for quick and effective expression with Zomee's hands-free wearable pumps. Rechargeable for hours of use and easy-to-use technology that doesn’t require an app.
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Elvie
BCBS PPO UPGRADE * Silent and Wearable
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MOTIF LUNA with battery
Sophisticated, strong, and soothing. The Luna is the powerful breast pump from Motif Medical, built for modern motherhood and proven to provide More Milk in Less Time®. With a battery-powered or non-battery version, the Luna is perfect for today’s busy mom
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Quantity
Elvie Stride
Hospital-grade performance, now hands-free (5oz/150 ml) With portable hospital-grade performance, Elvie Stride frees you to express efficiently wherever you please. No dangling bottles or balancing acts, Elvie Stride offers power and comfort — all while keeping your hands free.
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Evenflo Advanced Double Electric
no tote
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Freemie
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Milk Bags 120/pk ( monthly)
Made from BPA-free, lead-free, and phthalate-free materials, Zomee breast milk storage bags provide a safe and hygienic way to store your baby’s milk. Available in bulk packs of 120 bags are ideal for expressed milk storage, breastfeeding moms, and on-the-go feeding needs.
Why Choose Zomee Breast Milk Storage Bags?

Leak-Proof Design: Double-layer bags with secure zip closure prevent spills

Self-Standing & Easy to Use: Fill and pour without mess

Space-Saving Storage: Store flat or upright in fridge or freezer

Easy-Rip Pouring: Smooth transfer into bottles

Safe Milk Storage: BPA-free, lead-free, and phthalate-free materials

Accurate Measurements: Each bag holds up to 8oz (240ml) with labeling space
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Enter Coupon
Total cost
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Invoice ID
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Breast Pump Upgrade Charge Waiver and Disclaimer

I understand if I request an upgrade to a breast pump model that exceeds my insurance coverage. I agree to pay the difference in cost before receiving the upgraded pump.

Commercial Insurance: My insurance covers up to $150.00 for a breast pump. I can receive it up to 6 weeks before my estimated delivery date.

Medicaid/MCO Insurance: My insurance covers one breast pump for up to $120.00 or less every 367 days. I am not able to pay for an upgrade. I may choose to purchase accessories on my own. I must have given birth to receive the pump. I acknowledge that I am responsible for any charges exceeding my insurance coverage. I have been informed of the upgrade options and their associated costs.

By submitting the order and waiver, I release All American Medical Supply from any liability related to the upgrade charges and will inform them of my deposition accurately.
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Signature
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