Electric non-hospital grade breast pump request form (Anthem HealthKeepers Plus)
Form and instructions for requesting an electric, non-hospital grade breast pump (suggested Ameda Finesse) for Anthem HealthKeepers Plus Medicaid members; describes required member/provider information, eligibility (member must be Anthem HealthKeepers Plus), delivery timing, and submission contact details.
No material clinical/coverage changes
Policy summary and at-a-glance
This communication serves as a replacement for a prescription for Anthem HealthKeepers Plus members requesting an electric, non-hospital grade breast pump. It explains required member/provider information, eligibility, delivery timing, and submission instructions.
The Ameda Finesse is suggested as a model but is not mandatory; members may select another make or model. The form and instructions apply to Anthem HealthKeepers Plus Medicaid members.
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