Medela Insurance Breast Pumps 1Pump Selection2Accessory Selection3Billing4Submit Your Order HiddenFirst Name(Required) HiddenLast Name(Required) HiddenEmail(Required) Order HiddenMedela Provided Insurance Provider (Dynamically populated) StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificWho is your insurance provider? -- Select --While we are not considered in-network with your specific insurance plan, we can offer you a pump through your insurance benefit based on where the item is shipping. Your insurance plan will cover the benefit according to the delivery state/county. Please contact us at referrals@breastpumps.com so that we may send you an order form with pump offerings along with a payment link if you select an upgrade option.Selected Pump Selected Pump PriceHiddenPump SKU HiddenProvider ID HiddenCompany Selected Accessories Accessories Price Billing InformationOrder Total Price: $0.00 Card Type(Required)- Selected -American ExpressDiscoverMastercardVisaCard Number(Required) Expiration Month(Required)- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year(Required)- Select -202320242025202620272028202920302031Security Code(Required) Cardholder InformationCardholder First Name(Required) Cardholder Last Name(Required) Billing Address(Required) Billing City(Required) Billing State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBilling Zip Code(Required) Please select each box to indicate that by submitting this order you acknowledge the following: *Payment Obligation(Required) I acknowledge that I am responsible for paying any difference between the allowed amount from my Insurers and the DME Providers charges for an upgraded breast pump, code E0603. My Plan allows for reimbursement to the Provider, for the least costly item that meets my needs. I am fully aware I am taking on all obligation beyond my insurance payment for my electric breast pump code E0603. I have chosen to select a pump that is not fully covered by my Insurance as it is an upgrade. I have been given the option of choosing a breast pump that does not require an out of pocket payment other than potential co insurance. In choosing an upgrade, I give up any right to dispute the remaining balance due, either with the provider (HBE) or to the primary insurer of record. Disclaimer(Required) Authorization and HIPAA Privacy Policy Consent (Required) Your credit card will be authorized for the full amount of purchase price for the pump and accessories but will only be charged the discounted price of pump and accessories. If your insurance denies the claim we will charge the balance at that time (discount given) and provide you with the reason for such denial. Sometimes insurance companies deny claims because you may have already received a breast pump during this pregnancy, you may have terminated your insurance plan or your specific plan requires a deductible. If in our opinion an appeal of the insurance companies decision is warranted we will still charge your credit card for the discount given, file the appeal and if successfully appealed and payment subsequently received we will credit your credit card account and will notify you of such HiddenAuthorize.net Error Message HiddenInternal Entry StatusNewReviewed
