Breast Pump with Accessories

One free breast pump (excludes tax) from a participating provider or pharmacy is available per pregnancy for expectant mothers covered by an HMAA medical plan, regardless of participation in Baby & Me. If ordered through HMAA or Pharmacare, a special gift of accessories to help with nursing your baby will be included, courtesy of Pharmacare Hawaii.

Simply submit a request or contact our Wellness Department to have your breast pump conveniently delivered to your home at no charge, or pick it up at a Pharmacare Hawaii location. Available at 26 weeks of pregnancy if ordered through HMAA.

Request a Breast Pump

Prior to submitting this request, please review the eligibility requirements at the end of the form. We will respond with next steps and more information via email.

Note: In some cases, emails may be found in your “junk” email folder. If you do not see our email within 2 business days of submitting your request, please contact our Wellness Department.

Patient Name*
First Last
Plan Member ID #*
Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
Due Date*
MM slash DD slash YYYY
OB/GYN Name*
Are you participating in Baby & Me?*
- Yes
- No
Select Breast Pump Model*
- Medela
- Spectra S1
- Spectra S2
Select Pickup/Delivery*
- Pickup at Pharmacare location indicated below
- Deliver to address indicated below (at no charge)
Pickup Location*
Address*
Street Address City State ZIP Code
Eligibility Requirements:*
Expectant mother must be covered by an HMAA medical plan at the time of request and must not have already obtained a breast pump through her medical plan for this pregnancy. HMAA’s Wellness Team will contact you to confirm details prior to processing. Allow at least 10 business days for processing and expect to be contacted regarding pickup or delivery after 26th week of pregnancy. You will be responsible for payment of taxes billed by Pharmacare Hawaii.
I have read the eligibility requirements, and understand that submitting this request does not constitute an official order or approval of the breast pump.
Comments
This field is for validation purposes and should be left unchanged.

Breast Pump with Accessories

Request a Breast Pump

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