If an infant is critically ill, and when the mother’s breast milk isn’t available, or there isn’t enough, banked donor milk is an option.
TRICARE covers banked donor milk (BDM) for certain conditions and situations. To be eligible for BDM, (1) an infant must have one or more of the following conditions:
- Born at a very low birthweight (<1,500g);
- Gastrointestinal anomaly, metabolic/digestive disorder, or recovery from intestinal surgery when digestive needs require additional support;
- Diagnosed with Failure-to-Thrive (not appropriately gaining weight/growing);
- Formula intolerance, with documented feeding difficulty or weight loss;
- Infant hypoglycemia (low blood sugar);
- Congenital Heart Disease;
- Pre-or Post-organ transplant; or
- Other serious health conditions when the use of banked donor mild is medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. and supports the treatment and recovery of the infant.
AND (2) the mother’s milk must be contraindicated, unavailable (due to a medical or psychological condition), or available but lacking in quantity or quality to meet the infant’s needs.
A TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS has to prescribe BDM, as well as actively manage the infant’s care. This includes state-licensed nutritionists or registered dietitians who are under appropriate physician supervision.
- Each prescription is only good for 30 days.
- Prescriptions have to show the amount and frequency of feedings.
- Families can only get up to 35 ounces/day, per infant.
- Coverage may be for up 12 months of age, as long as it’s medically necessary and appropriate. Coverage determinations on banked donor milk for very low birthweight infants is on a case-by-case basis.
Banked donor milk is available through human milk banks (HMBs). Under TRICARE, HMBs have to be accredited by the Human Milk Banking Association of North America (HMBANA), a nonprofit professional association of milk banks. HMBANA issues safety guidelines on processing human donor milk for member banks. This includes locations outside the U.S.
What’s not covered:
- Banked donor milk from any non-HMBANA accredited milk bank.
- Peer-to-peer donation, sale, or other sources.
- More than 35 ounces/day, per infant.
- Banked donor milk for healthy, normal birthweight infants.
- Banked donor milk provided for convenience (e.g., to facilitate the mother’s return to work).
- Separate shipping charges.
TRICARE’s reimbursement covers donor milk screening and processing charges. The coverage is to ensure the safety and quality of the banked donor milk. The breast milk itself is provided free of charge.
Your costs are based on beneficiary category and provider type.
Where can I find information on approved donor milk banks?
To find a donor milk banks accredited by HMBANA, go to https://www.hmbana.org/find-a-milk-bank/.
If you have questions, you can contact HMBANA through their website: https://www.hmbana.org/about-us/contact.html.
How much do I have to pay for banked donor breast milk?
It depends on your beneficiary category and where you are when you are getting the banked donor milk:
- If you get donor milk as part of an inpatient stay, the costs may vary based on the type of facility you are in. Costs may be included in the overall payment to the facility, or may be billed as an inpatient medical supply item.
- If you get donor milk on an outpatient basis, copayments/cost-shares are the same as outpatient medical supplies. You pay a copaymentA fixed dollar amount you may pay for a covered health care service or drug. or cost-shareA percentage of the total cost of a covered health care service that you pay. depending on whether or not your milk bank is a network provider.
- You may have to pay out-of-pocket for BDM and submit a claim for reimbursement.
- Visit TRICARE Claims for more information regarding beneficiary-submitted claims.
Cost information on medical supplies can be found in the TRICARE compare cost tool.