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New Modifiers for Unlisted Codes on Breast Pump Supply Claims

Monday, July 1, 2019

TRICARE recently revised the breast pump/breast pump supply benefit to include limits on what is covered. In order for Health Net Federal Services, LLC to accurately reimburse providers who bill for breast pump supplies using unlisted Healthcare Common Procedure Coding System (HCPCS) codes A9900 or A9999, we are requesting providers use the following modifiers. These modifiers will let us know specifically which supplies were provided to the beneficiary.

Supply Type Modifier
Replacement valves/membranes XG
Replacement breast milk storage bags XH
Replacement nipple shields XD
Supplemental nursing system XN
Breast pump kit XR


We recognize some breast pump supply companies operate on a national level. Therefore, we’ve coordinated with Humana Military, the TRICARE East Region contractor, to implement these same billing guidelines. 

As a reminder, one breast pump kit is covered per birth event but may not be reimbursed separately from the initial breast pump. (Visit https://health.mil for current reimbursement rates.) The following replacement supplies are covered without an additional prescription: 

  • 2 replacement bottles and caps/locking rings every 12 months
  • 1 power adapter after the first 12 months
  • 12 valves/membranes every 12 months (1 unit = a set of 2 valves and membranes)
  • 1 set (2) flanges/breast shields
  • 1 set of tubing
  • 90 breast milk bags every 30 days

A supplemental nursing system, two sets of nipple shields and additional replacement supplies in excess of the above limits may be covered with a prescription specific to the supplies needed.

Expecting mothers can access TRICARE’s breast pump and breast pump supply benefit starting at week 27 of pregnancy (or when the baby is born, if premature) or in the instance of adoption. Visit our Breast Pumps and Supplies Details page for benefit and claims submission details. 

We appreciate your cooperation with these guidelines.