TRICARE covers banked donor human milk for infants with certain serious health conditions, and Humana Military uses this one-page courtesy form to collect what East Region initial and reauthorization requests need. The ordering provider confirms that the mother's milk is contraindicated, unavailable or insufficient, identifies the infant's qualifying condition, and attaches the form to the referral in provider self-service.
The ordering provider, typically the infant's neonatologist or pediatrician, completes the form with the beneficiary's name, date of birth, DoD benefit number and the provider's tax ID or NPI, and supplies the 30-day prescription.
Download the current version from the source each time; forms change without notice.
Request for Banked Donor Milk (BDM)
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Infants whose mother's milk is contraindicated, unavailable or insufficient, and who have a condition such as birthweight under 1,500 grams, a digestive disorder or surgery, failure to thrive, formula intolerance with feeding difficulty or weight loss, low blood sugar, heart disease, organ transplant, or another serious condition where donor milk is medically necessary.
The initial prescription, stating quantity and frequency, is valid for 30 days. Each subsequent prescription must also state quantity and frequency and be renewed every 30 days, which is why the form covers both initial and reauthorization requests.
No. Humana Military provides it as a courtesy, and providers are not required to use it. However, the referral must include the clinical information it lists, because missing information can delay or terminate authorized care or cause pended claims to be denied.