Pharmacare Hawaii Breast Pump Order Form Rev.04.01.24

Pharmacare Breast Pumps Available

Breast pumps are included FREE with most insurance benefits. Select your breast pump and insurance below to see more details.
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Select breast pump:*

Spectra® S1 Electronic Breast PumpSpectra® S2 Electronic Breast PumpSpectra® 9 Plus Rechargeable Breast PumpSpectra® Synergy Gold Portable Breast PumpSpectra® Synergy Gold Double Adjustable Electric Breast PumpMedela Pump In Style® HandsfreeMedela Pump In Style® with MaxFlow™Medela Freestyle Handsfree Double Electric Breast Pump
Pictured - Spectra S1 breast pump with two milk bottles and four breast flanges.

Spectra S1

Spectra® S1 Plus Premier Rechargeable double electric breast pump brings comfort and convenience to breastfeeding. The hospital-strength breast pump is efficient, portable, and discreet, yet powerful. It comes with all the benefits of the S2 Plus but with a quick-charging built-in battery. The adjustable suction strength goes up to 270mmHg, and the device may serve as a single or double pump.

Like all Spectra® pumps, the S1 Plus is a closed system. That means breast milk is kept free from harmful bacteria, mold, and viruses. Using one-touch button and digital controls, the pumping program may be set to the user's own body speed and rhythm. There is also a timer and night light feature for pumping at any time of day.

Features:
- Single or Double Pump capability
- Adjustable Suction Levels – vacuum suction up to L12, which is a maximum of 270mmHg hospital strength suction
- Customizable – adjustable pump settings to sync with each mother’s body’s response and to follow her flow in finding her own best settings every time
- Closed System – prevents backflow into tubing and pump and protects breast milk and baby from bacteria, mold, and viruses while pumping
- Massage mode – stimulates natural suckling of baby
- Expression mode – mode settings optimize extraction
- Ultra-Quiet – for discreet pumping sessions at 45 decibels
- Lightweight – weighs only 3 pounds
- Portable – includes a quick charging built-in battery
- LCD Display with Auto-Timer – offers easy-to-read settings
- Night Light – allows you to easily pump at any hour
- 90-day Limited Manufacturer’s Parts Warranty
- 2-year Limited Manufacturer’s Pump Warranty
Includes:
- 24mm Breast Flanges (2)
- 28mm Breast Flanges (2)
- Wide Neck Milk Bottles, Discs, Locking Rings and Caps (2)
- Nipples (2)
- Duckbill Valves (2)
- Backflow Protectors (2)
- Tubing (2)
- Power Cord & 12V AC Power Adapter/Charger (1)
- Rechargeable Internal Battery (1)
Pictured - Spectra S2 breast pump with two milk bottles and four breast flanges.

Spectra S2

Mothers and lactation consultants favor the Spectra® S2 Plus double electric breast pump. It is lightweight (3 pounds) and ultra-quiet. Enjoy productive single or double pumping sessions via hospital strength suction (270 mmHg).

The closed system also protects milk from outside contaminants. A touch button and digital controls allow for adjustable speed and rhythm. Added extras include a nightlight and timer. Breastfeed with confidence and comfort!

Features:
- Single or double pump capacity
- Adjustable suction levels – vacuum suction up to L12, which is a maximum of 270mmHg hospital strength suction
- Closed system – prevents backflow into tubing and pump and protects breast milk and baby from bacteria, mold, and viruses while pumping
- Massage mode – stimulates the natural suckling of baby
- Expression mode – advanced mode settings optimize extraction
- Ultra-quiet – for discreet pumping sessions
- Lightweight – weighs only 3 pounds
- Customizable – adjustable pump settings to sync with each mother’s body’s response and to follow her flow in finding her own best settings every time
- LCD display with auto-timer – offers easy-to-read settings
- Night light – allows you to easily pump at any hour
- 90-day Limited Manufacturer’s Parts Warranty
- 2-year Limited Manufacturer’s Pump Warranty
Includes:
- 24mm Breast Flanges (2)
- 28mm Breast Flanges (2)
- Wide-Neck Bottles with Discs, Caps, & Covers (2)
- Duckbill Valves (2)
- Backflow Protectors (2)
- Tubing (2)
- 12V AC Power Adapter (1)
Pictured - Spectra 9 Plus breast pump with two milk bottles, two breast flanges, tubing, nipples, and power adapter.

Spectra 9 Plus

The Spectra® 9 Plus Portable Rechargeable double electric breast pump is here! The compact and discreet hospital-strength pump weighs only a 1/2 pound. The built-in rechargeable battery makes it perfect for travel. The closed system protects breast milk from outside contaminants. Several massage modes aid in a more natural nursing process.

Features:
- Single or double pump capacity
- Suction levels – vacuum suction up L10, which is a maximum of 260mmHg hospital strength suction
- Massage mode – advanced mode settings stimulate the natural suckling of baby
- Expression mode – advanced mode settings optimize extraction
- Closed system – backflow protection prevents contamination
- Quiet – for discreet pumping sessions
- Lightweight – weighs only 0.5 pounds
- Portable – built-in rechargeable battery for pumping on the go
- LCD display – for easy viewing
- Night light – soothing 3 level illumination allows you to easily pump at any hour
- 90-day Limited Manufacturer’s Parts Warranty
- 2-year Limited Manufacturer’s Pump Warranty
Includes:
- 24mm Breast Flanges (2)
- Milk bottles (2)
- Nipples (2)
- Duckbill valves (2)
- Backflow Protectors (2)
- Tubing (2)
- 9V AC Power Adapter/Charger (1)
Pictured - Spectra Synergy Gold Double Adjustable Electric Breast Pump.

Spectra Synergy Gold Double Adjustable Electric Breast Pump

The Synergy Gold electric breast pump offers the latest technology in the industry. It is the first pump of its kind that allows users to adjust each side independently. The true closed-system creates a hygienic barrier between outside contaminants and mother’s milk. Pumping sessions are more productive, saving time with comfort and ease.

The LED lamp shines a mild indirect light for breastfeeding in dark rooms and as a sleep lamp.

Features:
- Dual controls allow for independent settings on each breast
- Suction levels - powerful suction of up to 270 mmHg on each side
- Massage mode - 5 stages of soft massage mode settings
- Closed system - backflow protection prevents contamination
- Ultra quiet - for discreet pumping sessions
- LCD display - touch screen with timer control and mute mode
- Night light - soothing 3 level illumination allows you to easily pump at any hour
- 90-day Limited Manufacturer’s Parts Warranty
- 2-year Limited Manufacturer’s Pump Warranty
Includes:
- 24mm Breast Flanges (2)
- 28mm Breast Flanges (2)
- Wide Neck Storage Bottles. Includes nipple, cap, disc and cover for each bottle (2)
- Backflow Protectors - includes silicone membrane, uppercase, and lowercase caps for each Backflow Protector (2)
- Duckbill Valves (2)
- Tubing with Adapter Ends for each Tubing (2)
- 12V AC Power Adapter/Charger (1)
Pictured - Spectra Synergy Gold Portable Adjustable Electric Breast Pump with two milk bottles.

Spectra Synergy Gold Portable Adjustable Electric Breast Pump

The SG Portable Double Adjustable Electric Breast Pump is quiet and discreet. The 3 lb. pump features adjustable suction levels for more natural operation. The closed system protects the breast milk from contaminants. Advanced technology promotes productive pumping sessions with comfort and ease. An LED lamp with indirect light allows for use in the dark.

Features:
- Dual controls – independent vacuum preset cycle settings for each breast
- Adjustable suction levels – vacuum suction up to 270mmHg on each side
- Comfort – Natural Nursing Technology stimulates the natural way a baby nurses, promoting a more comfortable pumping experience
- Massage mode – stimulates the natural suckling of baby
- Expression mode – optimizes extraction
- Closed system – backflow protection prevents contamination
- Ultra-quiet – for discreet pumping sessions
- Lightweight – weighs only 1.5 pounds
- Portable – built-in battery uses one separate battery-operated motor for each breast
- Customizable – adjustable pump settings to sync with each mother’s body’s response and to follow her flow in finding her own best settings every time
- Preset cycle levels – eliminates the need for manual cycle adjustments
- Touchscreen LCD Display – with timer control
- Night light – soothing 3 level illumination allows you to easily pump at any hour
- 90-day Limited Manufacturer’s Parts Warranty
- 2-year Limited Manufacturer’s Pump Warranty
Includes:
- 24mm Breast Flanges (2)
- 28mm Breast Flanges (2)
- Wide Neck Storage Bottles - includes nipple, cap, disc and cover for each bottle (2)
- Backflow Protectors – includes silicone membrane, uppercase, and lowercase caps for each Backflow Protector (2)
- Duckbill Valves (2)
- Tubing with Adapter Ends for each Tubing (2)
- 5V AC Power Adapter/Charger (1)
Pictured - Medela Pump In Style Handsfree with collection cups, breast shields, tubing, battery pack, and power adapter.

Medela Pump In Style® Handsfree

The Medela Pump In Style® Hands-free Breast Pump is Medela’s most powerful hands-free breast pump. You get hospital grade performance in a compact pump. The device is effective, trustworthy, and easy-to-use. Anatomically-designed hands-free cups, with only three parts to clean, may be worn discreetly and comfortably under a nursing bra. The closed system pumps more milk in less time. Compatible with PersonalFit Flex™ Connectors only.

Features:
- MaxFlow technology – advanced motor technology generates vacuum with MaxFlow™ micro-vibrations. Makes for effective breast milk expression (more milk in less time)
- 10 adjustable levels
- No compromise in vacuum performance - whether using Hands-free Collection Cups or classic PersonalFit Flex™ pumping kits
- 105 degree angled breast shields are anatomically shaped and clinically proven to increase milk volume by 11.8%
- Comfortable – designed for mothers to find their maximum comfort vacuum without worry
- Hospital Performance – inspired by Medela’s hospital-grade (multi-user) Symphony® breast pump combined with 2-Phase Expression® technology to mimic baby’s natural sucking rhythm for more efficient pumping
- Closed System – one pump but two ways of pumping allows for freedom of choice in how to collect milk. Prevents backflow into tubing and pump when using classic PersonalFit Flex™ parts and protects breast milk and the baby from bacteria, mold, and viruses while pumping
- Natural sucking rhythm – mimics the baby’s rhythm. Medela’s clinically-proven 2-Phase Expression® Technology shows that additional suction phases are not needed
- Easy cleaning and assembly – collection cups have 3 parts to clean and is dishwasher safe
- Wearable, ultra-lightweight collection cups - weighs only 2.7 ounces each
- Portable – includes a battery pack for convenient pumping away from power
- Safe – all parts that come in contact with breast milk are made without BPA
- Collection cups stand vertically to avoid spills, and comes with an easy pour spout
- Transparent design to easily check milk flow and milk volume
- Four (4) simple buttons for intuitive use
Included:
- Pump In Style® Breast Pump (1)
- Hands-free Collection Cup with 24mm breast shield and O-ring (2)
- 21mm breast shield and O-ring (2)
- Complete tubing (1)
- Battery pack (8 AAs not included) (1)
- Power adaptor (1)
- Instructions for use and Quick start
Pictured - Medela Pump In Style with Maxflow breast pump with two milk bottles and breast shields.

Medela Pump In Style® with MaxFlow™ (E0603)

The Medela Pump In Style with MaxFlow is a double electric breast pump. You get hospital grade technology in a compact pump. The device is effective, trustworthy, and easy-to-use. The closed system pumps more milk in less time. Compatible with PersonalFit Flex™ Connectors only.

Features:
- New MaxFlow technology – advanced motor technology generates vacuum with MaxFlow™ micro-vibrations. Makes for effective breast milk expression (more milk in less time)
- PersonalFit PLUS breast shields – soft rim and oval shape for better fit. Clinically proven to increase milk volume by 11.8%
- Comfortable – designed for mothers to find their maximum comfort vacuum without worry
- Hospital Performance – inspired by Medela’s hospital-grade (multi-user) Symphony® breast pump
- Pre-programmed research-based settings – takes the guesswork out for more effective pumping
- Closed System – prevents backflow into tubing and pump when using PersonalFit Flex™ connectors. Protects breast milk and the baby from bacteria, mold, and viruses while pumping
- Natural sucking rhythm – mimics the baby’s rhythm. Medela’s clinically-proven 2-Phase Expression® Technology shows that additional suction phases are not needed
- Easy cleaning – few dishwasher safe parts and simple assembly
- Lightweight – weighs only 1.18 pounds
- Portable – extra battery pack for convenient pumping away from power
- Safe – all parts that come in contact with breast milk are made without BPA
- Four (4) simple buttons for intuitive use
Included:
- Pump In Style Breast Pump (1)
- 5 oz/150 mL bottles with lids (2)
- 24 mm PersonalFit™ PLUS breast shields (2)
- PersonalFit Flex™ Connectors with membranes (2)
- Complete tubing (1)
- Battery pack (8 AAs not included) (1)
- Power adaptor (1)
Pictured - Medela Freestyle Handsfree Double Electric breast pump with collection cups, breast shields, and power adapters.

Medela Freestyle Handsfree Double Electric Breast Pump

Medela’s smallest and first wearable hands-free double electric pump is designed so mothers may perform other tasks while expressing. The portable, pocket-sized unit pairs with the ultralight collection cups for discreet pumping. It fits inside the bra without weighing down the breast.

Features:
- Wearable and lightweight – the lightest collection cups weighing at 2.7 ounces fit comfortably in the bra
- Separate pump – stays in the pocket and does not weigh down the breast
- Transparent design – easy nipple alignment and to see if milk is flowing
- Comfort – anatomically shaped collection cups optimize milk expression while reducing breast compression
- Expression – 2-Phase Expression™ technology mimics baby’s natural sucking rhythm: faster at first to stimulate milk flow, then slower to express milk
- Easy cleaning – collection cups contain only three parts and are few dishwasher-safe
- Portable – built-in battery is USB-rechargeable for convenient pumping, allowing mothers to multi-task
- Smart – connectivity to the Medela Family™ app to create a personalized profile tailored to your needs
Includes:
- Tubing (1)
- Cups (2)
- Membranes (2)
- 24mm hands-free cup breast shields (2)
- 21mm hands-free cup breast shields (2)
- Power adapter and USB-C charging cable (1)
- Instructions for use (1)
Your Insurance Company:*
Your Breast Pump Out-of-Pocket Cost
Check out these additional accessories compatible with any Spectra model breast pump!

*Accessories and breast pump copay that are not covered by insurance are subject to Hawaii State tax
Please select any accessories you would like to add to your cart. A Pharmacare representative will contact you to complete your order and collect the total amount due (if any).

Spectra CaraCups Wearable Collection Inserts 24mm* ($64.99)Spectra Simple Storage Milk Bags Collection Kit 200mL* ($26.99)Spectra Simple Store Milk Bags Collection Bag Replacements 200mL* ($17.49)
Please select if you would like to add to your cart the Spectra Simple Storage Milk Bags. Spectra's disposable breast milk storage bags are designed for easy milk transfer and can be used in combination with all breast pumps. A Pharmacare representative will contact you to complete your order and collect the total amount due (if any).

Spectra Simple Store Milk Bags Collection Bag Replacements 200mL* ($17.49)
Spectra CaraCups Cost
Spectra Simple Storage Milk Bags Collection Kit Cost
Spectra Simple Storage Milk Bags Collection Bag Replacement Cost
Spectra CaraCups Wearable Collection Inserts 24mm*

CaraCups make hands-free pumping safe, convenient, and easy. CaraCups are a true closed system and compatible with all Spectra® breast pumps. Simply place them in the bra, and mothers will be able to express breastmilk hands-free. Transferring breastmilk after pumping is easy and sanitary.

Included:

CaraCups (2), Milk Collection Cups (2), Flange (2), Valve Connector (2), Silicone Valve (2), Membrane (2), Backflow Prevention Cap (2), Tube Adapter End (2), Tubing (2), Bottle Connector (2)
Spectra Simple Storage Milk Bags Collection Kit 200mL*

The Simple Store Milk Collection Kit lets mothers pump, store, and feed babies breastmilk all in one product. This convenient system prevents the exposure of germs and outside contaminants that are often present when transferring milk from one storage solution to the next. The kit includes a Bottle Connector and 10 Milk Collection Bags. The Bottle Connector easily connects to a Spectra® flange when pumping and seamlessly converts to a nipple connector when choosing to feed directly from the bag. All Spectra® Milk Collection Bags are double-lined, providing a strong seal ensuring leak-free insulation. Assembly is intuitive, clean, fast, and easy.
Spectra Simple Storage Milk Bags Collection Bag Replacements 200mL*

These Simple Store Milk Bags Collection Bag Replacements are for use with the Simple Store Milk Collection Kit. The double-lined bags provide a strong seal, ensuring leak-free insulation.
Your Estimated Out-of-Pocket Cost (Breast Pump Copay + Accessories)
$$$
Complete the details below to order your breast pump today!
Breast Pump Order Form
Submission Date

MonthDayYear
First & Last Name:*
Date of Birth:*

MonthDayYear
Address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Best Contact Phone Number*
Please enter a valid phone number.
Email Address:*
example@example.com
Other Insurance Company Name*
We are currently unable to accept Kaiser insurances. Please contact your doctor to be referred to another provider.
Have you already given birth?*

YesNo
Expected Due Date*

MonthDayYear
Weeks of Pregnancy: *
Delivery Date:

MonthDayYear
Insurance Member ID:*
Cardholder’s Name:*
Cardholder’s Date of Birth:*

MonthDayYear
Physician's (OB/GYN) First & Last Name*
Please include the name of the Physician that is overseeing your pregnancy
Physician's (OB/GYN) Phone Number*
Please enter a valid phone number.
Have you already picked up a breast pump for this pregnancy?*

YesNo
How did you hear about us?*

ProviderPharmacare Hawaii WebsitePharmacare Hawaii EmployeeFriend or FamilyOther
Pick Up/Delivery Options:*

I consent to having the breast pump I’ve selected to be mailed to me at the address indicated above.I consent to having the breast pump I've selected to be picked up at Aiea Medical Pharmacy.
I authorize the release of any medical or other information necessary to process a claim and payment of medical benefits to the supplier or pharmacy provider for the services above. I further acknowledge that Pharmacare will bill my health plan on my behalf, and am financially responsible for fees not paid by my health plan. If I am not the person named above, I hereby affirm that I am over 18 years of age and can legally consent for the person named above to receive services.*

Clear
Aiea Medical Pharmacy's Address:

99-128 Aiea Heights Drive, Suite 103

Aiea, HI 96701
Date:*

MonthDayYear
To be filled out by Physician:

ICD10: Z34.90 (pregnant)ICD10: Z39.1 (post-partum)
Physician’s Printed Name:
Date:

MonthDayYear
Physician’s Address:
Physician’s Fax:
Physician’s Fax:
Oral Code:
Breast Pump Instructions:
Please allow up to 10 business days for pick up or delivery of your pump.

Should you have any issues, questions, or require an accommodation to be able to submit this form, please contact us at (808) 840-5681 or email smattos@pharmacarehawaii.com for assistance.
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Pharmacare Breast Pumps Available

Check out these additional accessories compatible with any Spectra model breast pump!

Complete the details below to order your breast pump today!

Breast Pump Order Form