Breast prostheses instead of reconstruction

Under the Women's Health and Cancer Rights Act (WHCRA), health plans that cover mastectomies must also provide coverage of certain services or products related to the surgery. This often includes a post-mastectomy breast prosthesis or mastectomy form (for one or both breasts), breast prosthesis garment and/or mastectomy bras.

The law also covers the replacement of a prosthesis, mastectomy form or breast prosthesis garment when the life span of the item has lapsed. Insurer policies on this vary but many will replace:

• Silicone prostheses every 2 years
• Mastectomy forms made of fabric, foam or fiber-fill every 6 months
• When medically appropriate due to a change in condition, or
• If the prosthesis becomes defective despite normal use

Most plans also cover an external breast prosthesis garment (a camisole undergarment with polyester or foam fill) used after surgery but before the permanent breast prosthesis, or as an alternative to a mastectomy bra and/or breast prosthesis.

A prescription from your doctor is typically needed for a breast form. Some health insurers require a referral or pre-authorization just like they do for specialists or other medical procedures referred from a primary care doctor.

WHRCA does not require 100% coverage by health insurance so copays, coinsurance and deductibles may apply. 

Medicare & Medicaid

Medicare and Medicaid are public programs that are not bound by the WHRCA. They have their own rules. Medicare Part B (medical insurance) covers some breast prostheses (including a post-surgical bra) after a mastectomy. Medicaid coverage varies by state.