Anyone else's insurance NOT cover their specialty formula?

dragonflyinn

My one DS has been prescribed Neocate.  We are nearing the end of the bottles that were given to us so I took my prescription to the pharmacy, and my insurance doesn't cover it!!

The pharmacist sent a "pre authorization request" to the dr. and they have already filled that out and sent it to the insurance company and we are waiting.  I was wondering if others have encountered this and if you have successfully appealed it and how.  I got the address for the appeals department and will be writing a letter, but am looking for any suggestions that may have worked for you.  It is so expensive!!

I did go on the Neocate website and found that, in my state AZ, they only have to cover it if the child is diagnosed with " eosinophillic gastrointestinal disorder" which I am not familiar with but don't think he has.

Any suggestions?

ravens_grl

DS is also on Neocate. My first suggestion is to see if the kids would qualify for WIC or Medicaid  due to the high cost of formula. Also, talk to the GI drs because eosinophillic gastrointestinal disorder is baiscally a differnt way to say milk/soy protein intolerance. "eosinophillic" are the things in your intestin that can be damaged if introduced to an allergan. HTH

Lizard1131

Hi!!!  We are on elecare and according to DH's ins rep our ins. United has an automatic denial for formula even if it is written in the policy.  I agree with the pp as well.  We live in CT and state law mandates that formula be covered for the treatment of a medical condition.  We finally had to threaten legal action action citing the state law before they relented.

Mrs. Destructo

Ugh, insurance companies are the bane of my existence

I have no idea about getting insurance companies to pay for formula, but I did find out that special formulas are FSA eligible. So if you have an FSA set up you could use it to buy formula.... though I'm sure formula wasn't something you were planning on paying for with it.

 

pmkmp

Neither our insurance nor Medicaid will cover Neocate.  I guess it's not technically a prescription formula.  They just keep it in the pharmacy so that Joe Schmoe doesn't just decide to put their kid on it without a recommendation and because it's so expensive.  Nice, huh?  Because of DD's extreme preemie status, she qualifies for WIC, so we're going through them.  They give us 9 cans a month. 

njkaren

I jst found out that my insurance company won't cover ours either.

tryingforbabyL

(hi, I have no reason to be on this board...but you know how one post can lead to another can lead to another -- and here I am)

Anyway - I work in the insurance field.  FIGHT IT! Keep appealing it.  Eventually after you appeal it it may be covered.  We had a successful appeal in our office a little while back.  After fighting it it finally got approved. 

Knowing the cost - it will be worth the fight.

Start by writing a letter of appeal to your local insurance commissioner.  CC the insurnace company and whoever you get your insurance through (i.e. HR at your/spouse employer)

Good luck!

SaranJonathan

I would fight and fight. I am in Ohio and I know the laws for special formula here pretty well.

Anyways our Ohio Medicaid covers anything WIC does not plus anything above and beyond. So if DC is on 11 cans a month (9 from WIC and 2 from the provider) it would be covered. See if your pharmacy benefits do not cover if you can get it from a local durable medical equipment company.

Ohio also has a program called BCMH that covers what your insurance does not for children with special needs.

Do an appeal with the insurance... I just did that for one of my children who has blue cross and guess what we got it covered!!!

PS I am a home tube feeding/oral supplement dietitian (where I get my knowledge from)