How to get Similac Alimentum covered by insurance?

mclere

Ok left the Dr's. office and she wrote me out a script so now what do I do just go get it filled? Do I call them first? What do I say if I need to call them? She also will only take the rtf kind does it matter what kind she gets? I don't mind paying a higher copay if need be to get it but she WILL NOT take the powder plus I don't like that it has corn in it. We have Aetna btw.

browneyedgoil

we got ours approved no problem but the dr's office had to call in & get it preauthorized. we filled it at the pharmacy & ordered the rtf. it was not a problem. 

mclere

I found this online Anyone HAVE Aetna and STILl got around this?

1. Food supplements, specialized infant formulas (e.g., Alimentum, Elecare, Neocate, and Nutramigen), lactose-free foods, vitamins and/or minerals may be used to replace intolerable foods, for lactose intolerance, to supplement a deficient diet, or to provide alternative nutrition in the presence of such conditions as allergies, gastrointestinal disorders, hypoglycemia, and obesity. Food supplements, lactose-free foods, specialized infant formulas, vitamins and/or minerals taken orally are not covered, even if they are required to maintain weight or strength and regardless of whether these are prescribed by a physician.
2. Most Aetna plans do not specifically include coverage of infant formulas when taken orally. In the absence of a specific inclusion or state mandate, specialized infant formulas are not covered.

mylove2005

I had to sent it in to the pharmacy and it was denied which I was told it would be until they got a letter of medical need then it was covered

dmd3026

Do you have an Aetna plan with the prescription coverage through Express Scripts? 

britanyd

I work in a pharmacy and deal with formula billing all the time.  The first thing you need to know-- there are THOUSANDS of different insurance plans and it's unlikely that anyone here has the same plan as you, and therefore can't tell you if your child's formula will be covered.  The easiest way to find out if it is covered is to call the number on the back of your insurance card and ask them.

Also, formula coverage greatly varies by state.  I recently moved, and in my old state, insurance companies were allowed to reject formula claims.  In my new state, they are required by law to cover the claim as long as it's billed correctly and the child's sole source of nutrition.

Take the prescription to your pharmacy.  They will bill the insurance company and if it's rejected, they will contact the doctor to do a prior authorization--that is, he/she makes phone calls and fills out paperwork for the insurance company proving this formula is medically necessary--and then your insurance company may cover all or part of the prescription.  If the store does not carry the formula and it's covered by your insurance (or if it's not and you still request it), they will order the product for you.

Bottom line--call your insurance company or take the prescription to the pharmacy to get the ball rolling.  Most pharmacies handle this kind of thing every day.

mclere

I called insurance yesterday and luckily had a rep on the phone who knew right what to do. I'm in FL so there is a mandate. She did say i'd have to go through a medical supply company fill it there and they bill insurance. The medical supply company will ship it fedex right to the door! They will cover 80% which is WAY better than $300+ a month.

Arurye

Hi

I have Aetna, live in FL and my baby is on similac alimentum - I asked the pediatrician if they would write a script so I could try to get it covered by insurance - he said he doubted the would and didnt write the script. 

I also contacted Aetna and asked if they cover formula and got the same data - that if taken orally it doesn't cover it. I am very interested if/ how you got the insurance company to cover the cost and where you had to purchase it.

I would like to see if they will even cover part of the cost of this formula - as it is the MOST expensive one Similac makes.

Pls let me know at ryan.leitch@gmail.com

Thanks

Arurye

Not sure Oley is for us since we don't have to feed her through a tube, she takes it from a bottle - was just looking for some assistance to off-set the cost of the high priced formula she eats.

BlessUrHeart29

We couldn't get it covered bc it wasn't given through a feeding tube. However, my husband emailed Similac and asked for samples of it and they did send us two cans of the powder. Also our doctor gave us 8 of the 32oz RTF bottles. Does your doctor have any samples? Thankfully we didn't need do to keep LO on it bc we figured it would cost us around $300/month and we definitely don't have that just laying around.