hypoallergenic formula and insurance info!!

Oliver715

I'm writing this post in hopes that I can save someone the headache I just endured. We have Aetna PPO and I have fought with them over a couple different issues.

1 was about Prevacid. It should be covered (yes, BRAND NAME not generic) because there is a shortage of the generic SOLUTAB. You specifically have to say the 15 mg solutab. Thats what babies get anyways.

And the most recent fight was over formula being covered. I ordered EleCare from Abbot nutritional not knowing anywhere else it could be bought. Depending on the state you are in, there may be pharmacies (Walgreens in particular) where you can get this formula. Florida is not one of those states. Aetna proceeds to tell me that I can choose from a number of medical supply stores that they have a contract with and get the formula. I looked into it and was told they don't take Aetna for formula. I finally asked to speak to a supervisor (they call them Sr CSR's) and she called around for me. She found out that Aetna indeed does not have a contract with anyone that covers this formula In Network BUT in certain states there are state statutes that give you certain rights. I was horrible in government but basically how it works out for me is that I would only have to meet an in network deductible as opposed to out of network. Once that ded is met I pay 20 % of the formula. She apologized for them processing it wrong and resubmitted my claim and said to expect a check within a wk or so! 

BATTLE your insurance company is something doesnt sound right. Every person you talk to, make sure you get their name AND employee ID number. Even if its formula ask where you can find IN Network providers. If you can't find any, look up your state laws or have a representative do it for you. AND don't let them tell you supervisors are all busy and you can't talk to one. Thats crap! You CAN talk to one and I recommend doing so!

Here is some info I found:

 https://www.ncsl.org/issues-research/health/medically-necessary-foods-and-formula-laws.aspx

 

Title XXXVII INSURANCE Chapter 627  INSURANCE RATES AND CONTRACTS View Entire Chapter

627.42395 Coverage for certain prescription and nonprescription enteral formulas.?Notwithstanding any other provision of law, any health insurance policy delivered or issued for delivery, to any person in this state or any group, blanket, or franchise health insurance policy delivered or issued for delivery in this state shall make available to the policyholder as part of the application, for an appropriate additional premium, coverage for prescription and nonprescription enteral formulas for home use which are physician prescribed as medically necessary for the treatment of inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein, in an amount not to exceed $2,500 annually for any insured individual, through the age of 24. This section applies to any person or family notwithstanding the existence of any preexisting condition.History.?s. 1, ch. 95-340. Note.?Former s. 627.64195     I hope this helps someone! Or pass along the word!!

tardiswho10

I wish it would help us, but unfortunately it doesn't.  DH's company is based out of our state and in that state (which is where our coverage technically is) the provisions don't apply to us.  We've filed an appeal 3 times with insurance and, still nothing.   I am, however, passing this along to one of my college girlfriends who is having an insurance struggle as well.  Thank you for this!

greyt00

There is legislation that says if you live in certain states, insurance has to cover special formula.  However, if the insurance plan is *self-funded*, they are exempt.  My plan is self-funded.  We got lucky with DS1 and got free supplies of Neocate for 8 months from our pediatrician.  We won't get that lucky with DS2 and I'm trying elimination diets so I can continue to BF.  Fighting insurance is so time-consuming and frustrating.  Good luck to all!