How to get Elecare covered by insurance?

Kara03 · November 2011

I know some of you have had success, how where you able to get it covered?

Fuzzy8252 · November 2011

We eventually just had to buy it out of pocket and submit a reimbursment claim to our medical. Pharmacutical will not cover it.

faith194 · November 2011

Pedi GI wrote a letter stating it was medically necessary.f

KathW · November 2011

Check your state laws. There are some qualifiers (of course!) but in our state if a child is on an elemental diet due to medical issues, the insurance company has to pay for the formula even if it isn't covered under the plan.

Call a medical supply place in your area, they should be able to help you navigate if there is a way to get them to cover it.

mcarter127 · November 2011

We get ours from a home medical supply company & they deal with the insurance.

MommyRN1 · November 2011

Carefully review your insurance handbook. Look for a section on "Enteral Formula". This section should outline exactly what type of formula that they will cover and why.

We had to submit our under our medical coverage (vs our pharmaceutical benefits) and then go round and round. They kept trying to run it under pharmacy benefits. Also, our member handbook says that our deductible does not apply to enteral formula, but we had to fight about that too. The more familiar you are with the benefits straight from your handbook, the better. Everyone we spoke to at the insurance company would tell us different things.

Also, we have to get our Elecare from a DME (durable medical equipment supplier). We had to go about 1 1/2 hours out of our area bc no one in the area had ever ordered it. We had several places flat out refuse bc their reimbursement rate from ins company was so low that it would've cost them to provide us with it. We did end up asking the insurance company to check where they had paid a claim to. The formula gets shipped to our house, so it's not a big deal.

Let me know if you have any questions. I spent my maternity leave trying to get this all figured out!

LadyExtravaganza · November 2011

Like a pp said, we had it covered as a medical supply NOT as a prescription. We get ours through Edgepark Medical, I don't know where they're based, but they mail it to our house.

amy21tom · November 2011

faith194:
Pedi GI wrote a letter stating it was medically necessary.f

This.

LadyExtravaganza · November 2011

amy21tom:
faith194:
Pedi GI wrote a letter stating it was medically necessary.f
This.

This won't get it covered, though. Laws vary from state to state, and obviously it depends on your insurance plan.

OP, I assume you're seeing a pedi GI if you've gotten to the point that you're on EleCare, right?

My GI's office was actually fabulously helpful and helping us get it covered. They have been through this before with other families, ask them for help and they'll probably know some different approaches.

Rob & Tori · November 2011

We get ours through edgepark as well. When our LO was first put on Elecare I had no idea how expensive it was and that you couldn't just go pick it up at the store! I ended up calling my insurance company about it and was on the phone for quite some time being transferred to many different departments. I finally got someone helpful that said I would be ordering it through their mail order medical supply company (edgepark). They connected me to them on their end and I have now had two successful orders with them. They actually handle all the insurance claims and headaches. I also found out that they run it through the medical insurance, not the pharmacy side, so since I do not have a deductible for our plan it is covered at 100%. Make sure to check your state though since some states have requirements whether it is in the plan or not. This info can be found at the elecare site.

Want a personalized experience?

How to get Elecare covered by insurance?

Re: How to get Elecare covered by insurance?

Choose Another Board

Search Boards