Insurance paying for specialty formula? How to find out if they will?

Yellow_Daisy · December 2011

This may be a dumb question but I'm wondering if anyone has tried to get insurance to pay for specialty formula? Our pedi is writing a script for Alimentum to see if a hypoallergenic formula will help with DS's eczema, on the off chance it's due to food allergies. If you have gone this route did you just call the insurance company or did you take the script to the pharmacy? I always get different answers on things when I talk to people at the insurance company and half the time the rep tells me the wrong thing, so I'm hoping someone who has been there done that can give me some advice. TIA!

naflmj · December 2011

I did but in MA insurance covers any formula with a script so I didn't have to jump through hoops. GL, that stuff adds up.

MrsMAF · December 2011

We just did this yesterday! DH called insurance and they asked us to have pedi called them to authorize the prescription and say it's necessary. Then it goes into review, once approved, the insurance company will send us the alimentum directly!

I'd start by calling insurance...I know it's annoying and you may get a run around, but they should know right off the bat even if they are willing to cover it at all.

Good luck!

GuitaristsGirl · December 2011

Gah, I remember that. So frustrating!

For us, the key was having a written script (since one isn't needed just to purchase it) - which you do, so that's awesome! From there, I would recommend making friends with your pharmacist. If yours isn't overly helpful - find another!! See if you can find someone willing to run it for you and communicate with the insurance company for you. They might get better luck than you will.

GL!

KYRN · December 2011

I don't have experience with this but you may also need to check medical vs. Rx benefits. Ours are separate companies so I don't know if that's an issue and/or which would cover it.

LuckySunshineBaby · December 2011

I checked out the website/google Childrens Magic, which seems (?) to advocate for insurance coverage? It had info on it for some states requirments.

Recently learned on Friday our insurance coverage is required to cover it, but at our out if network benefit level and after deductible. That was after a 45 minute conversation with the Rep who still isn't sure she has it correct. We were told we would need a letter of medical necessity that specifically states our child has "mulitiple protein intolerances and has not been responsive to non cow based formulas". We are OOP till we hit our deductible and will need to fax our receipts into the claims dept for a 70% reimbursement.

We'll take any help we are eligible for!

HTH

pamela-matt · December 2011

With Ry and his nutramigen I just took the script to the pharmacy and no problem. With JJ I have had to jump through hoops to get them to pay. This time I went through the progression of formulas myself since I have been down this road before. I did not want to pay a copay three weeks in a row. When the doc requested insurance pay, they made me try regular again for a week, soy again for a week, and also do a guiac for blood in the stool. They covered up until JJ was 6 months old. Then they told me I had to do another one week trial of reg, followed by a week of soy again to see if he grew out of it. My pedi said NO WAY putting him through that again and to just call each week and say we did it. She knows a lot of pedi GI specialists and they have told her infants seldom grow out of the sensitivity before a year. Go in today for 6 month WB and for her to put the order in to the insurance. We will see what they do. Check your state laws to see if it is covered. Good luck.

Yellow_Daisy · December 2011

I talked to our insurance company and they said they don't cover formula on any of their plans, not even medically necessary formula. I am going to try and call again, but I think I will probably get the same answer. It doesn't really surprise me since out state doesn't mandate much when it comes to insurance. Although it ticks me off that if we had MediCal they would pay for it, but because we have private insurance we are out of luck. I love that my tax dollars pay for others to have things that my child can't have :-(.

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