Wednesday, November 12, 2014

Getting CIGNA To Cover Baby Formula

I haven't posted on this blog for a long, long time and still consistently get requests every day on how to get formula covered by Blue Cross, Aetna, United, Cigna, etc.  These are from parents that are going through what I went through a few years back with my daughter.  Since people are still coming here to seek help, I thought it would make sense to post my responses in case they help others win their battles against the insurance companies ...

This is one from yesterday:


HELP! How do you get Cigna to cover alimentum.DME says it must be categorized "enteral" (through a feeding tube) and the pharmacy coverage says they will not cover an OTC drug like Alimentum. Feel free to email me I am desperate ...[email excluded]

My Response

First off, I definitely feel your pain.  I've been there.  We had to go with Nutramigen AA (Now PurAmino), which was $700 per month without insurance.  Yikes.  I eventually did win the fight though.

Here are a few things you will need to consider/do:

1. Make sure you get your pediatrician to refer you to a GI doctor so that they can do a thorough examination on record and understand exactly why the child needs that formula.  This is VERY important.  Usually the admin of the GI department will be a strong advocate on your side and help to try and push things through.

2. Note that you will likely be getting the formula through Apria or another similar provider OUTSIDE of the normal pharmacy network.  They won't cover it.  Ask Cigna who they use to deliver formula.  Sync up with an agent there, as they will ALSO be on your side since they want the Rx to go through and make money.  They can help expedite things.

3. For my daughter, it was simple.  She was allergic to milk and needed different formula.  It fell into a grey area and got approved.  Not sure what your diagnosis is?  The "enteral" requirement differs by state as well.

4. Even if they say it won't be covered - you still need to try.  Get a letter of medical necessity from the GI doctor and TRY to hit up Cigna.  They will go through a process and may end up approving you.  If they don't approve you, there will be the opportunity for an appeal.  If you write a passionate letter during the appeal, they will 99% of the time approve it.  They really don't want to keep fighting.

Let me know if this makes sense?  I'm happy to help.

Monday, March 18, 2013

How I FINALLY got insurance to cover baby formula ...

Wow, so it has been a long time since I have updated this blog!  When I wrote this my daughter was just a few months old and we were fighting like mad to get $700 Nutramigen AA covered for her.

I figured after thousands of hits and a couple years I owed it to everyone who found this site to provide on what actually happened.

Well, I did finally end up getting the formula covered - the insurance company ended up covering 90% of it.  At the time it was Aetna, and then we switched to Cigna and I had another fight on my hands.  They required it to be an "in-born inability to digest". Well, my daughter is deathly allergic to Milk and Casien so that definitely applied.  Cigna covered it at 80% or something like that.

I know a lot of you are going through exactly what I did a few years back (my daughter is STILL on the formula by the way).  Since many of you are looking for help, I thought I would provide some tips below that helped me either get things approved or survive until they did.

  1. Get a SEVERE letter from the pediatrician saying that you're child will NOT SURVIVE without the forumula.  Those strong words tend to work very effectively with an insurnace company that is worried about being sued.
  2. See a specialist in addition to your pediatrician.  This could be an allergist or GI doctor depending on the issues your child is having.  Get them to write a severe letter as well.
  3. Target a supplier that your insurance covers via DME (Durable Medical Equipment).  This just means that they will ship your formula out instead of you getting it at the pharmacy.  This also means its covered out of your norma. health plan vs. the prescription plan.  I would HIGHLY recommend you find a national supplier like APRIA that has some muscle and people that will actually work your case for you.  Think about it - they want your business.  If they help you get the formula approved then it could mean $700 per month for them, so trust me they work hard for you.
  4. Keep all that paperwork handy - all doctor visits, notes, letters of necessity, etc.
  5. Call the insurance company once per day and keep harassing them  as to the status of getting the formula covered.  Talk to a manager once per week.
  6. Get the doctor to "prescribe" more oz of formula than you actually need.  This is important because (A) you will spill some and (B) you might have some extra at the end of each month you can either stockpile or sell via Ebay to help fund the monthly formula costs. 
  7. Ebay and Craigslist:  These were by far the cheapest places for me to find formula while it wasn't covered.  It's really just a bunch of people with leftovers - I never had a bad experience.
  8. If you need to survive, put the maximum $2500 into an FSA at work.  This is pre-tax money, so it actually costs you maybe $1600 to get that $2500.  That will cover a LOT of formula if you need it.

 I will update this as I think of other things that helped me along the way.  As I said, my daughter is still on the formula even though she is 2 1/2 now so I feel your pain.
Also - I do tend to have a few cans of extra formula (Nutramigen AA) every month that I can sell pretty cheap to anyone who needs it.  If you do, just leave a comment below.
Good luck to everyone!!!!!

Wednesday, November 17, 2010

How to get your insurance company to cover baby formula?

So I just found out last week that my two-month old daughter has several allergies, including milk and soy.  This means that she will have to be put on a hypoallergenic formula, specifically Nutramigen AA.

The downside to this is obvious, as one 12.5 oz can of Nutragimen AA goes for about $60, which turns out roughly to be almost $700 a month!!!

Right now I'm in the middle of fighting with my insurance company and keeping my hopes up that I can get all or some of this covered, but I have my doubts.

I was wondering if any of you out there have had any luck with getting your insurance company to cover formula costs, and if so how you did it???  ANY ADVICE WOULD BE TRULY HELPFUL.  I would love to get a running list of ideas that future parents can use ...