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.
- 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.
- 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.
- 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.
- Keep all that paperwork handy - all doctor visits, notes, letters of necessity, etc.
- 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.
- 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.
- 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.
- 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!!!!!