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 ...
THANKS EVERYONE!!
Hi, I saw a link to this on a babycenter board. If you qualify for WIC, you could see if they offer the formula there. I'm currently getting a special formula for my son through the local WIC clinic, who gets it from the nearby children's hospital. Also, if you haven't already seen a nutritionist through a children's hospital, that might be a good idea. The nutritionist we saw was really helpful in making sure that we don't pay more than we had to for our formula, including figuring out for us what our insurance would cover. Hope that helps!
ReplyDeleteThanks Sheri - Unfortunately we do not qualify for WIC. We have seen a GI specialist, and they have been more than helpful with providing us samples, but we have not seen a nutritionist. That might be really helpful to get one involved. I'm still keeping my fingers crossed that my insurance comes through!
ReplyDeleteThanks!
Well, it sounds like to me you need to find out if they cover prescribed formulas, and if they do, which ones.
ReplyDeleteYour doc and you might have to do a trial and error system before the insurance company will cover anything, just to prove that the specific formula is needed.
And talk to the insurance/medical billing person in the doctors office or pharmacy. They may be able to point you in the right direction, and to the right formula to be covered.
Good luck.
I used to authorize claims for an insurance company. All insurance companies cover formula to some extent (ie. TPN, PKU, etc).
ReplyDeleteFirst, get a letter of medical necessity written by a physician (pedi, gi doesn't matter) but it needs to be an MD. This letter needs to include the formula's you have tried, for how long you used them, what the side effects were, etc. Basically the insurance company needs to see you have exhausted all cheaper option.
Include your child's height, weight and percentiles on the growth chart. Children who were less than the 10% percentile were almost automatically approved.
Include any rashes, medications that you have used to control symptoms. Include any weight loss (a history of percentiles submitted is a bonus - especially if they show a weight loss). If the child shows a significant weight loss they were more easily approved.
If your child has experience any developmental delays as a result of the allergies, this is good to include as well.
Make sure they include diagnosis codes in the letter.
A nutritionist will be able to provide you with additional information and more specific resources within your community as well as have some insight regarding your specific insurance.
Good luck.
Wow! Thanks for the great advice everyone! I wanted to let you all know that it did get approved today by the insurance company (Thank god!). Such great tips though, thank you :)
ReplyDeleteUnfortunately it looks like I've spoken too soon. The insurance company "approved" the fact that it is medically necessary, but did not actually "authorize" the coverage for the formula. So aggravating! I'm still going to keep fighting them though.
ReplyDeleteOur insurance company will cover the cost (up to 90%) after we met our medical equipment need-which is based solely on our child and not any medical equipment we may have claimed.
ReplyDeleteHowever prior to their ok, we had to get a medical necessity form and etc. as the previous poster stated. We still haven't seen a single penny back yet and we filed months ago.
Very interesting. After another week or so of battling, I finally won and got the insurance company to cover it through the DME channel. They will cover 80% after my deductible. So in the end, this special formula cost about what regular formula costs.
ReplyDeleteAnon - Did you try and get the insurance company to contact the DME provider directly and get the formula covered that way? That way the discount is up front instead of having to wait for it ...
Im going though this same this right now. What insurance do you have and in what state do you live?
ReplyDeleteMy daughter was on Nutramigen but not AA and now she is on Elecare and that is super expensive along with her reflux meds. I appreciate the advice already given but what is DME? Any additional info would be great. I did submit for Nutramigen but was denied becuase we do not have over the counter covereage!!! I even had a letter from her Ped stating that it was medically nec becuase she had blood in her stool. Hopingthe Elecare will be approved since it's almost double the price.
I have Aetna and live in Mass. DME stands for "Durable Medical Equipment". Instead of going to your pharmacy to pick up the formula, you would actually get it through a "DME" such as Apria, etc. It totally makes sense that you don't have "over the counter coverage" - mine didn't either. You just need to get your health insurance company (not your prescription provider) to say "yes, we will cover you, it is medically necessary". After that you just go to the DME and you are all set.
ReplyDeleteWorst case scenario, if you don't get coverage, just get the formula on Ebay. People sell their leftovers quite cheap and I've never had a problem (did it before our formula got covered).
Good luck!!!!