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:

Question: 

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.