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Paying For Prescription Formula: "Thinking Outside the Can" part 1
Dear Red Tape,
My son is 8 and he has life-threatening food allergies and a clinical diagnosis of Mito. He needs to drink Neocate Jr. for nutrition. Our private health insurance doesn't cover it, and we make about $50 over the monthly income limit for Medicaid. Some weeks I have to choose between buying my son's formula and paying a utility bill, or buying healthy food for the rest of the family. Is there any way that we can get a discount on his formula? Help!
Jen in Texas
Your family is certainly not alone in the fight to make drastic financial decisions in order to provide medically necessary nutrition to your child. Nutritional supplements are expensive, and elemental formulas can easily cost more than a thousand dollars per month. For many children who require supplemental nutrition or specialized elemental formulas, vouchers can be obtained through WIC and the Federal School Lunch Program, and new state legislation requiring private insurances to cover medically necessary formulas and supplements exists in thirteen states and is being lobbied for in two more.
Private insurances are often able to choose whether or not to coverage a specific medical treatment, procedure, diagnostic test, or medication for cost-containment purposes, and prescription formulas are often left to the family to pay out-of-pocket. Still, it doesn't hurt to appeal your insurance's decision.
Reimbursement Legislation Efforts are underway to create laws that mandate private insurance companies to cover the costs of medically necessary formulas. Children's Milk Allergy and Gastrointestinal Coalition (MAGIC) is committed to promoting healthcare coverage and reimbursement of amino acid-based elemental formulas for children who are unable to consume a natural, life-sustaining diet due to various allergies or diseases. Children's MAGIC is composed of parents, organizations, institutions, and like minded individuals. For more information, visit MAGIC. As of September 1, 2009, Texas laws require private insurance to cover medically necessary formulas, congratulations! The other states that have this requirement are Arizona, Connecticut, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Oregon,
and Rhode Island. (Click on each state for more information.)
Letters of Medical Necessity The major formula companies offer templates for that can be downloaded and submitted by your child's physician. For general insurance reimbursement tips, click here.
Here is the sample letter for your son's formula, Neocate Jr.
Nutricia North America makes Neocate and several other highly specialized formulas for a wide range of metabolic conditions. Two more products that you may recognize are EO28 and duocal. To view "Hints and Tips for Successful Reimbursement of Special Formulas Taken Orally or Via G-Tube," click here.
Ross/Abbott produces a long line of nutrition supplements and special medical formulas. Some of their most popular products are EleCare, Vital Jr., Juven, Pediasure, Ensure, Glucerna, and Polycose. Templates of medical necessity can be found here.
WIC is a federal program that provides nutrition assistance to pregnant women, infants, and children to age 5. Families must meet income guidelines. WIC provides vouchers for free medically necessary formula. For information about eligibility and covered formulas and medical food, click here: WIC
The Federal School Lunch Program is required to provide accommodations for students with developmental and special health care needs, including nutrition needs. Your child may qualify for federally subsidized specialized formula given during school hours. The USDA Guidance Manual "Accommodating Children with Special
Dietary Needs in the School Nutrition Programs" explains the school food service role in providing meals to students with special dietary needs. For a complete copy of this USDA manual, click here: USDA
Next week: "Thinking Outside the Can" part 2; coverage for adults, medicare and Medicaid, uninsured and under-insured patients; Pharmaceutical companies' financial and product resources; Private non-profit organizations that may provide financial assistance for nutritional supplements and special formulas; Links to enteral/parenteral nutrition resources including special medical diets, tube feeding support, parenteral nutrition support