Fighting With Insurance Over Formula Coverage

I have worked incredibly hard for everything I have ever gotten in life. I don’t feel like the world owes me anything and I very rarely seek assistance with things going on in my life. There are however things that I believe are wrong…..especially in the health care world. I believe that health care should be standardized. My coverage should be no different than the coverage of my neighbor, or the people who live 900 miles away.

Unfortunately I am in a position in life where I need assistance paying for Luke’s formula. Ronny has a job with amazing benefits, but a lot of health issues are not covered. Because we have health insurance we do not qualify for government assistance, and Ronny makes too much to qualify for W.I.C. or Medicaid. Our current health plan treats nutritional supplementation for a child with severe allergies as a grey area. Coverage is contingent on how well your doctor can spin words. Nothing in the policy specifically states that formula is not covered, but nothing says that it is either.

Our GI has to write a letter of predetermination to the health insurance company with his official diagnosis, what we have tried and saying why the formula is medically necessary. The insurance company will then run a phantom claim using the diagnostic codes provided to see if it is covered or not. All of this can take upwards of 30 days just to see if coverage exists.

I work hard for everything in life, and I will fight to have a PRESCRIPTION formula covered by the health insurance company. If it were only $15-$20 a can like “normal” formula is, I wouldn’t have a problem just paying for it. At $50 a can though, we are going to need some help. I can’t afford $500-$600 a month in formula for only God knows how long.

We do have a few options though. The representative from Enfamil is going to drop of sample cans of PurAmino (the Enfamil elemental formula) for us and get in touch with someone at the Helping Hands for Special Kids program. At the very least they can send us a case of formula, which will last about a month, and maybe more if we meet their undisclosed income guidelines. The good thing about the helping hands program is that it was designed to help parents pay for formula when it has been denied by insurance coverage.

The representative from Abbott Nutrition is also going to order us a case of Elecare when the year rolls over. They were put on a spending hold for the rest of the year, so it will be 2-3 weeks before we can get the formula from him. He is going to drop off a ton of samples too so that we can stay afloat while waiting to hear back on their Pathways Program. Like Helping Hands, Pathways was designed to help people who have been denied formula coverage from their health insurance company, and don’t qualify for Medicaid or WIC.

I am also going to fill out an application to the Neocate Assistance Program to see if we can qualify for that one as well. The benefit of these programs is that they have the ability to either send you free formula OR drastically price reduced formula without needing to go through the insurance company.

I have all of the paper work printed off. I just need a pay stub of Ronny’s…..because lets face it, I’m a spender not a maker, and then send it over to the doctors office for the doctor to fill out and send in.

Wish us luck, we’re gonna need it.


11 thoughts on “Fighting With Insurance Over Formula Coverage

  1. Omg I hate insurance. If there is a medical reason why a baby needs formula, cover the damn formula. The end. Blah!! I’m so sorry this entire process hasn’t been easy- at least it does sound like you have a few options if the insurance plans to be a pain in the ass. Keep us posted!

    Liked by 1 person

      • I ordered from American Home Patient. They filed to my medical insurance, well, to Olivers. Filing under medical got us better rates than filing through our prescription plan. This was all great until the year flipped over and we hadn’t met our deductible. We paid over $500/mo.


  2. I hate dealing with insurance and all the BS they put us through. I’ve been hiding my head in a hole about our current situation, and will probably continue to do so until the new year when hopefully someone can give us a straight answer. I hope that ALL of these things get approved for you and that you get so much formula that you won’t even know what to do with it! Good luck!

    Liked by 1 person

  3. I’m sorry that you’re having a hard time getting insurance coverage for the formula. The whole system pisses me off. It shouldn’t be this difficult. I hope that one (or more) of the options you’ve looked into does work out for you. Good luck!


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