Posted by: twinturbo
« on: May 21, 2013, 05:40:32 AM »There are three good sources regarding insurance coverage of long term prescription food formulas for 'inborn' conditions.
1. The manufacturers themselves such as what Links put up. They REALLY know the reimbursement process.
2. The state government may require that an insurer MUST cover formulas for infants (or older children) with this special need in order to sell insurance in the state. Check your state's .gov on infant formula insurance requirements.
3. A locally owned pharmacy hopefully run by a wily veteran of a pharmacist who knows about the third party pharmacy suppliers that most insurance companies use these days.
Again, clarifying we had Neocate for anaphylaxis to multiple food proteins not yet at the Failure to Thrive and tube feeding but categorically it's about the same under the eyes of insurance and the law.
We got a long term script from the pediatrician. It took at least two phone calls and another piece of paperwork for our pediatrician to fill out in order for us to use the insurance company's long term supplier. There's a special name for this subcontractor, a pharmacist will know. While we were waiting for the supplier to gear up monthly supplies it was a mad race to see which pharmacies locally could cough up the Neocate we needed in the meantime. We saved those receipts and later submitted them.
The one serious hiccup was initially getting horribly inaccurate information from the first customer service rep at the insurance company who stated if we don't use their slower preferred supplier then they would never cover the prescription food. We called back because what was the choice? He was reacting daily with nearly every meal, we couldn't wait two weeks. The second CSR corrected that statement and gave us clear directions on process and reimbursement.
The last part I'll add is be careful on how the formula is billed to insurance. By making it inborn they removed it as a prescription cost into a medical cost meaning it fell under costs leading towards a lifetime cap.
1. The manufacturers themselves such as what Links put up. They REALLY know the reimbursement process.
2. The state government may require that an insurer MUST cover formulas for infants (or older children) with this special need in order to sell insurance in the state. Check your state's .gov on infant formula insurance requirements.
3. A locally owned pharmacy hopefully run by a wily veteran of a pharmacist who knows about the third party pharmacy suppliers that most insurance companies use these days.
Again, clarifying we had Neocate for anaphylaxis to multiple food proteins not yet at the Failure to Thrive and tube feeding but categorically it's about the same under the eyes of insurance and the law.
We got a long term script from the pediatrician. It took at least two phone calls and another piece of paperwork for our pediatrician to fill out in order for us to use the insurance company's long term supplier. There's a special name for this subcontractor, a pharmacist will know. While we were waiting for the supplier to gear up monthly supplies it was a mad race to see which pharmacies locally could cough up the Neocate we needed in the meantime. We saved those receipts and later submitted them.
The one serious hiccup was initially getting horribly inaccurate information from the first customer service rep at the insurance company who stated if we don't use their slower preferred supplier then they would never cover the prescription food. We called back because what was the choice? He was reacting daily with nearly every meal, we couldn't wait two weeks. The second CSR corrected that statement and gave us clear directions on process and reimbursement.
The last part I'll add is be careful on how the formula is billed to insurance. By making it inborn they removed it as a prescription cost into a medical cost meaning it fell under costs leading towards a lifetime cap.