Insurance coverage for Alimentum

[coco758]

Hi,

My DS is now 3 months old and have been fussy, gassy, spit ups the whole time, and recently rash with milk based formulas. Eventually, our pedi and we figured out that he is milk allergic and started on Alimentum. He is doing much better with rash that is almost gone and gaining weight and sleeping much better! completely different and happy baby :) But now we are faced with the cost of Alimentum $$$ !! We live in CA and our insurance says that they will not cover it since it is OTC formula and will be taken orally (not through feeding tube).

Have any of you had success getting the insurance to cover Alimentum? We have our pedi writing a prescription that says it is medically necessary. Looks like some here have been successful with their insurance...is it dependent on what state you live in? and if the state has a law that says insurance has to cover it then you can get it (looks like NJ is that way?) would really appreciate any suggestions. thanks !

[Nyfeara]

We were able to. I was told to submit it to the insurance company or to your prescription plan. They denied us. When I called to ask why, they explained that they covered it for certain adult medical conditions but not infants. I was able to speak to someone who was nice enough to explain what we had to do.

We had to appeal their decision. We completed the necessary forms and I had to write a letter that included why he was being prescribed the formula, what we had tried (BM, regular formula, Gentlease, soy formula, whatever your case), the symptoms/reactions, and for us, how it had all cleared after him being on Alimentum for about 1-2 wks. We also had to include about how many cans/month he needed (so figure out conservatively what you need) and they wanted an approximate end-date (for us, around 1 year old). The ped had to submit the forms and fax the letter to the insurance company.

Once they approved it, we had to order thru a pharmacy (CVS did it for us), and it would take about a week for them to get it in. We got 10 cans/month and paid $10 as our co-pay. It's a HUGE difference. The pharmacy had to call the ped every month before "refilling" but the extra steps were well worth saving the $240 or so a month.

HTH - good luck!

[coco758]

Thank you so much for the info!

[tnrnchick74]

Here in FL (with my insurance) was NOT able to get Nutramagin reimbursed. Submitted prescription from ped; letter of medical necessity from 2 MDs; and went through an appeal process...still not able to get it even partially paid for.