Formula Insurance Coverage 

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Getting formula insurance coverage is usually very difficult. Depending on which insurance plan you have, the formula may or may not be covered.

Infant formula is usually not covered when taken by mouth because it is though of as food, and if your child were on a basic formula it would be your responsibility to provide it. Therefore, in the insurance company's view, you should provide whatever formula your child is on. 

Sound ridiculous? Of course it does! Remember though, that they care about the bottom line, and them having to pay 152.00 or more a week for formula does not fit nicely into that bottom line. The problem with this is that it doesn’t do well for you either. Of course if your child needs a specialty formula you are going to do your best to get it, however it can be financially devastating to a family to have to pay that kind of money each week on formula.

What can you do to get your child's formula covered by insurance?

Although your insurance company may deny your claim the first time (and second, and third), here are some tips to increase your odds of getting your child’s formula covered.

1. Ask your physician for a prescription for the formula. Without a prescription your chance for getting the formula covered is practically zero.

2. Ask your pediatrician, gastroenterologist, and/or allergist for a letter of medical necessity. The letter should include justification for the formula, including but not limited to your child’s growth chart, progress, diagnosis, labs and any other pertinent information your physician sees fit. He should also stress the cost effectiveness of nutrition management and the cost that will arise if your child is unable to access this formula.

3. As for what you can do, be persistent! Call and write as much as possible, and remember in this case it really is the squeaky wheel that gets the grease. Be careful and follow all the company’s rules and submit only complete submissions, and continue to appeal.

Speak to a case manager if customer service is giving you the run around, and each time you call write down the person’s name, date of call and what the conversation was about. If you finally succeed in getting formula insurance coverage, tell us how! Post it on this forum and on any other forum you belong too. This is very valuable information many parents would love to know!

If Insurance Still Won't Cover It...

1. If you have a mail order program, look into that and see if they will cover your child’s formula.

2. Most formula companies have programs that will give free formula to families. Look into these programs if cannot get formula insurance coverage. Although most families don’t think they will qualify based on income, they look at a few factors and most have a quota, so if they haven’t met their quota they will accept you into the program.

3. Find out when your insurance policy expires and research switching plans to one that will provide formula insurance coverage.

4. If all else fails, set up a flexible spending account and pay for the formula with that money. Since it isn’t taxed, the cost will hurt a little less if this is utilized.

5. Shop around. Although you won't find much of a deal on specialty formulas, consider Amazon or other online stores but be careful and make sure they are reputable and that all cans are sealed and new.

And remember, you’ve come this far. Chances are if you’re looking into how to get formula covered you’ve already been through the ringer with tests and doctors, and have finally found a formula that works. Give yourself credit, fight for coverage with all you’ve got, and if after everything you still need to pay for it realize that this is the best thing for your child.


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