Fighting with Insurance company to cover my son's prescription formula in Pennsylvania...?

Question

My son requires a protein-free formula called I-Valex-1 that is ordered via prescription by a Dr. My insurance comp is refusing to pay for the costly $850/month formula. His Drs submitted a letter of medical necessity to the Insurance Company back in FEBRUARY and they "misplaced it" last monday before it could be fully processed. They continue saying they will not cover the formula. So childrens hospital sent ANOTHER letter of medical necessity over last week. I was told that it would take no longer than 48 hours to process the letter since it was placed under "Urgent Review" However when I called today (6 days after it was received the 2nd time) I was told that it is STILL under review. In the meantime, my son's supply of formula is depleting and I cannot afford it at full cost. I have tried WIC, I have tried contacting the manufacturer of the formula....no luck. I'm going to appeal their decision with the Insurance Commisioner if they again say they will not cover it again.

Answer 1

Ok, I went to Abbott's site, the maker's of this formula.You may have already tried this, but here is a form you and your dr. can fill out to see if you can get it free or discounted directly from them. Hope this helps!

Edit: Would you be willing to take up a vegan diet for your own breast milk? I looked up the conditions why your baby would have to drink this formula. Bless your entire family's heart. I'm in healthcare and I've never heard of such a condition. Had you gone to the site I listed which is the manufacturer of the formula? s***w your insurance, they're gonna do whatever possible to get out of paying for it. Good luck.

Answer 2

Can he take breastmilk?  Because a baby with that severe milk needs can qualify for breastmilk under most insurance, and it is probably a lot cheaper.  Talk to the doctor and the insurance company about this.  Maybe you know a nursing mom that wouldn't mind helping you out???

Answer 3

Well, I wouldn't hesitate about filing that complaint with your state insurance commissioner.  I'd include copies of the letters of medical necessity, printouts of whatever his disorder is, and documetation about the conversations you've had with your carrier.

Also, if it's possible your baby could tolerate human milk, I'd contact the local La Leche League and beg the mamas for any milk donations they could make, and see if you can get a prescription to your local human milk bank.

Answer 4

omg, i'm so sorry that this is happening to you. i would call again and ask to speak to the supervisor in that department. escalate that phone call to get what you want.

Answer 5

I would call 5 times a day if I needed to...and flat out be a B**ch.  This is a child you are talking about...they need to understand that.  I don't have a real answer for you...but I'll give you a star so that others can see this question.

Maybe try asking this question in the baby section too.