Re: Peptimen Jr. cost need ideas

[Guest guest]

Hi Jenyfer,

With our insurance, they will cover it at 100% if the child is tube

fed. However, it goes under a special code for enteral feedings and

not under their usual code for formula. Otherwise we would have a

huge out of pocket cost.

Call your case manager and see if they have separate codes for

enteral supplies that should be used in this case.

Good luck,

Judith, Steve, (RSS) and (non RSS) 4 year old twins

[Guest guest]

As previously stated, it all depends how your policy is written. A

lot of policies have a section called Medical Food. It says if a

child has a metabolic disorder it will cover medical food.

You might want to see if your policy mentions that. Due to Jake's

hypoglycemia, our insurance will cover pediasure (which he only

takes via his tube a night) but eats orally during the day. We

just needed a note from his doctor.

Alison

> Hi everyone- We're having such a time getting insurance to cover

the

> cost of the Peptimen Jr. for Pippin. Right now she is still on

> Alimentum formula for infants and she's 16mo old! As is stands,

our

> insurance will only cover $2 per can which would be $1800 a month

out

> of our pocket I'm so surprised because until now we've

never

> had more than $20 out of pocket for anything. Even for all of our

> hospitalizations. Any ideas? I know I could contact the

insurance

> specialist at MAGIC but thought I'd start here first. My home

> medical co. is also working on it with my ped. but I'm getting

> frustrated. Today I'm going to contact my Individual Case Manager

> and see if I can't get any ideas from her. I really thought if

your

> child was 100% GT fed that insurance had to cover the cost of the

> food. TIA!

>

> Team Lapish

> Jenyfer, Dan, Tully & Pippin (16mo-RSS)

[Guest guest]

Jenyfer,

My son has been tube fed his whole life (he is almost 10.5 years), and our

insurance has covered his formula 100% all along. Actually, up until age 5, we

used

the state WIC program (Women, Infant, Children - but it may be called something

else

in your state) to provide the formula. I am not sure this is a good idea to

admit this

in a public forum, but we did not meet the minimum income requirements to

qualify

for WIC at that time. We had a social worker advise us that WIC did not ask for

income verification upon my son's discharge from the hospital (he was

hospitalized for 7.5 months after being born at 28 weeks). At the time, I

didn't know

whether my insurance would cover formula, and already had over $1

million

in medical bills. However, when he turned 5, I had no choice but to get the

formula

through the insurance. Luckily, I didn't have a problem, but I remember

corresponding with someone from another state who did. She had a lawsuit

against

her insurance company to be reimbursed for about $40,000 worth of formula costs

over a period of a few years. The poor woman had to pawn her wedding ring and a

bunch of other valuable belongings! She won the lawsuit, and I remember her

telling

me that insurance companies had to pay for formula for tube- fed kids if they

were

100% tube-fed, and the doctor wrote a letter stating it was medically necessary.

If

you have a case manager, she should be able to help you get this. We get our

formula delivered every month from a medical equipment suplier, so it may be

classified under durable medical equipment. You may want to check to see if

this is

the case with your insurance company. Good luck!

Kim C.

> Hi everyone- We're having such a time getting insurance to cover the

> cost of the Peptimen Jr. for Pippin. Right now she is still on

> Alimentum formula for infants and she's 16mo old! As is stands, our

> insurance will only cover $2 per can which would be $1800 a month out

> of our pocket I'm so surprised because until now we've never

> had more than $20 out of pocket for anything. Even for all of our

> hospitalizations. Any ideas? I know I could contact the insurance

> specialist at MAGIC but thought I'd start here first. My home

> medical co. is also working on it with my ped. but I'm getting

> frustrated. Today I'm going to contact my Individual Case Manager

> and see if I can't get any ideas from her. I really thought if your

> child was 100% GT fed that insurance had to cover the cost of the

> food. TIA!

>

> Team Lapish

> Jenyfer, Dan, Tully & Pippin (16mo-RSS)