Re: Insurance coverage of formula

[Guest guest]

Hi Kim,

As of now I have not had any problems. We have Healthnet insurance

and so far they pay for everything.

One question, did you ask what if anything they will reimburse you

if you pay out of pocket for the formula?

Good luck,

Judith, Steve, (RSS) and (non RSS) 4 1/2 year old twins

[Guest guest]

Kim,

I have had the insurance problem, too. Whenever Max is sick and

cannot eat, he must use Peptamen,Jr. for feeds. This costs

$180/case in our area and he can go through several cases in a

week. Despite letters of medical necessity from our doctors, they

still will not pay. (We have Oxford.)

About eight months ago, when Max was really sick and going through

formula like crazy, we turned to our state senator and

assemblyman. The aides were more than happy to help and sent off

letters to the insurance commissioner and promised to champion our

cause. They even asked me to go to Washington with them to speak on

behalf of other families in the same situation. Well, as government

usually goes, this became less and less interesting to them as time

went on. Now they have not been in touch for months. They don't

even return calls or emails. So much for them.

According to our insurance company, we should be pureeing food and

putting it down Max's tube when he is sick. Besides worrying that

it would clog up the tube, that just does not seem reasonable or

balanced enough for me. I'm just thankful that we have not had to

use the tube for more than 24-48 hours since his last long

go 'round.

I know I am not helping, but I wanted you to know that I

understand. What I don't understand is that you have to get the

formula from the company and then pay for it??? Maybe I read that

wrong. We just order ours from CVS.

Jodi Z.

[Guest guest]

Jodi,

I have been through the having political people interested in our case too from

time to

time, especially the insurance commissioner. But, you are right, after awhile

it's no big

deal anymore, and things never change with insurance companies anyway. I always

joke

around that if I had a nickel for every minute that I have spent on the phone

arguing with

insurance companies, doctors, medical equipment companies, etc. that I would be

rich &

wouldn't have to work!

I have only tried to puree food for one or two days to go down the g-tube, and I

couldn't

get it to go down to save my life. I don't know if it was clogged or what the

problem was,

but it surely wasn't moving!

I honestly thought there was some class action suit many years ago that involved

tube

feeding & the need for formula & that insurance companies couldn't deny this if

it was life

sustaining, but now, of course, when I am looking for info on this I can't find

it.

What I meant about having to get formula from the company & then pay for it is

that in

order for them to cover any portion of formula (up to $2500), I have to use the

DME

company they contract with. This company is so expensive that I would exhaust

my

benefit in less than 4 months. Then I would still have 8 months I needed to pay

for

formula out of my pocket, but then I could get the formula from wherever I

wanted to. If

they let me get the formula from where I wanted to get it from in the first

place, I would

spend anywhere from $1500 - $2100/year on the current formula he is on. This

would be

under my calendar year benefit amount of $2500, so it would save the insurance

company

money & it would also save me $1000 - $1400/ year out of pocket. You would

think this

would make logical sense to the insurance company, but of course, it does not.

Kim C.

>

> Kim,

>

> I have had the insurance problem, too. Whenever Max is sick and

> cannot eat, he must use Peptamen,Jr. for feeds. This costs

> $180/case in our area and he can go through several cases in a

> week. Despite letters of medical necessity from our doctors, they

> still will not pay. (We have Oxford.)

>

> About eight months ago, when Max was really sick and going through

> formula like crazy, we turned to our state senator and

> assemblyman. The aides were more than happy to help and sent off

> letters to the insurance commissioner and promised to champion our

> cause. They even asked me to go to Washington with them to speak on

> behalf of other families in the same situation. Well, as government

> usually goes, this became less and less interesting to them as time

> went on. Now they have not been in touch for months. They don't

> even return calls or emails. So much for them.

>

> According to our insurance company, we should be pureeing food and

> putting it down Max's tube when he is sick. Besides worrying that

> it would clog up the tube, that just does not seem reasonable or

> balanced enough for me. I'm just thankful that we have not had to

> use the tube for more than 24-48 hours since his last long

> go 'round.

>

> I know I am not helping, but I wanted you to know that I

> understand. What I don't understand is that you have to get the

> formula from the company and then pay for it??? Maybe I read that

> wrong. We just order ours from CVS.

>

> Jodi Z.

[Guest guest]

Yes, I have asked that. The answer is no, because they want me to use their DME

provider. My insurance is an HMO, and with managed care, they want you to only

use

their providers, and as far ask I know, it is very difficult to get anything

reimbursed to you.

Kim C.

>

> Hi Kim,

>

> As of now I have not had any problems. We have Healthnet insurance

> and so far they pay for everything.

>

> One question, did you ask what if anything they will reimburse you

> if you pay out of pocket for the formula?

>

> Good luck,

>

> Judith, Steve, (RSS) and (non RSS) 4 1/2 year old twins