Insurance coverage of formula

[Guest guest]

I was wondering if anyone whose child is 100% tube fed has had trouble getting

their

insurance to pay for formula. is 11 years old (been 100% tube fed since

6 mos.

old), and I have never had a problem up until now. I have an HMO, but it is

basically the

same policy we have had 's entire life. As far as I knew there were

never any limits

or exclusions when it came to paying for enteral nutrition. Now, I am being

told there is a

$2500/year limit on formula, and that we were actually over this limit in the

middle of the

year. In 11 years, I have only had to get a new authorization/prescription from

the doctor

one time (plus each time a new DME company took over) that I can remember to

keep

allowing to get formula delivered monthly. I found out that the DME

company is

charging the insurance company $643/month for 5 cases of Nutren 1.5. This is

not an

expensive formula. I called around some pharmacies, and the cheapest price I

found was

$25/case of 24. So, it would only cost me $125/month for 5 cases as opposed to

the

$643 the DME company is charging the insurance company & exhausting my benefits.

's case was sent to medical review, and the insurance company denied

getting him

formula for the remainder of the year. For next year, if I continue to use the

DME provider

they say I have to use, his benefits will be exhausted by April, and I will have

to pay for 8

months of formula out of my pocket. Meanwhile, if I could get the formual from

the

cheapest pharmacy I found, the formula for the whole year would o nly cost $1500

as

opposed to the $7716 the DME company is charging the insurance company. I asked

to

be allowed to use the alternate pharmacy for this for next year, and the

insurance

company told me no. I think this is ludicrous, because it would save both me 7

the

insurance company money to go this route. Has anyone else ever dealt with an

issue such

as this, and if so do you have any suggestions for me? I am also curious if

anyone has an

insurance company that will not cover formula. I didn't think an insurance

company could

deny this if a doctor said it was medically necessary and this was a child's

sole source of

nutrition.

Kim C.