Seems like yesterday my little bundle was born. Because this was my first child, breast milk was the extent of my knowledge of how to feed her. After Plan A did not work out, I figured we would just go to the store, buy some formula and all would be fine. Little did I know, there are a multitude of formulas out there both in the store and online. From basic to medicated. Overwhelming is an understatement. I needed to take a college class to understand all this!
We tried several formulas before realizing store bought was not working for our daughter. Consequently, we needed the premium for everything here. Thanks be to God, a friend told me about medicated formula. Neocate is the brand we decided to go with. You can see a chart of the differences in brands here. Immediately, the crying stopped. Within two weeks I learned what other mothers were talking about with regard to different cries. Her bowl movements were normal. Read about how we discovered she had acid reflux here.
There is a bit of a cost difference between store bought formula and medicated formula, especially when you are on a budget. Similac Organic is $27.49 per 23.2 can (1.45 pounds) while Neocate is $38.75 per 14.1 ounce can (you buy a case at a time on their website). We did what we had to do in order to afford the formula (cancelled cable, took lunch to work, etc.).
Other parents, however, have already cut back as much as possible and still cannot afford the cost difference. This is where insurance should come in. Unfortunately, not all health plans cover medicated formula. Well, not automatically. Since it isn’t covered, you have to appeal and fight! Isn’t that the case for everything these days. Note: Some insurance companies will pay for “specialty formulas” which can be bought at your grocery store, i.e., Similac Alimentum. My advice is to file whichever formula you have with insurance and fight it. In the end, you could save yourself a lot of money!
At the time, we had BlueCross BlueShield health insurance with CVS Caremark for our pharmacy benefit plan. We initially filed the claim with our health insurance after then being denied and told we had to file with our pharmacy benefit plan. Be sure you contact your insurance company to find out where you need to file. There number is on the back of your insurance card. This will save you a lot of time and energy!
Neocate has extensive information on their website for filing with insurance companies. It can be found here. After our pharmacy benefit plan denied our claim, the appeals process was started. Below are the steps taken to win the claim:
Save every single receipt from Neocate (or the formula you choose). You will get one when you check out online as well as in the shipping box. Be sure to only buy the medicated formula from their website. This ensures the quality of the food and helps with the appeal process. Note: I created an folder to keep track of all paperwork for the claim.
Prescription Claim Form
This can be found by logging into your prescription carrier’s website. Be sure to take your time and read over everything twice. One small mistake and they will reject it. All insurance claims I have filed require the original receipt so make a copy of both the completed claim form and receipt before mailing. Place the copy in your folder for safe keeping.
If you are denied, you will be mailed a letter explaining why. The denial letter will have directions for the appeal process. There is a separate mailing address for appeals, which will be in your denial letter. A fax number is also available if you would rather fax the documents.
For CVS Caremark, there are two levels of appeals. The first is called “Initial Benefit Reconsideration” and the second is called “Medical Necessity Appeals.” Be sure to put the correct level in your letter. Here is the EDITABLE appeal letter I used. It is a combination of all three letters I sent. This is where to find the EDITABLE letter for the pediatrician to sign (for Neocate). The letter is located at the bottom of the page.
Hopefully these will be the only two documents you will need to win your appeal. Note: I prepared the document for the doctor so all he had to do is read and sign. The doctor will be more willing to do this rather than think of what to write! Make it as easy as possible for them.
Mark your calendar
You should contact your insurance company 15 days after you mail/fax your appeal letter to get the status. Be sure to write down the date, time, who you spoke with, your claim number, and as many details as possible. There will probably be additional information needed. Once you mail the new information to the appeals address, mark your calendar again for 15 days. If new information is not needed, follow-up your telephone conversation with a letter.
It is a brutal process, but for you to win you have to keep contacting them. In the end, if you continue to fight and prove your case, they will pay. They just want to see how long you will fight. Note: It took me 8 months to get the formula approved; however, they paid 80% of the total cost. A huge savings!
Continue to submit your claims for your formula. This will be a separate address from the appeal letters so double check before mailing. Again, copy everything before mailing. There were many times I had to resubmit something to insurance because they “lost” it or it was never received. Keep all copies together in your folder. You will be surprised how much paperwork can be accumulated during this process.
Check in the Mail
Once your appeal has been approved, you will receive a check in the mail. Make a copy of the check and place in your folder prior to cashing it. While it is a grueling step, it is very important.
Keep your Records
Be sure to keep your records in a safe place for at least five years. You never know if/when you might need them.
I pray these steps help you win the battle with your insurance company! What steps worked for you fight the good fight?Charissa