Our Insurance is paying for baby formula

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Way back on January 1st of this year I posted about my daughters colic: The Colic Chronicles – Episode 1. At the time, I truly thought it would be a nice series of posts describing our couple of months of dealing with colic: what worked, what didn’t and basically provide some support for others who might end up experiencing the same thing. Well, it turned out to be more than just “colic” and my planned series of posts turned to mush as I dealt with a baby that SCREAMED night and day and threw up constantly. We were living a NIGHTMARE, and my poor daughter was caught in the middle. We knew something was wrong, but what?

We were at the doctor’s office every week for over a month trying different things. I was breast-feeding so the thought was that it was reflux or some sort of digestive problem. She had x-rays, urine tests, blood tests, you name it. They even talked about doing some GI tests which involved putting tubes down her throat and making her utterly uncomfortable for a few days. I prayed it wouldn’t come to that. After trying all the reflux meds, one of which – Reglan – made her jittery, the doctor (whom we adored) suggested we try not nursing her for a day. I was floored by this! Not feed my baby? The doctor suggested that she might not be able to process the breast milk; that she might have a milk protein allergy. So, Abby got nothing but Pedialyte for a day. The biggest challenge with that was getting her to take a bottle as she’d never had one before.

While on the Pedialyte, once she was taking the bottle…sort of…we noticed something – she didn’t cry and scream like she was before. Here we are, NOT feeding our baby and she seems happier. I can’t even begin to explain how confusing that was and how bad I began to feel since I had been the one feeding her and therefore causing her pain and discomfort.

The doctor was pretty sure we had isolated the problem, but now what? In order to confirm her suspicion, she suggested we try giving Abby a hypoallergenic formula for a week while I pumped and see if her discomfort continued to subside. They gave us samples of Nutramigen by Enfamil and within 2 days we noticed that she had still not screamed at us and was spitting up less. We were then faced with a dilemma. Do I try an elimination diet and risk her having more problems, or do we look at this expensive alternative as a cure and continue with what we know works. We opted to stick with the formula. When your baby has been that uncomfortable and you finally fix it, YOU DON”T MESS WITH IT! As disappointed as we were that she only had the “benefits” of breast milk for 2 months, we knew we were doing the right thing.

So, as I dealt with engorgement (I can’t believe I said that out loud, let alone in public) and the issues my body had with weaning my daughter, we had a new baby! She was no longer screaming AT ALL and was happy and content all day. She napped very well and was sleeping great, in her crib, at night. We were finally ready to breathe a sigh of relief. At least until she got her 4 month vaccinations. Since then she will forever be known as “Crabigail” but that is a story for another time.

Since my daughter had been on the Nutramigen, we were shelling out $300-$400/mo just on formula, which is quite a shock when your plan is for the baby’s milk to be free. It was worth it for her comfort, but I had been doing some research on the web about babies and milk protein allergies and I discovered that some insurance companies are covering infant formula when prescribed by a physician. I also learned of a hypoallergenic formula that was available only by prescription, thus making it more likely the insurance will cover it. In addition, this formula was supposed to help with reflux as well, and Abby still spit up quite a bit and was still showing signs of reflux.

I contacted my insurance company, Tricare (my husband is a retired Navy Veteran) and asked them if they would cover Neocate infant formula in cases of severe milk protein allergy and reflux. After over an hour on the phone with Tricare, they indicated that it was a covered benefit (they would pay 80%) provided the doctor could present adequate medical proof of its necessity. A team of nurses would then review the information and determine if they would cover it.

We met with Abby’s doctor (a new doctor…long story) and told him what we found out and he told us that he would do whatever the insurance company asked to get them to cover the formula. In the meantime, he wrote a prescription for the Neocate so we could get her started on it and make sure she tolerated it well. Neocate runs anywhere from around $39 to $55 for A 14 OZ. CAN which is over twice the cost of regular formula. The cost varies depending upon where you get it. We were getting it from Walgreens for around $39 per can but we knew that if the insurance approved it, we would get reimbursed. We spent $600 the first month she was on it while waiting for the insurance to make a decision.

Our insurance Company went back and forth with Abby’s doctor requesting numerous additional information, but in the end, one month later, they approved the coverage and set us up with an account through Apria Healthcare. They UPS the formula to us and although their prices per can are on the high end, our 20% cost share is around $170 per month, much better than $600 or even the $400 we were spending for Nutramigen.

Abby is now six months old and while she still spits up frequently and is on Prevacid to help with her reflux, she has gained weight steadily (although she’s barely in the 50th percentile for weight while in the 95th percentile for height) and aside from the fussiness that appears to be in her nature (nothing like her mother, nope…not me), she seems quite happy.

If you have a young infant and are experiencing any kinds of colic or symptoms of discomfort with your baby, I really recommend that you ask your doctor about the different types of formula if you are formula feeding or about elimination diets if you are nursing. I have done extensive research on colic and its symptoms and there is a ton of new evidence that suggests that it is likely due to reflux or a food allergy. I’m no doctor but I am convinced that no baby (or the parents) needs to endure colic, especially if caused by a food allergy.

If you have any questions, please feel free to post a comment here or email me through our contact form at the top of the page. Additionally, a simple Google search for your baby’s symptoms, or any of the formulas I’ve mentioned will provide a fantastic list of useful resources. The internet is a wonderful tool for researching ideas and suggestions to help your baby, but please always check with your doctor before implementing any of them.

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  1. JOSI says

    Hi! I am currently battling tricare trying to get them to cover it. Do you know the codes your doctor used? I can’t find your email at the top of the page, if you cold email me I would really really a million times really appreciate it. josirobinson@gmail.com. I just need help dealing with tricare. They have told me so far, a milk allergy, esophageal issues, acid reflux issues, soy and the list goes on and on are not covered. The only way is if he has to take the formula through a feeding tube. Any help/advice you have would save me :)

    Josi

  2. Kathy Hutchins says

    I have a grandson who is a little over 4 months old. He has been battling eczema since he was just 3-4 weeks old along with major colic. My DIL tried breast feeding and could not do it so he was put on Similac Sensitive at about 1 week old. He was so fussy and then the eczema started. Dr said he thought it was contact eczema and changed laundry soaps etc but he continued to get worse. My son and DIL left him with me for 4 days when they went on a trip and I changed his formula while they were away to Alumintum and his eczema started getting better. DIL added rice cereal to his diet at 4 months and the eczema got much worse…dr changed his formula to Nutramegin and he continued to get much worse. He now has infection on his face from the constant scratching. The dr on Monday has changed him back to Alumintum and he will be going to a dermatologist on Thursday. I was wondering if it would be more beneficial for him to be on Neocate or for them to at least try it to see if it helps him more than the Alumintum. How would they go about getting Tricare to cover it?

    Thank you for any advice you can give.

    Kathy

    • says

      I think you really have to talk to your doctor about it, and buy a can and try it if the dr says it’s ok.

      Does he cry a lot, like colic?

      As for Tricare, read carefully through all the comments on this post and then call Tricare and ask them what you need to do because the doctor is saying the formula is “medically necessary” – again read through the comments here a lot of people give tips and advice.

      Good luck!

  3. Rita Hoffmann says

    We have a very similar story. Our little one is now three months old and it has been a very long three months! Her problems are all things whe will hopefully outgrow but in the meantime….seem a bit overwhelming! She has had severe reflux since birth. She chokes on her formula and snores and wheezes constantly due to a ‘floppy eppliglottis’ (there is a medical term that I can’t spell). She has torticollis from being twisted in the womb then sleeping in the slanted bassinet for the reflux! She is allergic to milk, soy and corn. Corn is in EVERY powdered formula, even the hypoallergenic ones, except for the ready to feed varieties. She has been a new baby on the Alimentum Expert Care (ready to feed). It is 360.00 a month and putting us in the poor house. By the time she is one, it will have doubled! My husband is active duty Navy and we are trying desperatly to get Tricare to cover it. Our Dr. is cooperative but not knowledgable of the codes and paperwork that they need so the first claim was denied. I’m not giving up.

  4. Angela says

    I gave up breast feeding due to my son’s severe Milk allergy and is on the nutramigen. He is a piggy that goes through 5 cans a week. My Insurance denied the prescription my doctor gave me. How do I get United Health care to cover it. What codes are needed? Its financially killing me when it was free and now 600 plus a month on formula alone.
    Thanks for all the help.

  5. Janette says

    Does anyone know about Aetna? I see a lot of Tricare, but we aren’t military. Aetna says they will only cover it if state law mandates coverage, and although they say that, they also say that I have to provide them with that information. I got into a conversation about the circular logic of that statement with the help desk at Aetna, and I don’t think they saw the irony. We live in Indiana and i’ve searched the internet, called everyone I can think of, etc. and have had no luck figuring out if Indiana has mandatory coverage for special formula. We’ve been using Nutramigen for my son about 2 months and we’ve probably spent $300 so far. Our doctor’s office is saintly and gives us a few samples and coupons as they can but they try to help out as many people as possible with what they have.