If you’re currently paying for baby formula out of pocket, you may be wondering does health insurance cover formula? We decided to take a look at this question as well as look at some specific insurance companies to see what their policy is on formula coverage.
There is no federal requirement for insurance companies to cover formula for any reason but 17 states mandate that insurance companies cover specialized elemental formula that is prescribed to babies with certain allergies or other health conditions. In all covered cases, the formula must be deemed medically necessary.
If you’re looking for assistance in paying for your infant formula, keep reading to find out what all your options are and how you can qualify to get your formula covered.
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Is baby formula ever covered by insurance?
Families all across the country choose to use baby formula instead of breastmilk for many different reasons. Some moms are unable to breastfeed their baby and some choose formula for ease and convenience. Regardless of the reason, formula is not exactly cheap and many families have trouble keeping up with the costs.
According to the US surgeon general, many parents spend between $1200 to $1500 on formula just in their baby’s first year. Due to this enormous cost, many parents wonder if the baby formula can be covered by insurance. In most situations, the answer is no. Insurance companies won’t cover infant formula unless there is a medical need such as a gastrological condition or a food allergy. Without a medical condition, the formula is considered a food product, which is why most policies don’t cover it. Insurance companies will not cover standard formula at all, but even getting specialized formula covered can be tricky.
One of the only ways to get your insurance to cover formula is to have your pediatrician give you a prescription. Even if you’re not sure if your child is eligible to receive a prescription, it’s still worth discussing with your doctor. Although the conditions required vary with each insurance company, they typically all fall under the same category. In order for it to be medically necessary for your child to receive a specific type of formula, they must have a condition that restricts what products they can consume.
Can you get a prescription for baby formula?
It is possible to have your doctor give you a prescription for formula, and this is one of the only ways you can get insurance to cover the cost. The most common reason why the pediatrician would give you a prescription is because of an allergy or need for a special diet. If your baby is allergic to dairy or another ingredient, then you may be able to get a prescription.
There are also many other common diseases that would require your child to consume specialized formulas such as Crohn’s disease, cystic fibrosis, or malabsorption. The important part is the doctor would have to make it clear that it’s medically necessary for your baby to have the formula, and typically they would need to prescribe one specific type of formula in order for the insurance company to approve the request.
Does insurance cover hypoallergenic formula like Alimentum?
If your child does suffer from some type of food allergy, they may need to drink a hypoallergenic formula such as Alimentum. Alimentum is a well-known formula designed specifically for children with allergies and also bad cases of colic.
Your insurance company may cover formula such as Alimentum, but in order to request coverage, you will still need documentation from a physician stating that it is medically necessary. There are some services out there that can work with parents to see if their formula might be covered by insurance but they are essentially just going to call your doctor and ask if a prescription if available. The best advice is to have that conversation with your doctor early.
States that mandate formula coverage
Standard formula coverage is not mandated in any state, but when it comes to elemental formula coverage, there are currently 17 states that mandate insurance companies to cover formula for children with allergies or other related conditions.
The Children’s Milk Allergy and Gastrointestinal Coalition focuses on getting healthcare coverage and reimbursement for families who need special types of formula for their children. These amino acid-based formulas are more expensive than standard formula, which already cost families hundreds of dollars every week.
A full list of states that mandate coverage for elemental formula can be found on the Food Allergy Awareness website as well as a link to the specific bill for each state.
Does Blue Cross Blue Shield cover formula?
Blue Cross Blue Shield does cover elemental formula in some cases, but it depends on the state and the circumstances. One Blue Cross Blue Shield policy from the state of Massachusetts for instance claims to cover specialized formula when the infant has a condition such as Crohn’s, Ulcerative colitis, or Gastroesophageal reflux (GERD).
There are other conditions that may allow you to get your formula covered by Blue Cross Blue Shield, but documentation is required from your child’s doctor.
Does Medicaid cover formula?
Medicaid may cover the cost of infant formula, but it depends on the state you live in and the condition of your child. Much like other insurance companies, each state has different restrictions and mandates as far as what’s covered, and the Medicaid program in each state differs. Even with Medicaid, in order to have your infant formula covered, you would likely still need medical diagnosis and possibly a prescription from your child’s doctor.
The good news is if you qualify for Medicaid, you will likely also qualify for WIC (Women’s Infant and Children Benefit) and if you do, the WIC programs in each state agree to cover some type of formula for low-income families.
Does United Healthcare cover formula?
Based on some of the coverage listed by United Healthcare, they will cover specialized formula for infants, but only in certain states and under certain conditions. For example, one of their more recent plans lists elemental formula coverage for Connecticut and New Jersey. However, there is an extensive list of requirements and criteria that must be met before they will provide coverage.
Does Cigna cover formula?
According to the Cigna website, specialized formula may be covered due to state mandates if you’re located in one of the states listed by the FAACT (Food Allergy & Anaphylaxis Connection Team). They also stated that specialized formula will only be covered under certain conditions and there is a list of items that are considered not medically necessary.
If your child has food allergies, protein intolerances, celiac disease, or other similar sensitivities, Cigna may cover elemental formula, but it depends on your specific policy and state.
Does Anthem cover formula?
Anthem does provide coverage for amino acid-based formula for children under 2 years of age if the child’s doctor has provided documentation that the child has one of the required conditions such as a history of anaphylaxis, cystic fibrosis, malabsorption, or allergic colitis.
A full list of the conditions can be found on Anthem’s website, and the doctor must show that the formula is medically necessary due to one of these conditions.
Other ways to receive coverage for baby formula
If you are really in need of help getting your baby formula paid for but can’t get your insurance to cover it, don’t lose heart. Insurance coverage isn’t the only way to get help paying for formula. Most hospitals and pediatricians offer free formula samples for their patients. Every little bit helps, and it doesn’t hurt to ask if there are any samples available before you leave the hospital or during your next doctor’s visit. Many of the larger formula companies, such as Similac and Enfamil, also have rewards programs and offer free coupons to moms which can help you shave a little bit off the cost of formula.
If there is a real financial need, there are many government programs to which you can apply to help you pay for what you need. The WIC Program (Women, Infants, and Children) is designed specifically to help mothers and their children receive help with basic needs such as food and formula. All of the requirements for eligibility can be found on the USDA website. Even if you’re not sure if you will qualify, it doesn’t hurt to apply and see if you’re eligible to receive any assistance.