Insurance paying for tube feeding formula? UPDATE!!! pg 2 post #30

[Mono~rail]

Thanks, dclfun. I'm sorry that driver made such a mean comment to your dh.

When I call the CS line it says that their calls are monitored and recorded so maybe someone will actually listen to it and hear what she said. It was mean what she said to me. And, you are right - until someone walks a mile in our shoes they don't know what it is like.

I'm going to keep at it until I get it paid for! If I can't get Pediasure covered then we will switch her to a rx only formula!

 

[don8life]

You really need a case coordinator. i don't see why you don't have one.
When my daughter was being tube fed her pediasure was covered it was sent out by the same company we got the machine from. We got a delivery of 4 cases a month. On the can it says enteral feeding only.(through the tube)
We had a script. They should pay for it.
They paid for it while she was on the tube. That was one year. For the last 3 yrs we have been paying for it becasue she loves it. Won't drink milk. Thank God they started out with store brands.

Good Luck!

 

[Mono~rail]

Hi, don8life, I've asked for a case manager 3 times. They tell me they will assign one when they feel it is necessary.

This is the first time we've been without a case manager. We were assigned one when I was put on hospital bedrest, and she called me every other day or so to find out if I needed anything. Then when the girls were in the NICU she continued to call every other day on my cell. When we switched insurance within a few days, a new case manager called us. We had her for over a year before dh took this new job.

 

[pumpkinboy]

...I'm giving up on this one. It would have been nice if it were covered under out plan, but it isn't so we will trudge along. At least now I know that it isn't covered because it would suck to spend all that money then find out it is covered...

We have a 9 yr old DS who is tube fed (for the past two years), among many other issues. One thing we have learned in our 9 years of experience fighting various systems is to persevere and persevere and persevere. Make yourself such a pain in the *** that they finally give in and get you what your child needs and deserves.

When applying for State benefits to cover DS (copays on insurace, any medical equipment not covered by our insurance, etc) they turned us down flat the first time. When we went in to meet with them, my DW, who happens to be a Lawyer with a subspecialty in disabilities law here in Massachusetts, made it clear that we were going to make thier lives miserable until they approved us for this program to which DS was clearly entitled due to his condition. We had the approval within a week. Admittedly, we have the advantage to having a cranky lawyer in my DW who can point to the section of law that covers the case and argue it, but from what we have seen, it is standard operating procedure in Mass at least for the State simply to turn down the first request, regardless of the merits. I hate to think of what other folks, with fewer resources and less knowledge of the Law do in similar circumstances.

Also, admittedly, Massachusetts (and most other "M" states) seem to be more supportive of disabled citizens in general, and have generally had much better services, at least once you can get them approved.

In any case, our State regulates the local insurers, including BCBS of Mass (apparently BCBS is a different organization in every state), and fortunately, Massachusetts has made them cover a lot more than our friends in Georgia get covered with their wheelchair-bound child. Sadly, it may be that your State isn't looking out for you here. But it is worth continuing to do reserch and keep making yourself a nuisance with the company, HR dept and the State. Getting your State legislator involved can also be helpful, bcs every politician likes to be seen helping children, and they can often cut thru red tape for you.

Good luck!

 

[homedad]

I have been a employee benefits consultant for the last 10 years, if your husbands an employer is large and self insured, then BC/BS is administering the plan as the company is directing them. If their small, and the plan is fully insured, the the insurance company makes the rules. Fully insured plan are governed by state mandates but I'm not familiar with Cal. If the plan doesn't currently cover tube feeding, they not supposed to change coverage in mid year because that can be determined discriminatory(in reference to self-funded plans) . You need to ask where the contract language is in the SPD(summary plan description) that they are making their decision. I hope this helps. Good Luck. One last question, have they just chnaged insurers recently?

 

[dclfun]

OP--- any updates? I just took a look at my recently delivered cases of formula and realized that the same product has now been under three different names: Pulmocare, Respalore, and Nutravent. I'm still hoping that you'll find an equivalent for Pediasure that is prescription only. Would your physician or a dietician be able to look that up? ---Kathy

 

[fenfur]

I too would suggest to try to switch to a prescription based formula that cannot be bought in the store. DS is pretty much all tube fed (just won't eat grrr) and because of one of his medications he can't do the pediasure, but he is on Kindercal. From my understanding it is very similiar to pediasure (smells like it, looks like it), it's just not made by Ross, it's made by the other big manufacterer. I know it has more fat than pediasure (to help them gain more weight), but for us it worked better because it has half as much vitamin K, which is what we watch for.

And ohhh I wish I read your post months ago (if you had posted then lol), we had CASES of extra pediasure and they expired and we had to throw them out because I couldn't figure out what to do with them, because anyone around here that would need it would have it covered.

Is their a childrens program in Texas that will cover special needs kids? I know here in Ca there is one but it has a income limit, but also it has a clause that says that if the expenses would be more than a certain percent of income then they would cover it too.

Good luck!

 

[Mono~rail]

OMG, fenfur, when you said "he just won't eat, grrr," I can so relate. That's basically Lydia's problem. She can eat, but she just won't. Well, it's deeper than that. . . diagnosis of oral aversion. she had so much negative stimuli in her mouth and down her throat while she was in the NICU that she associates anything in her mouth as bad and something that is going to hurt. It's so frustrating!

I don't have any updates. I haven't heard from that website I signed up with or insurance either.

 

[fenfur]

Ya, I had to laugh when you said that feeding your dd pediasure was like the rest of the family eating filet mignon all the time, because steak is one of the few things my son WILL eat. Although he NEVER eats enough to get far, it is one of his few preferred foods he will eat.

And I hear ya on the oral aversion. Ds has had 3 cardiac surgeries, so we know exactly where the aversion came from (all the tubes and intubation), we were lucky enough that he would take 2-3 cans of pediasure by a bottle a day, but after his last surgery (11/05) when we had to give him something else post op he REFUSED a bottle of ANYTHING, so he got his tube 2/06. We have been REALLY lucky this past year with weight gain on the Kindercal, he started at 24 lbs and now 11 months later he is up to 36 lbs. He gets (and has always gotten) 3 cans a night, and we just run it when he goes to bed at night so he isn't used to it during the day so he will sometimes get hungry of a evening and actaully eat a little if it is something he likes. We are up to a 160 ml rate, so it isn't too bad, it's just like a newborn, gotta wake up in the middle of the night to unhook him.

We are waiting for insurance to approve a 3 week inpatient feeding clinic here locally, but they have never had one run across their desk so it is taking awhile to get an answer, should know this week, it went to the medical director last week.

Hey that's an idea, you can ask to speak with the medical director, thus cutting out the customer service reps with their canned reply.

Good luck!

 

[Mono~rail]

Woo hoo! I'm so happy!

Our medical supplier just called me to let me know! She called and talked to the coding department for BCBS, and the coder looked at our plan and said that it is definitely covered at 100% because it is a medical necessity related to Lydia being totally tube dependent. The rep at our medical supplier is faxing the necessary form stating her medical needs to our GI specialist right now. Her Doc just has to sign it and fax it back to our supplier.

I'm so happy I feel like crying! A huge burden has been lifted from us. I'm glad we stuck to it and got it done! It just took contacting the *right* person.

 

[RNMOM]

Be sure to resubmit all your bills from the feedings. They should be covered at that level also. Honestly, no excuse for that.

If the insurance company gives you difficulty on the past bills, which they should NOT, you can certainly write them off as medical costs on your itemized income taxes.

I certainly dislike insurance companies also for a lot of different reasons.

 

[ColleenS]

Congratulations! I'm so happy for you. Good for you for being so persistent!

 

[mcmom]

Are you in Southern CA? If so email me at brownla@cox.net. We get more then we can use each month from our insurance. We get both Pediasure TF and KinderCal and give it out to whoever nees it.

Lori B

 

[Mono~rail]

Are you in Southern CA? If so email me at brownla@cox.net. We get more then we can use each month from our insurance. We get both Pediasure TF and KinderCal and give it out to whoever nees it.

Lori B

I *wish* we lived in SoCal! I love it there!

We're in South Louisiana. Dh works for a CA based company - their newest division is down here.

 

[Daydreamer64]

I'm glad that you got the food covered.

My middle son is insulin dependent- our insurance covered pen needle toppers but not the pens? Not as big of a deal as your situation but what gives? Are the people that work for these medical plans not speaking and understanding english well enough-they need classes in common sense- I asked her why they covered the pen toppers but not the pens and her answer was -"I don't know but they just do!" There is nothing that you can use the toppers for except attaching them to the pens?

My oldest has severe lung problems and uses a nebulizer daily and has for 12 years now. When the last one wore out, I had a new perscription for another.

The rental portion for us was $20 per month- a new one only cost around $200 so I suggested to the insurance co. that they allow me to purchase a new one and pay our deductable- it would have completely paid for in a few months anyway-I don't know what planet these people are from but they said that we had to rent the nebulizer

- I asked for how long and they said as long as it takes. I replied that he has used one for over 10 years or whatever the years where at that time, and she said that was just the way it worked! I just went ahead and bought ir out of pocket - sent the forms in and was reimbursed 100% ?? no co-pay or deductable. This did not come out of our pre-tax insurance medical funds either? I don't know what gives but I didn't look a gift horse in the mouth.

The oldest has a rare disease called Chronic Granulomatous Disease- there is only one specialist ( to my knowledge ) that treats pediactic patients and understands this (usually) terminal disease in the state of Georgia- most docs have never heard of the disease.

Anyway, she is not in our network- every 6 months it takes at least 3 weeks to argue with the insurance co- they state that thay have immunologists in the network that he can use. I called all of them and none of them treat this disease. I've had to jump through hoops to see this doctor since he was diagnosed at the age of 7. Finally, this last January, The Emory Children's Clinic- Jeffery Modell Center has been added to our insurance. It's really a sad state of affairs but I'm thrilled to make the appointment and not have to argue until I'm sick to my stomach to get to see this doctor.

Honestly, it's hard enough to take care of three special needs childen without getting the run around from the insurance people for gosh sake.

 

[fenfur]

YAY!!!!!!! I'm glad it finally worked out for you! I think the rest of the family should eat filet for a few days just celebrate, LOL.

I HAVE to ask... in the pic in your signature, are the redneck kittens baby skunks???? Sorry, city girl here, lol.

 

[Mono~rail]

YAY!!!!!!! I'm glad it finally worked out for you! I think the rest of the family should eat filet for a few days just celebrate, LOL.

I HAVE to ask... in the pic in your signature, are the redneck kittens baby skunks???? Sorry, city girl here, lol.

Yes! But those aren't my kids playing with them. I have no idea who the kids in the pic are. . . I got it from an email forward.