Coverage for Formula

Getting insurance coverage for PKU formula usually requires prior approval from your health insurance company after you have seen your PKU specialist.

Follow these steps to obtain coverage:

STEP 1:
Get insurance coverage through your work:

1. Get insurance card with ID number
2. Read your insurance benefits book about metabolic coverage.

If you are not working or do not have insurance through your employer, you may be eligible for state health programs such as Medicaid. Speak with your PKU doctor for more information.

STEP 2:
Call for appointment at clinic:

1. Get a referral to be seen by PKU doctor from your Primary Care Doctor (PCP) who is a designated provider with your insurance plan.
2. Call customer service number on insurance card and ask: When needing prior approval for medication, does the letter need to come from the specialist or the PCP? What does the letter need to say? Where should the letter be sent?

STEP 3:
At the clinic appointment:

1. Decide with the dietician which formula you prefer.
2. Get a prescription for a year.
3. Get letter of medical necessity (for prior approval).

The letter of medical necessity must include:

• Diagnosis
• Prognosis (probable outcome)
• Duration of treatment
• Treatment details with formula National Drug Code (NDC#)
• The low protein food companies with the CPT code S9435

STEP 4:
Send letter to insurance company from metabolic physician

STEP 5:
Call insurance customer service:

1. Ask if PKU formula has been approved through prior approval.
2. Ask where you should get the formula:
1. Take prescription to approved pharmacy or
2. Call medical supply company to get it delivered.

If pharmacy or medical supply company has trouble getting the formula it may be that the pharmacy or medical supply company needs to call the formula company directly to order the product, since the wholesaler may be unable to do so.

STEP 6:
Refill formula when you open your last case of formula, re-order it so that you don't run out. Call pharmacy or medical supply to get more.