Formula Funding

Consider costs when selecting a formula type. Formulas tend to be slightly cheaper if purchased through a home care company, commissary (if a parent is in the military), or warehouses (such as Costco or Sam's Club). Store brand and generic formulas offer more reasonably priced options and they have to meet the same basic requirements as name brands formulas.
Some insurance companies have absolute exclusions regarding formulas, while others will pay for nutritional formulas only after infancy or if the formula is needed for a special diet (e.g., malabsorption or PKU).
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), for families with children under age 5, provides a limited selection of standard formulas in its formulary and requires a medical prescription with a valid diagnosis to provide alternative formulas. WIC does not necessarily cover all of the formula needed by infants, so caregivers may still be responsible for purchasing some.
Medicaid will usually fund formula if it is going through a feeding tube. Appeals may be necessary if the formula is being taken by mouth or is not approaching 100% of the child's caloric needs. These appeals are often successful if the clinician writes a letter of medical necessity (see Tips for Writing a Letter of Medical Necessity (Rifton) and Writing Letters of Medical Necessity). Many formula companies offer sample letters of medical necessity for their specialized formulas. To aid in appealing an insurance company or Medicaid, it is helpful to demonstrate that the child cannot tolerate a cheaper formula first (e.g., try PediaSure first, if the child demonstrates intolerance, this information might help with the appeal for the more expensive hydrolyzed formula). Also, the diagnosis used to request the funding is important as Medicaid will not cover formulas for all diagnoses.
There are few mechanisms available to support those who fall between the cracks. Carnation Instant Breakfast or Ovaltine are examples of drink additives which can be a cheap alternative for the child who needs a caloric boost and added vitamins and minerals (although these products often add calories through sugar). A family can apply to Hospital Foundations or charity programs to help with costs, and a non-profit pharmacy may be able to provide formula at a non-profit rate. Technically, the public school system is required to supply the formula as part of lunch (and breakfast if the child qualifies for the free breakfast program).

Resources

Services

Medicaid

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WIC Clinics

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Authors & Reviewers

Initial Publication: August 2018; Last Update: August 2018
Current Authors and Reviewers (click on name for bio):
Authors: Jennifer Goldman-Luthy, MD, MRP, FAAP
Lynne M. Kerr, MD, PhD