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Old 09-02-2014, 04:07 PM   #1
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Anyone gotten Pediasure 1.5 covered by insurance?

Has anyone gotten Pediasure 1.5 covered by insurance when the child is NOT tube fed?

Dd just had open heart surgery and is FTT. She has gross motor delays but does not have a diagnosed condition. Am I fighting a losing battle with insurance to get it covered?

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Old 09-02-2014, 07:45 PM   #2
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Re: Anyone gotten Pediasure 1.5 covered by insurance?

It depends on your state laws and private insurance contract, state law obviously trumps contract. Your other alternatives are WIC (under 5) and your subsidized lunch program (5 and above). Believe it or not the schools can't get out of providing a prescription diet if your child qualifies for the free or reduced lunch so they at least have to provide for all the formula needs during school hours. WIC covers about 80% for qualifying families (have to have a Rx). If you qualify for CHIP (state health insurance for kids) they have to cover it if it is indicated as necessary under the right diagnostic code.

I'm not sure if your child is sick/disabled enough for Children with Special healthcare needs program but it is a federally mandated program so is in every state in the USA. They will sometimes but not always pick up costs or point you to local resources.

You can also check out medical exchanges. Kids especially in the early years suddenly tube wean and parents are left with tons of formula and misc supplies or parents who always have a surplus due to hospitalizations and gut shut downs. Many parents will often ship to you for the cost of postage which can be considerable if it is ready to feed. Back when they unsuccessfully tried Pediasure Jr RTF formulation with Alec (gut was too compromised to digest it though). I could not even give it away due to no one willing to pay freight and I finally had to toss hundreds of dollars worth of formula into the trash.
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Old 09-02-2014, 08:38 PM   #3
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Re: Anyone gotten Pediasure 1.5 covered by insurance?

Thanks Mekat. DD is 16 months so she isn't in school. Her doctor is awesome and the nurses at the clinic have been doing so much legwork trying to get this figured out. Hopefully we magically come up with the right diagnostic code, but I'm not holding my breath!

ETA: We do not qualify for WIC.

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Old 09-14-2014, 04:21 PM   #4
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Originally Posted by teacherpippi
Thanks Mekat. DD is 16 months so she isn't in school. Her doctor is awesome and the nurses at the clinic have been doing so much legwork trying to get this figured out. Hopefully we magically come up with the right diagnostic code, but I'm not holding my breath! ETA: We do not qualify for WIC.
We were getting boost 1.5 for my daughter for a long time but we have dual coverage. She had a tube BUT was not using it and had not been for years. It was approved and they knew she was taking it orally. However our first insurance, Aetna only covered 30% then the Texas Medicaid kicked in the rest.
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