When you have a baby who needs special formula, it can get expensive quickly. Will Tricare cover baby formula? There’s a lot of confusion about whether Tricare will cover formula, and how to make it happen. And, unfortunately, it appears that the answers are: “In some situations” and “You have to push hard and be persistent.” It seems hard to get a straight answer.
Military.com marketing manager Raleigh Duttweiler learned this first-hand when her child was born with multiple serious health issues. The only formula the baby could tolerate was super-expensive, so they had to be pushy to get some solid answers and the help that their child needed.
What Tricare Won’t Cover
Raleigh taught me a lot about formula:
“There’s a ladder for milks. So when babies have trouble, you start with Gentlease or similar – something that goes down easy and shouldn’t be thrown up by reflux babies to the same degree as regular formula. Things are partially broken down. Then you go to a Nutramigen or Alimentum, which are partially hydrolyzed and for kids with dairy intolerance, they can be suitable.”
They may be suitable for the baby, but Tricare isn’t going to pay for them because they are commercially available and still considered within the range of “regular” formulas. Here’s what the policy manual says, “For children less than one year of age who require enteral nutritional therapy, formulas that are readily available in a retail environment and are marketed for use by infants without medical conditions as described in paragraph 2.0 are excluded from coverage.”
When Tricare Will Pay
If the baby still isn’t doing well, the next step is a prescription formula such as Elecare, Neocate, and PurAmino. If your baby is totally reliant on this type of formula for nutrition, then Tricare may pay.
Raleigh shares that it took some effort to get Tricare to cover her child’s formula, and that there was a secret weapon in their efforts:
“Tricare will help you with a personal case manager if you have chronic health issues. Severe food allergies and/or GI digestive issues constitutes a need. You need to request one, and your doctor can help you in that process by also requesting one.
Once you have a case manager, they can help you navigate coverage effectively. They know the ins and outs for how to get things pushed through.
We tried for two weeks by ourselves to get formula covered, and we kept getting no for an answer. Then we were assigned our case manager, Gina.
Gina helped us work through the Tricare system. First, she advised that we should try to get our child on Neocate. It’s very similar to Elecare and PurAmino, but for some reason Tricare prefers Neocate.
Then, she advised us to send our prescription to Tricare, along with a letter of medical necessity that says the following things:
- that baby cannot tolerate breastmilk,
- that baby has tried Gentlease, Nutramigent, Alimentum, and Ali RTF (in our case) and due to severe food allergies, could not tolerate them, and
- that she will be consuming the formula as her sole source of nutrition.
This should result in an approval. I put the should in italics because it’s not a sure thing, and you may have to appeal. However, this is what the policy says. You can read the whole bit at the Tricare Policy Manual, Section 8, Nutritional Therapy.
How To Get The Formula
A major area of confusion is that while this is prescription for formula, it isn’t filled as a prescription. If you try to go through the pharmacy or Express Scripts, your request will be denied. Specialty formula, when approved as nutritional therapy, is considered durable medical equipment, much like a wheelchair or an oxygen generator. Therefore, the formula must be obtained by the durable medical provider indicated by your regional Tricare contractor.
Once you’ve been approved, the durable medical provider will deliver the formula directly to your house.
If your child’s formula doesn’t qualify for Tricare coverage, you do have other options. The Women, Infants and Children (WIC) program will cover specialty formulas by prescription. It never hurts to apply for WIC, even if you don’t think you will qualify.
You can also reach out to the manufacturer of your child’s formula. Most companies have programs that can help offset the cost of the specialty product. For example, the maker of Enfamil offers a single shipment of free formula, or a reduced price for a larger amount, to eligible applicants.
If your child’s formula is commercially available, check to see if you can sign up for their “club” to receive coupons through the email or regular email. You can also ask your friends to share the coupons that they won’t be able to use. When I had small babies, I was bombarded with high-value coupons that I didn’t use. I loved sharing them with others!
Lastly, be sure to check with your doctor’s office. The sales representatives for formula companies give samples to doctor’s offices, and they give them out to patients. In addition, they may be able to let you know if another patient, who no longer needs the formula, may have extra to share.
When your baby needs an expensive formula, life is stressful. Understanding when and how Tricare will cover formula can help eliminate some of your stress. If this article doesn’t apply to you, please file the information away in the corner of your brain for the next time a friend, neighbor or co-worker asks, “Will Tricare cover baby formula?”
I welcome your additions to this article so that we can make it even better and more helpful for more people.