Enteral formula coverage

Oct 1, 2009 2:55 PM

The enteral formula benefit (for in-service members and their families) covers nutritional prescriptions — not supplements — that are taken by mouth to treat any number of illnesses, such as Crohn’s disease, gastroesophageal reflux, severe food allergies and others.

In order to receive this benefit, members must use the Welfare Fund’s prior approval process and it must be renewed every year.

The formula must be for home use and must be prescribed by a physician or other legally authorized health care provider.

Although the Fund was not mandated under New York legislation to provide this coverage, the Fund’s trustees decided to offer the benefit to assist those members who would otherwise not have coverage for such prescriptions.

To access this type of prescriptions members should follow these steps:

1. Contact the Fund’s pharmacists with the request for the enteral formula.
2. The written order presented to a pharmacy must state that the enteral formula is medically necessary, meaning that it has proven effective as a disease-specific treatment regimen for a disease that, if left untreated, will cause chronic disability, mental retardation or death.
3. Coverage for a calendar year is limited to $2,500. Quantities are limited to 30-day supplies and are considered non-preferred brand (tier 3) for co-payment purposes.