Prescribed Infant Formula Claim Denied – Any Help?
My 9 month old was diagnosed with a milk protein allergy when they were 2 days old. Since then, we have had to give him Similac Alimentum, which was prescribed for the first year by our pediatrician. Our coverage with United Healthcare/Oxford includes a pharmacy benefit for this prescribed formula, which covers ~50% of the cost.
The infant formula shortage in the USA is still very much a thing. We have tried to order the formula through OptumRX (UHC's pharmacy) to receive our pharmacy benefit, but they are out of stock and have been for months. It is out of stock at local pharmacies (mom/pop shop, CVS, Duane Reade, etc.), so we needed to buy wherever available (Target, Amazon, local grocery). I need to feed my baby.
I submitted my claims for the formula, however they were denied as 1) they were not purchased at a pharmacy and 2) they were considered out of network and I have not yet met my deductible. I live in NY, so I believe Hannah's Law applies. My claim appeal has also been denied. It has been legitimately impossible to purchase this necessary formula through a pharmacy of any sort.
https://www.uhcprovider.com/content/dam/provider/docs/public/policies/oxford/formula-specialized-food-ohp.pdf
I am preparing to respond for a second appeal, and I wanted to see if anyone had input. I am fortunate that spending $15/day for this formula as opposed to $7-8 doesn't hurt THAT bad, but what is my insurance coverage worth if I cannot take advantage of this benefit.
Any suggestions or tips would be greatly appreciated!
submitted by /u/bjm525
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