Formula Funding

Formula funding for children with chronic conditions (post-infancy)

There is a huge difference in cost of the various formula preparations which should be considered when choosing a specific formula. Formulas are generally slightly cheaper if purchased through a home care company as opposed to a grocery or pharmacy. If the parents are in the military, some formulas can be bought for a lesser amount at the commissary. Warehouses such as Costco and Sams Club sometimes stock more common formulas.
Insurance companies vary widely on their willingness to pay for nutritional formulas. Some will, but only after infancy, some will if the formula can be justified because of a need for a special diet (e.g., malabsorption or PKU), and some have an absolute exclusion. WIC is an alternative for some families with children under age 5. Medicaid will fund formula easily if it is going through a tube. Appeals may be necessary if the formula is being taken by mouth or is not approaching 100% of caloric need. These appeals are often successful if the physician knows how to write an effective letter of medical necessity. The diagnosis used to request the funding is important. (e.g., Medicaid may fund formula for a diagnosis of brain malformation with oral aversions but not for a diagnosis of autism with oral aversions.) To aid in appealing an insurance company or Medicaid, its 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).
There are few mechanisms available to support those who fall between the cracks. Carnation Instant Breakfast is a cheap alternative for the child who only needs a caloric boost. A family can apply to Hospital Foundations or charity programs to help with costs. Technically, the public school system is required to supply the formula which is part of lunch (and breakfast if the child qualifies for the free breakfast program.) .A non-profit pharmacy may be able to provide formula at a non-profit rate.


Compiled and edited by: Lynne M Kerr, MD, PhD - 10/2008
Content Last Updated: 2/2014