Enteral formulas are liquid food products that are specially formulated and designed to increase the amount of various food elements and nutrients that will maintain proper physiological function of the body process. They may also be used to correct an existing deficiency.
New York State law regarding coverage of enteral formulas is not applicable to the Welfare Fund. However, we will cover specific formulas for our in-service members providing the following guidelines are met:
1. Members requesting access to these formulas will be subject to the Fund's prior approval process.
2. The formulas are for oral home use and have been prescribed by a physician or other legally authorized health care provider. These formulas are distinguished from nutritional supplements taken electively. They are not covered if they are administered via nasogastric tube, via feeding gastrostomy or via needle-catheter jejunostomy since the patient's health insurance plan usually covers it with prior authorization. The patient should contact their health plan.
3. The patient's provider must send a letter of medical necessity to the Welfare Fund's Pharmacy program that states that the enteral formula is clearly medically necessary. This means that the formula has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic disability, mental retardation, or death.
4. The formulas must be the patient's sole source of nutrition and for specific diseases, which include, but are not limited to:
- inherited diseases of amino-acid or organic acid metabolism;
- Crohn's disease; Phenylketonuria Disease (PKU)
- gastroesophageal reflux with failure to thrive;
- disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction;
- multiple severe food allergies.
5. Coverage for a calendar year for any covered individual shall not exceed seven thousand, five hundred dollars ($7,500.00).
6. Quantities are limited to 30-day supplies per dispensing and are considered non-preferred brand (Tier 3) for co-payment purposes (see more information about prescription drug tiers).