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Can Formula Be Covered By Insurance? Find Out If You Qualify

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While some families choose to feed their babies formula for the sake of convenience or personal preference, there are many who don't have a choice. But, can formula be covered by insurance? Some mothers can't produce milk even though they'd like to. Adoptive parents obviously can't breastfeed. And some children have conditions such as low birth weight, allergies, or a gastrointestinal disorder that require formula feeding. In some cases, insurance does cover formula, but the requirements are pretty strict.

First of all, there is no federal requirement that health insurance providers cover formula. "Each plan is very different and can also be state-specific," Fallon Matney, founder and president of the International Food Protein-Induced Enterocolitis Syndrome (FPIES) Association, tells Romper. Currently, 20 states do have laws on the books that require some form of coverage, which varies widely.

The Food Allergy and Anaphylaxis Connection Team has a breakdown of elemental formula coverage by state, but currently, none cover standard formula. Specialized formula, whether available by prescription or over the counter, may be covered if it's indicated by a doctor as medically necessary. Most states also specify which medical conditions make a child eligible. For example, Arizona requires coverage only for children with eosinophilic gastrointestinal disorder, while Maine also counts anaphylaxis, allergic gastroenteritis, gastroesophageal reflux disease, and severe vomiting or diarrhea as medically necessary diagnoses, among others.

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Unfortunately, this means many families are coming up short, as hypoallergenic and amino acid formulas such as Alimentum and Neocate are far more expensive than regular formulas, often costing families hundreds of dollars per week (yes, week). Parents who have a flexible spending account, health savings account, or health reimbursement arrangement may be able to use those pre-tax dollars on formula if they obtain a prescription or a letter of medical necessity from a doctor, which could help the family budget.

"Whenever I work with a family, especially one that has a child diagnosed with a complex disorder like FPIES, I first like to have them establish a relationship with a nurse case manager," Matney says. This nurse can help parents decipher if their plan covers formula and if they need to bill it as medical, pharmaceutical, or durable medical equipment, she adds.

Families whose insurance doesn't cover formula do have other avenues to consider. Many hospitals and pediatricians have free samples provided by formula manufacturers. Similac and Enfamil, manufacturers of both specialty and standard formulas, each offer rewards programs that provide coupons and samples.

"There are some nonprofits like the Children's Medical Nutrition Alliance who require an application process to fund free formula for a year," Matney says. However, she adds that funding for organizations like this are limited, so only a select number of patients can receive the support.

Finally, parents should investigate whether their family qualifies for the USDA's Women, Infants and Children program. Eligibility is based on income. If your state doesn't require insurance to cover medically necessary specialized formula, consider joining an advocacy group to lobby for change. "In my experience, the loudest voice seems to have been the most effective," Matney says. "Families have to be willing to fight and not give up."

Sources interviewed:

Fallon Matney, founder and president of the International FPIES Association

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