What does it mean when the insurance company says they’ll pay 80% after deductible with no co pay?.. we are going through trying to find the right formula for our daughter. Nutramigen seems to be the formula that has worked best for her so far. Our pediatrician is having us try one more formula before she write a prescription for the nutramigen… But for $70 a can, I dont know how were expected to pay for this 1-2 times a week. Luckily, our insurance does cover this formula since it is medically necessary. So my husband called our insurance company, Aetna, and they said they will cover 80% after deductible with no co-pay. Our deductible is $6,000. $3,000 already paid. So does that mean we have to buy $3,000 worth of formula before they start covering 80%? Im so very confused.
Yes, you have to pay your deductible first then they’ll pay 80%.
I agree. Another thing to check is the “allowed amount” set by your insurance. The only upside might be that your insurance company could limit the charge to $50 (just an example) per can.
Great, so by the time we reach the deductible, she won’t need to be on formula anymore
Is that the price your DME company quoted? What they bill you might be higher than the retail price.
Check if you qualify for Medicaid in your state, and also look into WIC. Even if your income is too high, you might qualify if there’s a disability.
$70 is retail price. We would have to purchase the formula and file our receipts as a claim and get reimbursement through insurance. Just more hoops to have to jump through… im praying this formula she’s on right now works out. Much rather spend $45 a can than 70… the price of formula is insane right now…
Yes, you would pay the full contracted insurance rate until you reach your deductible. After that, you’ll pay 20% of the contracted rate.
I’m not a formula expert, so I can’t say if it works like prescription drugs. If someone has more knowledge, feel free to share.
Talk to your doctor to see if you can use the over-the-counter version.
Check if the manufacturer offers a savings coupon. If not, call the pharmacy to ask for the cash price without insurance. If it’s much cheaper, remember that paying cash might not get you reimbursed and may not count toward your out-of-pocket costs.
You should also look into WIC to see if they cover formula in your state.
It might be a good idea to contact your state office to find out what you qualify for, like Medicaid or SNAP.
I was able to get some rebate checks from the manufacturer. A few $5 off and 2 $15 off… but those won’t go very far at $70 a can… The cost of formula is insane. When my daughter was first born we had her on a sensitive formula. For a 48oz can it was $40. But for the nutramigen (a formula that’s generally only used if it’s medically necessary. Not by choice) is $70 for a 28oz can. So to keep my daughter from being sick and in pain, I have to pay almost double. It’s like a cruel joke…
Can your doctors office get samples!! If they can— take them! Ask if they can get samples, some can!
I got 1 tiny sample can at her last appointment. That’ll maybe last a day. They were going to give more, but apparently, that was the only can in the entire building