Affording Formula

This resource provides clinicians with information and strategies to support families who need formula to feed their child. Occasionally, brand names or companies are mentioned to provide examples—the Medical Home Portal does not endorse a specific company or type of formula.

All regulated formulas meet the same basic nutritional requirements, so it is important to consider costs when selecting a formula type.

• When available, powdered formula tends to be less costly than liquid concentrate or ready-to-feed.
• Store brand and generic formulas offer more reasonably priced options than brand name formulas and are frequently made by one of the well-known brand name companies.
• Formulas tend to be slightly less expensive if purchased through a home care company, commissary (if a parent is in the military), or warehouses (such as Costco or Sam's Club).
• For specialty formulas that are more difficult to find in stores, buying in bulk online (AmazonSmile, etc.) can be a great option.

Some insurance companies have absolute exclusions regarding formulas, while others will pay for nutritional formulas only after infancy or if the formula is needed for a medical indication (e.g., malabsorption, PKU, tube feeding). Many formula companies offer sample letters of medical necessity for their specialized formulas.

Insurance companies, including Medicaid, will usually fund formula if it goes through a feeding tube.

When formula is taken by mouth, formula costs are less consistently covered. An appeal may be necessary if the formula is taken by mouth to adequately meet the child's caloric needs. These appeals are often successful if the clinician writes a letter of medical necessity (see Tips for Writing a Letter of Medical Necessity (Rifton) and Working with Insurance Companies).

When a different formula is needed, an appeal is more likely to be successful if the clinician demonstrates that the child was not able to tolerate a less expensive formula first (e.g., an intolerance of PediaSure® may assist in the appeal for a more expensive hydrolyzed formula). It can be helpful to include the patient’s growth chart to demonstrate fluctuations in weight and unsuccessful formula trials in cases of faltering growth (failure to thrive) or when formula intolerance impacts growth. The diagnosis used to request formula funding is vital because insurance may not cover formulas for all diagnoses. If the appeal is rejected, it is reasonable to ask the insurer for suggestions on reworded diagnoses that might be accepted.

There are a few mechanisms available to support those who fall between the cracks. Carnation Instant Breakfast, Ovaltine, and PediaSure drink additives are examples of relatively cheap alternatives for the child who needs a caloric boost and added vitamins and minerals (although these products often add calories through sugar). Many companies sell drinks and shakes as meal supplements or to provide nutritional variety for picky eaters. Some families supplement liquid nutrition by making smoothies at home, adding healthy ingredients like fruit, vegetables, and dairy or plant-based milks, yogurt, protein powder, nut butters, chia or flax seeds, a dash of flax or coconut oil, or avocados to round out the nutrition. Note: not all of these may be compatible with tube feeding. Refer tube-fed children to a dietician if the family plans to offer a blenderized, DIY diet.