16 Del. Admin. Code § 4103-3.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 4103-3.0 - Eligibility

3.1 Any Delaware woman of child bearing age or child diagnosed with an Inherited Metabolic Disorder, that warrants the prescription of a specialty formula may be eligible to receive assistance through the Specialty Formula Fund if uninsured or if current insurance benefit does not include this coverage. The assistance will be based on the current Department of Health and Social Services Ability to Pay Fee Schedule (see attached), less the average cost of formula for a normal newborn/infant or citizen using soy based milk products annually. The Fee Schedule is adjusted annually with the revised federal poverty guidelines.

3.2 The Division of Public Health may provide assistance from the Fund to a woman of child bearing age or child diagnosed with an Inherited Metabolic Disorder, if:

3.2.1 The specialty formula is prescribed as medically necessary for the therapeutic treatment of an Inherited Metabolic Disorder; and

3.2.2 The specialty formula is administered under the direction of a physician; and

3.2.3 The client's insurer does not provide benefits to cover prescribed formula for inherited metabolic disorder or there are special circumstances as determined by the Division of Public Health, Case Review Panel.

16 Del. Admin. Code § 4103-3.0