Section 4256 - Coverage for medically necessary infant formulaAll individual and group health maintenance organization policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section. [2007, c. 695, Pt. C, §16(RAL).]
1.Determination of medical necessity. Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is medically necessary health care as defined in section 4301-A, subsection 10-A, that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas have been tried and have failed or are contraindicated. A licensed physician may be required to confirm and document ongoing medical necessity at least annually. [2007, c. 695, Pt. C, §16(RAL).]
2.Method of delivery. Coverage for amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula. [2007, c. 695, Pt. C, §16(RAL).]
3.Required diagnosis. Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:A. Symptomatic allergic colitis or proctitis; [2007, c. 695, Pt. C, §16(RAL).]B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis; [2007, c. 695, Pt. C, §16(RAL).]C. A history of anaphylaxis; [2007, c. 695, Pt. C, §16(RAL).]D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies; [2007, c. 695, Pt. C, §16(RAL).]E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider; [2007, c. 695, Pt. C, §16(RAL).]F. Cystic fibrosis; or [2007, c. 695, Pt. C, §16(RAL).]G. Malabsorption of cow milk-based or soy milk-based infant formula. [2007, c. 695, Pt. C, §16(RAL).] [2007, c. 695, Pt. C, §16(RAL).]
4.Health savings accounts. Coverage for amino acid-based elemental infant formula under a health insurance policy, contract or certificate issued in connection with a health savings account as authorized under Title XII of the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate. [2007, c. 695, Pt. C, §16(RAL).]
2007, c. 695, Pt. C, §16 (RAL) .