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Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
NEW JERSEY STATE MANDATES
Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups, but may be included or excluded at the option of the group; therefore, individual group benefits must be verified.
W JERSEY SPECIALTY INFANT FORMULA PROGRAM
For members enrolled in a
product, Coverage of
L. 2001, Ch 361,
makes provision of insurance coverage for specialized nonstandard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk.
In accordance with NJ Statute,
P.L. 2001, c.361
specialized nonstandard infant formula is available only to infants (ages 0 through 12 months) enrolled in a New Jersey plan that includes coverage for prescription drugs or who have a freestanding prescription drug program. Coverage for specialized infant formulas is subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.
New Jersey Members with a Pharmacy Benefit
ecialized nonstandard infant formulas are covered only through the pharmacy benefit when
of the following criteria are met:
The individual is enrolled in a New Jersey
that includes coverage for prescription drugs.
The individual requires these formulas from
birth through 12 months of age.
The individual has
been diagnosed with multiple food protein intolerance and has
non-cow milk-based formulas, including soybean and goat milk.
The professional provider has determined that specialized infant formulas are medically necessary.
Continued coverage for specialized infant formulas is subject to utilization review, including periodic review, of the continued medical necessity of the specialized non-standard infant formula.
Examples of specialized
, but is not limited to,
the following: Elecar
Infant or Jr
utramigen; Progestimil; Neocate
Junior or Infant
; Portagen; Alimentum; NeoSure
For additional information addressing the New Jersey Specialty Infant Formula Program, contact the individual's Prescription Benefit Plan.
New Jersey Members without a Pharmacy Ben
If the individual has a pharmacy benefit with another company, the individual should be directed to seek coverage from that plan.
If the individual does not have a pharmacy benefit with another plan,
nutritional formulas for individuals with inherited metabolic disorders are covered under the membe
r's medical benefit when the medical necessity criteria contained within the policy are met.
Coverage of these products is subject to periodic review for continued medical necessity.
All other requests for nutritional formulas are treated as a benefit exclusion.
MEDICAL FOODS AND LOW-PROTEIN MODIFIED FO
OD PRODUCTS FOR INBORN ERRORS OF METABOLISM ADMINISTERED ORALLY OR THROUGH A TUBE
For members enrolled in a
An Act concerning coverage for foods and food products for inherited metabolic diseases (Chapter 338, Approved January 12, 1998)
Ch 27, 17B:27-46.1r (1998)
provides for insurance cover
age for the following:
Coverage for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low-protein modified food products, when the disease is diagnosed and the treatment is determined to be medically necessary by the individual's physician.
"Low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.
Approved January 12, 1998.
Medical foods and low protein modified foods are covered under the medical benefit when both of the following criteria are met:
The individual is diagnosed with an inherited error of metabolism.
The required medical necessity documention is provided the individuals' physician.
DONATED HUMAN BREAST MILK
For members enrolled in a New Jersey product, An Act concerning coverage for donated human breast milk (Public Law 2017, c 301; Approved January 16, 2018) provides for insurance coverage for the following:
Expenses incurred in the provision of pasteurized donated human breast milk (including human milk fortifiers) are covered by the Company in accordance with the state mandates for individuals enrolled in a New Jersey product subject to New Jersey's insurance law.
Coverage of pasteurized donated human breast milk, which may include human milk fortifiers, is based on meeting criteria which include the following:
I. The covered person is an infant under the age of six months
II. The milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health
III. The licensed medical practitioner who is prescribing the milk must meet
of the following requirements:
a. The licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or
b. The licensed medical practitioner has issued an order for an infant who meets
of the following conditions:
1) a body weight below healthy levels determined by the licensed medical practitioner
2) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis
3) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health
Coverage for donated human breast milk is subject to utilization review, including periodic review, of the continued medical necessity.
NOTE: If there is no supply of human breast milk that meets the above requirements, the insurer shall not be required to provide coverage of expenses pursuant to this section.
NJ Effective January 1, 2019.
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