Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 08.00.18m


Attachment:A

Policy #:08.00.18m

Description:PA Mandates

Title:Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk



COMMONWEALTH OF PENNSYLVANIA MANDATE

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.

For members enrolled in a Pennsylvania product, The Medical Foods Insurance Coverage Act makes provision of insurance coverage for the following:

NUTRITIONAL FORMULAS AND ENTERAL NUTRITION

Pennsylvania mandates require coverage of orally or enterally administered amino acid-based elemental medical formulas (i.e., formula made of 100% free amino acids as the protein source) when ordered by a physician as medically necessary for infants and children with food protein allergies, food protein-induced enterocolitis syndrome, eosinophilic disorders and short bowel syndrome.

NOTE: Members described above are not required to meet the Company's definition of sole source of nutrition (i.e., the formula provides more than 75 percent of estimated basal caloric requirements); therefore, an estimated basal caloric requirement is not required.

MEDICAL FOODS FOR INBORN ERRORS OF METABOLISM ADMINISTERED ORALLY OR THROUGH A TUBE

Prescription medical foods (formulas) administered orally or via a tube into the alimentary canal for individuals diagnosed with a rare genetic (inherited) inborn errors of metabolism (IEM), such as phenylketonuria (PKU), homocystinuria, branched-chain ketonuria, and galactosemia are covered for individuals of all ages who need administration of a formula that is manufactured for the therapeutic treatment and dietary management of individuals with IEMs and is administered under the direction of a physician.
  • Medical foods are not required to meet the Company's definition of sole source of nutrition (i.e., the formula provides more than 75 percent of estimated basal caloric requirements); therefore, an estimated basal caloric requirement is not required for IEMs.
  • Medical foods are exempt from Deductible requirements.

LOW-PROTEIN MODIFIED FOOD PRODUCTS FOR INBORN ERRORS OF METABOLISM

Pennsylvania Mandate does not require coverage for low-protein modified food products such as breads, pasta, pastry shells, and rice pizza shells that can be purchased commercially without a prescription and are used in the dietary management of rare hereditary genetic metabolic disorders such as PKU, branched chain-ketonuria, galactosemia, and homocystinuria.

REFERENCES

Laws of PA. 1492. Act 1996-191. HB 1532. Approved 12/20/1996. Available at: http://www.palrb.us/pamphletlaws/19001999/1996/0/act/0191.pdf or http://www.legis.state.pa.us/cfdocs/billinfo/billinfo.cfm?syear=1995&sind=0&body=H&type=B&bn=1532 . Accessed June 21, 2018.

Amended Act of Oct. 22, 2014, P.L. 2564, No. 158. Cl. 40. PA HB 1436. Available at: http://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2014&sessInd=0&act=158 . Accessed June 21, 2018.


Version Effective Date: 01/01/2019
Version Issued Date: 12/31/2018
Version Reissued Date: 10/23/2019



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