enteral formulas — Highmark

Initial criteria

• Member has a valid prescription from a licensed prescriber for the requested enteral formula
• Prescriber attests the benefits of the requested enteral formula must not be duplicable through calorie supplementation that could be obtained through alternative dietary means alone
• Prescriber attests the enteral formula is medically necessary and has been proven effective as a disease-specific treatment regimen for an appropriate diagnosis listed in the covered indications

Reauthorization criteria

• Member has a valid prescription from a licensed prescriber for the requested enteral formula
• Prescriber attests the benefits of the requested enteral formula must not be duplicable through calorie supplementation that could be obtained through alternative dietary means alone
• Prescriber attests the enteral formula is medically necessary and has been proven effective as a disease-specific treatment regimen for an appropriate diagnosis listed in the covered indications
• If member is using enteral formulas for a chronic condition, prescriber attests that the member has experienced a therapeutic response defined as disease improvement or stabilization OR delayed disease progression

Approval duration

12 months