enteral formulas — Highmark
Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract
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