Enteral Formula and Supplies - (A022)

Coverage is determined by the member’s specific benefit plan and applicable state mandates; many enteral/oral nutritional formulas, enteral feeding supplies/equipment, specific infant formulas for allergies/intolerances/prematurity, baby/grocery/blenderized foods, supplements/weight-loss products, and HCPCS codes B4149, B4150, B4152, B4153, B4158, B4159, B4160, B4161, S9432, S9433 are excluded under many plans. Key requirement: confirm benefit availability, terms, limitations and medical-necessity criteria with the applicable benefit plan document and Cigna Medical Coverage Policy 0136, as this administrative policy provides no specific documentation checklist.

"Coverage for enteral nutritional formula is dependent upon medical benefit plan language and may be governed by state mandates. Refer to the applicable benefit plan document to determine benefit av..."