FruitiVits & Single Dose Amino Acids

Formula4Success® is able to assist patients seeking coverage of FruitiVits™ or Single Dose Amino Acids only in combination with an additional Vitaflo™ product. However, some patients may need assistance exclusively for these products (independently of other prescribed Vitaflo products). Therefore, Formula4Success developed the guide below for patients or guardians who independently seek access to FruitiVits or Single Dose Amino Acids.

Private Insurance: Medical Plan

1. Call the Member Services phone number located on the back of the insurance ID card.
2. Follow the prompts for Medical Benefits.
3. Speak with a health plan representative, and state that the intent of the call is to determine Medical Benefits for Enteral Formula Coverage.
4. Provide the product’s Procedure Code (HCPCS Code). FruitiVits is B4104 and Single Dose Amino Acids are B4155.
5. If necessary, provide the patient’s Diagnosis Code (ICD10 Code). The diagnosis code is obtained from your healthcare professional.

Private Insurance: Pharmacy Plan

1. Call the Pharmacy Services phone number located on the back of the insurance ID card.
2. Follow the prompts for Pharmacy Benefits
3. Speak with a health plan representative, and state that the intent of the call is to determine Pharmacy Benefits for Enteral Formula, Specialty Formula and/or OTCitems (as part of OTC-Drug coverage plan).
4. Provide the prescribed product’s Reimbursement Code (NDC-format number). FruitiVits is 50600-0513-25. Single Dose Amino Acids can be found here
5. If necessary, provide the patient’s Diagnosis Code (ICD10 Code). The diagnosis code is obtained from your healthcare professional.

Be Informed

FruitiVits and Single Dose Amino Acids are classified as “enteral formulas” according to the Procedure Code (HCPCS Code), but health plan representatives may not be familiar with the term. Therefore, when communicating with insurance representatives, it may be helpful to use keywords, such as: medical food, specialty formula, medical formula, nutritional formula, nutritional supplement, OTC-item (as part of OTC-Drug coverage plan), etc. Be sure to state that the product is medically necessary for the dietary management of inborn errors of metabolism and/or metabolic disorder/disease.

Provide Accurate Information

It is extremely important to provide the health plan representative with accurate codes for the product. HCPCS codes and/or Reimbursement Codes (NDC-format numbers) are information that representatives need to assist with benefit research and coverage verification. It’s possible that coverage may be excluded as a “non-covered service”. However, the health plan policy may have an inclusion clause which states coverage is allowed when “medically necessary” or for the dietary management of a specific metabolic disease or inborn errors of metabolism. Therefore, it is also important to state that the patient has a diagnosed inborn error of metabolism (IEM), inherited metabolic disease, or state the specific disorder such as Phenylketonuria (PKU), and provide the Diagnosis Code (ICD10 Code).

Documentation

Take detailed notes of the quoted coverage information. Representatives will typically offer coverage information for in-network benefits only. However, it is important to also request out-of-network benefits, if applicable. Key things to note include: deductible, out of pocket maximum, co-pay, co-insurance, prior authorization, predetermination, Primary Care Physician referral only, self-funded plan, fully insured plan, coverage inclusions and coverage exclusions. Request a hardcopy of the insurance policy, and make sure to obtain a call reference number from the representative.

Notice

The prescribed product(s) might qualify to be purchased with FSA funds. Be aware that product purchased prior to receipt of a determination letter detailing coverage parameters which are required to be followed may not be reimbursed.

***Disclaimer: This resource has been drafted to provide assistance with Vitaflo’s FruitiVits and Single Dose Amino Acids. This information is intended to be used by the patient or guardian. Please note that Vitaflo does not guarantee that use of this resource will result in insurance coverage or reimbursement by any third-party payor. Coverage determinations are ultimately made by the health plan. Information received is not a guarantee of payment. The final determination of coverage and reimbursement is made after the claim is submitted and processed. Vitaflo does not guarantee coverage by any insurance plan and will not reimburse any claims denied by third-party payers.***