Enteral Nutrition
Benefits are provided for enteral formulas and low protein modified food products, administered either orally or by tube feeding as the primary source of nutrition, for certain conditions which require specialized nutrients or formulas. Examples of conditions include:
  • Metabolic diseases such as phenylketonuria (PKU) and maple syrup urine disease.
  • Severe food allergies.
  • Impaired absorption of nutrients caused by disorders affecting the gastrointestinal tract.
Benefits for prescription or over-the-counter formula are available when a physician issues a prescription or written order stating the formula or product is Medically Necessary for the therapeutic treatment of a condition requiring specialized nutrients and specifying the quantity and the duration of the prescription or order. The formula or product must be administered under the direction of a physician or registered dietitian.
For the purpose of this benefit, "enteral formulas" include:
  • Amino acid-based elemental formulas.
  • Extensively hydrolyzed protein formulas.
  • Modified nutrient content formulas.
For the purpose of this benefit, "severe food allergies" mean allergies which if left untreated will result in:
  • Malnourishment.
  • Chronic physical disability.
  • Intellectual disability; or
  • Loss of life.