AN ACT

 

1Requiring prescription drug benefits and health care policies to
2provide coverage and reimbursement for amino acid-based
3elemental formulas for the treatment of a disease or
4disorder.

5The General Assembly finds that:

6(1)  Each year children in this Commonwealth are born
7with gastrointestinal disorders such as Gastrointestinal
8Reflux Disease (GERD), multiple severe food protein
9allergies, Eosinophilic Esophagitis (EE) and others, which
10either prevent proper digestion or result in negative
11reaction to certain natural milk or soy products, formulas
12and multiple foods.

13(2)  These above-listed conditions and others create a
14situation where a natural sustained existence is virtually
15impossible and threaten a child's ability to thrive.

16(3)  As many of these children are unable to process
17essential specific naturally occurring nutrients (e.g. whole
18milk proteins), parents at the advice and direction of a

1licensed health care professional must seek external or oral
2elemental formulas, such as amino acid-modified formulas and
3other specialized formulas, to provide proper and medically
4necessary nutrition.

5(4)  The amino acid-based elemental formulas and food
6products are widely available but expensive in nature due, in
7part, to complex scientific manufacturing processes, cost of
8raw materials and product quality assurance required for
9these at-risk individuals.

10(5)  Health insurance policies currently only cover the
11cost of specialized amino acid-based elemental formulas when
12administered by tube feeding for the most at-risk
13individuals, even though tube feeding is not always the least
14medically invasive or most cost-effective option available.

15(6)  Proper infant and child nutrition significantly
16reduces digestion problems and resolves the severe negative
17reaction to food protein allergens and other developmental
18and physical conditions as well as the need for future, more
19expensive medical treatments.

20(7)  Medicaid covers the cost of the formulas and food
21products.

22(8)  The Commonwealth is committed to give each and every
23child, regardless of consequence, proper nutrition and high
24quality of life.

25The General Assembly of the Commonwealth of Pennsylvania
26hereby enacts as follows:

27Section 1.  Coverage and reimbursement for amino-based elemental
28formulas.

29A hospital, medical service corporation, health insurance
30corporation, health maintenance organization and nonprofit group

1that provides a prescription drug benefit or reimbursement for
2health care costs under a health care policy delivered, issued
3for delivery or renewed in this State on or after the effective
4date of this section shall provide coverage and reimbursement
5for amino acid-based elemental formulas, regardless of delivery
6method, for the diagnosis and treatment of Immunoglobulin E and
7Non-immunoglobulin E mediated allergies to multiple food
8proteins, food protein-induced enterocolitis syndrome,
9eosinophilic disorders and impaired absorption of nutrients
10caused by disorders affecting the absorptive surface, functional
11length and motility of the gastrointestinal tract, when the
12ordering physician has issued a written order stating that the
13amino acid-based elemental formula is medically necessary for
14the treatment of a disease or disorder.

15Section 2.  Effective date.

16This act shall take effect in 60 days.