Nebraska Elemental Formula Reimbursement Program
What is this program:
Nebraska residents with certain medical conditions that require medically necessary amino acid-based elemental formulas may receive reimbursement of up to fifty percent (50%) of out-of-pocket expenses for these formulas. A maximum reimbursement of $12,000 is available in a twelve month period for out-of-pocket expenses incurred on or after July 1, 2014.
To be eligible, individuals must:
Need to know:
- Have a physician’s written order for an amino acid-based elemental formula for the diagnosis and treatment of Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins, food-protein-induced enterocolitis syndrome, eosinophilic disorders, or impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract;
- Have out-of-pocket expenses for this formula not covered by private insurance, Medicaid, WIC, or charitable grants;
- Reside in the State of Nebraska;
- Be a US Citizen or be legally present in the United States; and
- Provide the applicant’s Social Security number (or the parent’s/guardian’s if applicant is a minor) necessary to process the reimbursement.
Reimbursement for Amino Acid-based formula is on a first-come, first-served basis until funds available are exhausted in a fiscal year. All forms and documents required to determine eligibility must be properly completed and submitted in order to qualify. Reimbursement requests must include copies receipts that show the formula purchased and that it has been paid for. Reimbursements will not be processed on any incomplete Reimbursement Claim Form applications until all requirements are met. Complete applications will be processed in the order in which they are received.
How to apply:
After you have completed the Application form you may scan and email the completed forms and insurance denial if applicable to firstname.lastname@example.org
(not a secure site), or you may fax to 402-471-1541, or send by US mail to:
The submitted application will be reviewed and will be approved or denied. You will be notified through email of the determination. If approved, you will then complete the Reimbursement Claim Form
and attach your paid receipts.
Contact the Elemental Formula Reimbursement Program at the e-mail, phone, fax and/or address listed above under “How to apply.”
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