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Crohn's Disease Forum » Treatment » Enteral Nutrition & TPN » Tolerex (enteral) treatment & insurance coverage (Canada)


07-11-2011, 02:31 PM   #1
Tesscorm
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Tolerex (enteral) treatment & insurance coverage (Canada)

Hoping someone has had some experience in obtaining insurance coverage (in Canada) for enteral feeding therapy.

My son's initial treatment was a 6-week enteral treatment using Tolerex. He responded well to the treatment and his continued treatment will be a 'maintenance' therapy still using Tolerex (the only other medication he is being given are antacids).

My company has a premium insurance package but the insurance company is saying that Tolerex is only a nutritional supplement and is not considered a medical treatment, hence, not covered by our insurance plan.

Has anyone else had any experience with this? I have tried to explain that in my son's case, this is being used as his only treatment, thus it is not 'just' a nutritional supplement but to no avail...

Any ideas or suggestions would be appreciated!
07-11-2011, 04:06 PM   #2
glum chump
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Hi Tesscorm:

What province are you in? I'm wondering if you can get assistance from your provincial pharmaceutical plan.

In the meantime, did you talk to the 'customer service' folks at your insurance company or the health claims people? Whenever I've had an 'unusual' request, I've faxed a letter from myself and a supporting letter from my doctor to the health claims department and let them make the decision.

Good luck---dealing with insurance companies is a job unto itself!

Cheers,

Kismet
07-12-2011, 08:03 AM   #3
Tesscorm
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Thanks Kismet,

I'm in Ontario and, yes, there is a provincial drug assistance program. However, there is a deductible which will probably be approx. $5,000+ per year.

Contacting 'customer service' was going to be my next step and my son's doctor did offer to provide me with a supporting letter, so that will be next. Its frustrating because I know that Tolerex has been covered by our insurance company for other patients but they are saying it's not part of my company's package, however, my company has quite an extensive package so it's hard for me to imagine that there are many 'higher' levels of coverage that what my company already offers!

Oh well, we'll just have to take it one step at a time... Thanks for your suggestions!
07-12-2011, 11:01 AM   #4
hopeful
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I suggest you contact this place that supplies it https://www.specialtyfoodshop.ca/sfs...l-tolerex.aspx and check with them how to get coverage for it. If anyone would know how to do so - they would, as they are a major supplier of it.
07-12-2011, 03:08 PM   #5
Tesscorm
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Thanks very much, will call shop and see what they suggest!
04-22-2012, 12:51 AM   #6
supper
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I found tolerex for sale on kijjiji, the same that I would pay double the price for.
Hope it works for you, tolerex kept my son in remission for 18 months and allowed him to get taller and gain weight.
Take care
04-26-2012, 09:43 PM   #7
Tesscorm
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Thanks Supper! Will check Kijiji..

Is your son still on Tolerex?
05-12-2012, 09:46 AM   #8
Ms.Pickle
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hi, There is a fund that pays for the nutritional support. i had the same problem. You need to talk to your social worker at the hospital.
11-07-2012, 07:53 PM   #9
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hi, There is a fund that pays for the nutritional support. i had the same problem. You need to talk to your social worker at the hospital.
Same here. I currently have partial coverage on Modulin, and once upon a time had full coverage on Tolerex. There are 3 ways to get coverage:
1. Ontario drug coverage
2. Insurance Coverage
3. Private organizations.

Talk to someone at your hospital, they will have all the info you need to apply to either your insurance company and the drug plan coverage. Insurance companies tend to not be all that nice towards EN, but it's always worth a try. I believe I managed to get some coverage from them for Tolerex once a year and a half ago when I was on it
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