Metabolic Treatment Product Program (MTP)

The Metabolic Treatment Product Program (MTP) provides families and patients the opportunity to purchase select metabolic treatment products directly from the program. The program purchases these products in bulk and passes those savings onto program enrollees. The program adds an administration fee to cover administrative processing, and shipping costs, which is included in the costs listed on the product sheet and fee schedule.

The program will bill your health insurance to collect payment first for metabolic formula (metabolic food is not covered by insurance). While state law requires health insurers to pay for PKU treatment (WAC 284‐44‐450), patients will have deductible and co ‐ insurance for out-of-pocket cost. The program accepts the following coverage Regence, Premera/Lifewise, Aetna, United HC, Cigna, First Choice, Kaiser Permanente, Coordinated Care, and Fee‐for‐Service Apple Health.

DOH contracts with a third‐party billing vendor, OMNI, to manage insurance claims, authorizations, verifications, payment posting and follow up, patient and insurance account balance management, and follow up duties to recover costs for newborn screening services and MTPs.

Who is Eligible to Participate in the Metabolic Food and Formula Program

To be eligible for the Metabolic Food and Formula Program, the patient must:

• Be a Washington State resident with an inborn error of metabolism and current prescription for metabolic food and/or formula.
• Be followed in a designated Specialty Clinic on a regular basis.
• Follow prescriber treatment plans and recommendations and DOH program policies and procedures.

You will need to have a valid policy and coverage that the program accepts.

Enrolling in the Metabolic Treatment Product Program

Enrolling in the MTP may be a good option for many patients and families who require metabolic formula. There may be a cost associated with the MTP Program, so you need to determine whether the program is cost ‐effective for you or your family.

How to Enroll in the MTP Program

1. Have the Specialty Clinic submit a prescription to our office.
2. Mail, fax, or email the completed MTP Application (PDF) to DOH MTP Specialist.
3. Our insurance specialist, Omni Medical Billing Company, will contact your health insurance provider to verify coverage and do a benefits investigation.
4. You will receive an overview of your health insurance coverage and estimate of your financial responsibility. Patient will be responsible for bill or payment plan.
5. By signing the MTP Application, you agree to the terms and conditions of the MTP Enrollment Packet.
6. If you still have questions, call the MTP Program 206‐418‐5719.

Program Guidelines

1. Patient is responsible for the balance of payment that is not made by their insurance company.
   1. If final balance is not made within a 3-month period of the invoice, patient will be put on a payment plan (structured payment over 12 months).
   2. If patient fails to abide by the payment plan, they will receive a letter of discontinuation.
2. Patient/Parent is responsible for contacting Newborn Screening to request change in shipping address or insurance information within 2 weeks of change.

MTP Products

Children and Youth with Special Health Care Needs (CYSHCN) - Medical Food Support

• Intake form completed by individual or family member. CSHCN Intake Form (PDF)
• NBS determines eligibility for CSHCN financial assistance program and notifies families about decision.
• When children turn 18 years old, they are no longer eligible to receive foods at low cost, must pay full cost.
• Monthly quantity order 6 boxes per month, may switch foods or receive same foods.
• Patient/Parent is responsible for contacting Newborn Screening to request foods/change in shipping address.
• Medical food is not covered by insurance, therefore there will be an out-of-pocket cost.

CYSHCN Food Product List