Phenylketonuria
Provider Type
- Physicians
- Ancillary
- Participating Physician Groups (PPG)
Health Net covers the testing and treatment of phenylketonuria (PKU). Treatment includes formulas and special food products that are part of a diet prescribed by a participating licensed physician and managed by a health care professional in consultation with a physician who specializes in the treatment of metabolic disease. Coverage is only required to the extent that the cost of necessary formulas and foods exceeds the cost of a normal diet.
According to Health and Safety Code 1374.56 and Insurance Code 10123.89, formula means an enteral product for use at home that is prescribed by a physician or nurse practitioner or ordered by a registered dietitian upon referral by a health care provider authorized to prescribe dietary treatments, as medically necessary for the treatment of PKU.
Special food products means a food that is both:
- Prescribed for treatment of PKU consistent with recommendations and best practices in care and treatment of PKU (it does not include a food that is naturally low in protein, but may include food that is specially formulated to have less than one gram of protein per serving).
- Used in place of normal food products, such as foods from the grocery store that are used by the general population.
For additional information regarding the coverage of treatment of PKU, refer to the Coverage Explanation document.