Medi-Cal Rx List of Covered Enteral Nutrition Products ......1.00 0.04 70074064632 070074646329 070074646336 0.0049 0.0065 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction;

Medi-Cal Rx List of Covered Enteral Nutrition Products – Effective January 1, 2021 December 18, 2020

Effective for dates of service on or after January 1, 2021, the existing Medi-Cal Fee-For-Service List of Enteral Nutrition Products is updated with certain product additions, deletions, and costs. Medi-Cal Rx claims submitted on or after April 1, 2021, for enteral nutrition products require prior authorization and must be a product on the updated Medi-Cal Rx List of Covered Enteral Nutrition Products.

The updated list is attached below, along with the list of deletions effective January 1, 2021. Effective December 18, 2020, the list is also available in Excel® format on the Medi-Cal Rx Web Portal in the Forms and Information Section. Note that the list attached in this bulletin is current as of December 18, 2020. Any future changes to the list will be made in the Excel spreadsheet only. The spreadsheet will also be linked in the Medi-Cal Rx Provider Manual.

https://medi-calrx.dhcs.ca.gov/home/

https://medi-calrx.dhcs.ca.gov/home/

https://medi-calrx.dhcs.ca.gov/provider/forms/

1

Medi-Cal Rx List of Covered Enteral Nutrition Products

This spreadsheet contains enteral nutrition products eligible for reimbursement under Medi-Cal Rx when billed by Medi-Cal Fee-For-Service (FFS) pharmacy providers. Refer to the Enteral Nutrition section of the Medi-Cal Rx Provider Manual for coverage and established criteria, quantity limits, and additional billing information. This spreadsheet is subject to change with notification in the provider bulletins. "EAC" (Estimated Acquistion Cost) is the maximum product cost reimbursed. The manufacturers have guaranteed, upon request, that Medi-Cal FFS pharmacy providers can purchase the products at or below the Maximum Acquisition Cost (MAC) for dispensing to eligible Medi-Cal recipients and bill to Medi-Cal Rx. To receive reimbursement, the NDC/UPC on each product package dispensed must be an exact match to a product NDC/UPC in this spreadsheet and the NDC billing code submitted on the claim. In addition to the established criteria, the product-specific criteria in this spreadsheet must be met.

Product Category

Sub-Category Manufacturer Product Label Name Product-Specific Criteria Caloric density kcal/g or ml)

Protein per g or

ml)

NDC Billing Code

UPC Number per Item (For Reference

Only)

UPC Number per Case (For Reference Only)

MAC per gm or ml

EAC per gm or ml

Effective Date of Change

Description of Change

Standard Abbott Nutrition; 1-800-227-5767

JEVITY 1 CAL 1500 ML READY TO HANG

For tube-fed only patients 1.05 0.04 70074062688 070074626888 070074626871 0.0048 0.0064 January 1, 2021 No Change


JEVITY 1 CAL 1L READY TO HANG



JEVITY 1.0 CAL 8OZ RECLOSEABLE CARTON

For patients who are tube-fed only or have altered taste perception

1.05 0.04 70074064758 070074647586 070074647593 0.0048 0.0064 January 1, 2021 No Change


JEVITY 1.2 CAL 1.5L READY TO HANG

For tube-fed only patients 1.20 0.06 70074062668 070074626680 070074626673 0.0057 0.0073 January 1, 2021 Updated MAC and EAC amounts


JEVITY 1.2 CAL 1L READY TO HANG




For patients who are tube-fed only or have altered taste perception

1.20 0.06 70074064624 070074646244 070074646251 0.0057 0.0073 January 1, 2021 Updated MAC and EAC amounts

Standard Nestlé HealthCare Nutrition; 1-888-240-2713

Fibersource HN SpikeRight Plus UltraPak 4x1500ml



Fibersource HN SpikeRight Plus UltraPak 6x1000ml



Fibersource HN, unflavored, 24x250ml Tetra Prisma



Nutren 1.0 Fiber unflavored, 24x250ml Tetra Prisma



Nutren 1.0, unflavored, 24x250ml Tetra Prisma



Replete Fiber SpikeRight 4x1500ml



Replete Fiber SpikeRight PLUS UltraPak 6x1000ml



Replete Fiber, unflavored, 24x250ml Tetra Prisma



Replete SpikeRight PLUS UltraPak 6 x1000ml



Replete, unflavored, 24x250ml Tetra Prisma


Standard Caloric-restriction; high protein tube- feeding formula

Abbott Nutrition; 1-800-227-5767

OSMOLITE 1 CAL 1.5L READY TO HANG

For tube-fed patients requiring less than 2000 calories per day or increased protein requirements




OSMOLITE 1 CAL 1L READY TO HANG



2

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





OSMOLITE 1 CAL 8OZ RECLOSEABLE CARTON

For patients requiring less than 2000 calories per day or increased protein requirements




OSMOLITE 1.2 CAL 1.5L READY TO HANG





OSMOLITE 1.2 CAL 1L READY TO HANG





OSMOLITE 1.2 CAL 8OZ RECLOSEABLE CARTON

For patients requiring less than 2000 calories per day or increased protein requirements




OSMOLITE 1.5 CAL 1L READY TO HANG

For patients requiring less than 2000 calories per day or increased protein requirements; AND documentation showing patient is not maintained on a lower kcal/g or ml product




OSMOLITE 1.5 CAL 8OZ RECLOSEABLE CARTON

For patients requiring less than 2000 calories per day or increased protein requirements; AND documentation showing patient is not maintained on a lower kcal/g or ml product


Standard Calorie-dense formula


ENSURE PLUS BUTTER PECAN 8OZ RECLOSEABLE CARTON

For patients with documentation they have tried and failed lower kcal/ g or ml standard products on this List OR require a calorie-dense, volume restricted diet




ENSURE PLUS CHOCOLATE 8OZ RECLOSEABLE CARTON





ENSURE PLUS STRAWBERRY 8OZ RECLOSEABLE CARTON





ENSURE PLUS VANILLA 8OZ RECLOSEABLE CARTON





JEVITY 1.5 CAL 1.5L READY TO HANG

For tube-fed only patients with documentation they have tried and failed lower kcal/ g or ml standard products on this List OR require a calorie-dense, volume restricted diet




JEVITY 1.5 CAL 1L READY TO HANG






For tube-fed OR taste-altered patients with documentation they have tried and failed lower kcal/ g or ml standard products on this List OR require a calorie-dense, volume restricted



Nestlé HealthCare Nutrition; 1-888-240-2713

Boost Plus Creamy Strawberry 27x237ml Tetra Brik





Boost Plus Rich Chocolate 27x237ml Tetra Brik





Boost Plus, Creamy Strawberry 24x 237ml





Boost Plus, Rich Chocolate, 24x 237ml





Boost Plus, Very Vanilla 27x237ml Tetra Brik





Boost Plus, Very Vanilla, 24x 237ml



3

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Nutren 1.5 SpikeRight PLUS UltraPak 6x1000ml










Nutren 2.0 SpikeRight PLUS UltraPak 6x1000ml








Standard Calorie-dense pediatric formula


PEDIASURE 1.5 CAL VANILLA 8OZ CAN

For patients 1-13 years of age that have documented they have tried and failed lower kcal/ g or ml standard products on this List or require a calorie-dense, volume restricted diet;




PEDIASURE 1.5 CAL VANILLA 8OZ CAN





PEDIASURE FIBER 1.5 CAL 1L READY TO HANG

For tube-fed patients 1-13 years of age with documentation they have tried and failed lower kcal/ g or ml standard products on this List OR require a calorie-dense, volume restricted diet




PEDIASURE FIBER 1.5 CAL VANILLA 1L READY TO HANG

For tube-fed patients 1-13 years of age with documentation they have tried and failed lower kcal/ g or ml standard products on this List OR require a calorie-dense, volume restricted diet




PEDIASURE FIBER 1.5 CAL VANILLA 8OZ CAN





PEDIASURE FIBER 1.5 CAL VANILLA 8OZ CAN





Boost Kid Essentials 1.5, Creamy Strawberry Splash, 27x8fl oz, 237ml Tetra Brik





Boost Kid Essentials 1.5, Rich Chocolate Craze, 27x8fl oz, 237ml Tetra Brik





Boost Kid Essentials 1.5, Very Vanilla Vortex, 27x8fl oz, 237ml Tetra Brik





Boost Kid Essentials 1.5, Very Vanilla Vortex, Fiber 27x 8fl oz 237ml Tetra Brik



Standard Calorie-dense, high protein formula


Boost VHC Very Vanilla, 27x237ml Tetra Brik





Isosource 1.5 Cal SpikeRight PLUS UltraPak 4x1500ml





Isosource 1.5 Cal SpikeRight PLUS UltraPak 6x1000ml





Isosource 1.5 unflavored, 24x250ml Tetra Prisma





Isosource HN SpikeRight PLUS UltraPak 4x1500ml


4

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Isosource HN SpikeRight PLUS UltraPak 6x1000ml




Isosource HN, unflavored, 24x250ml Tetra Prisma




Resource 2.0 Very Vanilla Creme 27x 237ml

For patients with clinical documentation demonstrating they are not effectively managed by other formula on this List and require additional calories and protein; kcal requirements (kcal/kg/day) must be documented on each prior authorization request.


Standard Critical care formula Nestlé HealthCare Nutrition; 1-888-240-2713

IMPACT, SpikeRight PLUS 6 x 1000 mL UltraPak bags

For tube-fed patients with clinical documentation demonstrating they are not effectively managed by all other medically appropriate standard products on the List AND who are immediate post-surgery or recently post-trauma, or critical care


Standard Critical care formula Nestlé HealthCare Nutrition; 1-888-240-2713

IMPACT, Unflavored 24 x 250 mL Tetra Prisma

For tube-fed patients with clinical documentation demonstrating they are not effectively managed by all other medically appropriate standard products on the List AND who are immediate post-surgery or recently post-trauma, or critical care


Standard High Protein Abbott Nutrition; 1-800-227-5767

ENSURE ENLIVE CHOCOLATE 8OZ BTL

For patients requiring high protein diet. Clinical justification is required.



ENSURE ENLIVE STRAWBERRY 8OZ BTL




ENSURE ENLIVE VANILLA 8OZ BTL




PROMOTE 1500 ML READY TO HANG

For tube-fed patients; AND Clinical documentation is required justifying the need for a -very-high-protein formula



PROMOTE 1L READY TO HANG




PROMOTE FIBER 1.5L READY TO HANG




PROMOTE FIBER 1L READY TO HANG




PROMOTE FIBER 8OZ RECLOSEABLE CARTON

For patients with clinical documentation justifying the need for a -very-high-protein formula



PROMOTE VANILLA 8OZ RECLOSEABLE CARTON

For patients with clinical documentation justifying the need for a -very-high-protein formula


Standard Plant-based formula Kate Farms, Inc.; 1-805-845-2446

Kate Farms Standard 1.4, Plain, 325ml


1.40 0.06 11112003001 811112030010 811112030027 0.0085 0.0101 January 1, 2021 Added


Kate Farms Standard 1.4, vanilla, 325ml


1.40 0.06 11112003042 811112030423 811112030430 0.0085 0.0101 January 1, 2021 Added


Kate Farms Standard Liquid 1.0, chocolate, 325ml

1.00 0.05 51823000664 851823006645 851823006690 0.0061 0.0077 January 1, 2021 Updated Product Label Name


Kate Farms Standard Liquid 1.0, vanilla, 325ml


5

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Standard Plant-based pediatric formula

Kate Farms, Inc.; 1-805-845-2446

Kate Farms Pediatric Standard Formula 1.2, vanilla, 250ml

For patients 1-13 years of age 1.20 0.05 51823000690 851823006904 851823006997 0.0073 0.0089 January 1, 2021 Updated Product Label Name

Standard Tube-fed Only Functional Formularies; 1-844-631-8365

Liquid Hope, unflavored, 341g

For patients who are tube-fed only and do not receive ANY oral nutrition; AND have documented failure to two other standard products on this List; AND Not used as a convenience or alternative to blended food

1.32 0.07 57858000411 857858004113 10857858004110 0.0156 0.0172 January 1, 2021 Added

Standard Tube-fed Only Functional Formularies; 1-844-631-8365

Nourish, unflavored, 341g

For patients 1-13 years of age who are tube-fed only and do not receive ANY oral nutrition; AND documented failure to two other standard products on this List; AND Not used as a convenience or alternative to blended food

1.17 0.04 57858000412 857858004120 10857858004127 0.0123 0.0139 January 1, 2021 Added

Standard Tube-fed Only Nestlé HealthCare Nutrition; 1-888-240-2713

Compleat Pediatric Reduced Calorie, unflavored, 24x250ml Tetra Prisma




Compleat Pediatric, unflavored, 24x250ml Tetra Prisma




Compleat SpikeRight PLUS UltraPak 6x1000ml




Compleat, unflavored, 24x250ml Tetra Prisma



Standard Volume-limited Abbott Nutrition; 1-800-227-5767

ENSURE COMPACT 4OZ BOTTLE CHOCOLATE

For patients requiring a volume-limited diet. Clinical justification is required.

1.86 0.08 70074064363 070074643632 070074643625 0.0110 0.0126 January 1, 2021 Added


ENSURE COMPACT 4OZ BOTTLE VANILLA

For patients requiring a volume-limited diet. Clinical justification is required.

1.86 0.08 70074064357 070074643571 070074643564 0.0110 0.0126 January 1, 2021 Added


TWOCAL HN 1L READY TO HANG

For tube-fed patients with clinical documentation justifying the need for a volume-restricted diet



TWOCAL HN BUTTER PECAN 8OZ CAN

For patients with clinical documentation justifying the need for a volume-restricted diet



TWOCAL HN VANILLA 8OZ CAN




TWOCAL HN VANILLA 8OZ RECLOSEABLE CARTON




ENSURE ORIGINAL POWDER, 14.1OZ, VANILLA



ENSURE ORIGINAL POWDER, 14.1OZ, CHOCOLATE



ENSURE ORIGINAL POWDER, VANILLA 14OZ PWD 6CT



ENSURE ORIGINAL SHAKE, BUTTER PECAN 8OZ RECLOSEABLE CARTON



ENSURE ORIGINAL SHAKE, CHOCOLATE 8OZ RECLOSEABLE CARTON



ENSURE ORIGINAL SHAKE, STRAWBERRY 8OZ RECLOSEABLE CARTON


6

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




ENSURE ORIGINAL SHAKE, VANILLA 8OZ RECLOSEABLE CARTON



PEDIASURE 1 CAL VANILLA 8OZ CAN

For patients 1-13 years of age 1.00 0.03 70074067402 070074674025 070074674018 0.0061 0.0077 January 1, 2021 No Change


PEDIASURE BANANA 8OZ CAN

For patients 1-13 years of age 1.00 0.03 70074051885 070074518855 070074518848 0.0061 0.0077 January 1, 2021 Updated MAC and EAC amounts


PEDIASURE BANANA 8OZ CAN



PEDIASURE CHOCOLATE 8OZ CAN



PEDIASURE CHOCOLATE 8OZ CAN



PEDIASURE ENT VANILLA 8OZ CAN



PEDIASURE FIBER 1 CAL 1L READY TO HANG



PEDIASURE FIBER 1 CAL VANILLA 1L READY TO HANG



PEDIASURE FIBER 1 CAL VANILLA 8OZ CAN



PEDIASURE FIBER 1 CAL VANILLA 8OZ CAN 24CT INST



PEDIASURE FIBER VANILLA 8OZ CAN



PEDIASURE FIBER VANILLA 8OZ CAN



PEDIASURE REDUCED CALORIE 8OZ BOTTLES



PEDIASURE SIDEKICK VANILLA 8OZ BTL



PEDIASURE STRAWBERRY 8OZ CAN



PEDIASURE STRAWBERRY 8OZ CAN



PEDIASURE VANILLA 8OZ CAN



PEDIASURE VANILLA 8OZ CAN



Boost High Protein, Rich Chocolate, 27x 237ml



Boost High Protein, Very Vanilla, 24x 237ml



Boost High Protein, Very Vanilla, 24x8fl oz, 237ml


7

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




Boost Kid Essentials, Chocolate, Tetra Prisma 4-4 packs x 244ml



Boost Kid Essentials, Creamy Strawberry Splash, 27x8fl oz 237ml Tetra Brik



Boost Kid Essentials, Rich Chocolate Craze, 27x8fl oz 237ml Tetra Brik



Boost Kid Essentials, Vanilla, Tetra Prisma 4- 4 packs x 244ml



Boost Kid Essentials, Very Vanilla Vortex, 27x8fl oz 237ml Tetra Brik



Boost Original Nutritional Drink Rich Chocolate 8oz 237ml



Boost Original Nutritional Drink Creamy Strawberry 8oz 237ml



Boost Original Nutritional Drink Very Vanilla 8oz 237ml



Boost, Creamy Strawberry, 27x237ml Tetra Brik



Boost, Rich Chocolate, 27x237ml, Tetra Brik



Boost, Very Vanilla, 27x237ml Tetra Brik



Nutren Junior Fiber unflav SpikeRight PLUS UltraPak 6x1000ml

For tube-fed only patients 1-13 years of age 1.00 0.03 98716067390 00798716673907 00798716774000 0.0063 0.0079 January 1, 2021 Updated MAC and EAC amounts


Nutren Junior Fiber Vanilla 24x250ml Tetra Prisma

For tube-fed only patients 1-13 years of age 1.00 0.03 98716006063 00798716060639 00798716160636 0.0061 0.0077 January 1, 2021 No Change


Nutren Junior unflav SpikeRight PLUS UltraPak 6x1000ml

For tube-fed only patients 1-13 years of age 1.00 0.03 98716067370 00798716673709 00798716773805 0.0063 0.0079 January 1, 2021 Updated MAC and EAC amounts


Nutren Junior Vanilla 24x250ml Tetra Prisma

For tube-fed only patients 1-13 years of age 1.00 0.03 98716006062 00798716060622 00798716160629 0.0061 0.0077 January 1, 2021 No Change

Specialty Infant Amino Acid-based (100 percent) powder formula containing probiotics

Nutricia North America; 1-800-365-7354

Neocate Syneo Infant, 400g, powder, unflavored

For patients 0-12 months of age with clinical documentation demonstrating they are not effectively managed by peptide-based formula


Specialty Infant Amino Acid-based (100 percent) powder formula without probiotics


ELECARE IN 14.1OZ POWDER




Mead Johnson & Company, LLC; 1-800-457-3550

PurAmino Powder, 400gm



8

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Alfamino infant, Unflav powder, 6x400g

For patients 0-12 months of age with clinical documentation demonstrating they are not effectively managed by peptide-based formula AND demonstrating they have tried and failed OR have




Neocate infant with DHA/ARA powder, 400g



Specialty Infant Chylothorax or LCHAD deficiency


Enfaport RTU, 177ml For patients 0-12 months of age with chylothorax or LCHAD deficiency


Specialty Infant Extensively Hydrolyzed (peptide- based) liquid formula without probiotics


SIMILAC ALIMENTUM READY TO FEED (946 ML)


Specialty Infant Extensively Hydrolyzed (peptide- based) liquid formula without


Nutramigen concentrate liquid, 384ml


Specialty Infant Extensively Hydrolyzed (peptide- based) liquid formula without probiotics


Nutramigen RTU liguid, 946ml


Specialty Infant Extensively Hydrolyzed (peptide- based) powder formula containing probiotics

Gerber Products Company; 1-800-284-9488

Gerber Good Start Extensive HA 100% whey protein, 400g, unflav powd


Specialty Infant Extensively Hydrolyzed (peptide- based) powder formula containing probiotics


Nutramigen EnfloraLGG powder, 357g


Specialty Infant Extensively Hydrolyzed (peptide- based) powder formula without probiotics


SIMILAC ALIMENTUM, 343 G, PWDR


Specialty Infant Extensively Hydrolyzed (peptide- based) powder formula without probiotics


SIMILAC ALIMENTUM, 343 G, PWDR


Specialty Infant Extensively Hydrolyzed powder formula without probiotics


Pregestimil powder, 454g

For patients 0-12 months with fat hydolysis disorders 5.00 0.14 00087036701 300870367013 300870367211 0.0672 0.0688 January 1, 2021 Updated MAC and EAC amounts

Specialty Infant Human Milk Fortifier Abbott Nutrition; 1-800-227-5767

SIMILAC HUMAN MILK FORTIFIER POWDER (0.9G)

Restricted to breast-fed premature and late preterm infants under 3600 grams. Clinical documentation on the prior authorization of infant weight and breast feeding is required.


Specialty Infant Human Milk Fortifier Mead Johnson & Company, LLC; 1-800-457-3550

Enfamil Human Milk Fortifier powder 0.71g

Restricted to breast-fed premature and late preterm infants under 4500 grams in weight. Clinical documentation on the prior authorization of infant weight and breast feeding is required.


Specialty Infant Premature and Low Birth Weight (LBW)


SIMILAC NEOSURE (371 G PWDR)

For premature or LBW patients 0-12 months of age 5.13 0.14 70074057430 070074574318 070074574301 0.0500 0.0516 January 1, 2021 Updated MAC and EAC amounts



SIMILAC NEOSURE (371 G PWDR)




SIMILAC NEOSURE READY TO FEED (946 ML)

For premature or LBW patients 0-12 months of age 0.74 0.02 70074057456 070074574561 070074574554 0.0100 0.0116 January 1, 2021 No Change

9

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





SIMILAC SPECIAL CARE 24 (59 ML)

For premature or LBW patients 0-12 months of age under 3600 grams.




SIMILAC SPECIAL CARE 30 (59 ML)

For premature or LBW patients 0-12 months of age under 3600 grams.




Enfamil NeuroPro EnfaCare 22 kcal RTU, 59ml, 24cs

For premature or LBW patients 0-12 months of age 0.74 0.02 00087512203 300875122037 300875127315 0.0100 0.0116 January 1, 2021 Updated UPC Number (case)



Enfamil NeuroPro EnfaCare 22 kcal RTU, 59ml, 48 cs

For premature or LBW patients 0-12 months of age 0.74 0.02 00087512203 300875122037 300875122006 0.0100 0.0116 January 1, 2021 Updated UPC Number (case)



Enfamil NeuroPro EnfaCare powder, 363 g




Enfamil NeuroPro EnfaCare RTU 22cal, 946ml




Enfamil Premature High Protein 24cal, 59ml

For premature or LBW patients 0-12 months of age who are not breastfed.




Enfamil Premature w/iron 20cal, 59ml













Specialty Infant Renal Abbott Nutrition; 1-800-227-5767

SIMILAC PM 60/40 400G

Restricted to individuals 0-12 months with a diagnosis of impaired renal function


Specialized Modular Carbohydrate and Lipid


Duocal powd, 400g For patients not effectively managed by other formula on the covered list and require additional calories; kcal (kca/kg/day) and fat (g/kg/day) requirements must be documented on each prior authorization request.

4.92 - 49735018262 749735002803 749735182628 0.0612 0.0628 January 1, 2021 Updated MAC and EAC amounts

Specialized Modular Lipid Nutricia North America; 1-800-365-7354

Liquigen MCT (3x4x250ml)

For patients not managed by other products on the covered list and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a specialized modular product.


Specialized Modular Lipid Nutricia North America; 1-800-365-7354

Liquigen MCT 3x4x250ML



Specialized Diabetic Abbott Nutrition; 1-800-227-5767

GLUCERNA 1 CAL 1.5L READY TO HANG

For patients with a diagnosis of diabetes or hyperglycemia



GLUCERNA 1 CAL 1L READY TO HANG




GLUCERNA 1.0 CAL 8OZ RECLOSEABLE CARTON




GLUCERNA 1.2 CAL 1.5L READY TO HANG

For patients with a diagnosis of diabetes or hyperglycemia; AND documented they are not effectively managed by a lower-calorie enteral nutrition formula on the covered list.


10

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




GLUCERNA 1.2 CAL 1L READY TO HANG




GLUCERNA 1.2 CAL 8OZ CAN

For patients with a diagnosis of diabetes or hyperglycemia; AND documented they are not effectively managed by a lower-calorie enteral nutrition formula on this List.







GLUCERNA 1.5 CAL 1L READY TO HANG




GLUCERNA 1.5 CAL 8OZ CAN

For patients with a diagnosis of diabetes or hyperglycemia; AND documented they are not effectively managed by a lower-calorie enteral nutrition formula on this List.







GLUCERNA SHAKE BUTTER PECAN 8OZ RECLOSEABLE CARTON




GLUCERNA SHAKE CHOCOLATE 8OZ RECLOSEABLE CARTON




GLUCERNA SHAKE STRAWBERRY 8OZ RECLOSEABLE CARTON




GLUCERNA SHAKE VANILLA 8OZ RECLOSEABLE CARTON



Specialized Diabetic Nestlé HealthCare Nutrition; 1-888-240-2713

Boost Glucose Control, Rich Chocolate 27 X 8 Fl Oz Tetra Brik




Boost Glucose Control, Creamy Strawberry 27 X 8 Fl Oz Tetra Brik




Boost Glucose Control, Very Vanilla 27 X 8 Fl Oz Tetra Brik




Glytrol, Spikeright Plus 4 X 1500 ml Ultrapak Bags




Glytrol, Spikeright Plus 6 X 1000 ml Ultrapak Bags




Glytrol, Vanilla 24 X 250 ml Tetra Prisma



Specialized Hepatic Nestlé HealthCare Nutrition; 1-888-240-2713

Nutrihep, Unflavored 24 X 250 mlTetra Prisma

For patients with a diagnosis of hepatic disease or insufficiency


Specialized Modular Carbohydrate


Benecalorie, Unflavored 24 X 1.5 Fl Oz Cups

For patients not effectively managed by other formula on the covered list and require additional calories; kcal requirements (kcal/kg/day) must be documented on each prior authorization request.


11

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Specialized Modular Carbohydrate


Polycal, unflavored, 400g powder

For patients not effectively managed by other formula on the covered list and require additional calories; kcal requirements (kcal/kg/day) must be documented on each prior authorization request.


Specialized Modular Lipid Nestlé HealthCare Nutrition; 1-888-240-2713

MCT OIL, Unflavored (946)

For patients not managed by other formula on this Lsit and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a metabolic modular product


Specialized Modular Lipid Nestlé HealthCare Nutrition; 1-888-240-2713

MICROLIPID, Unflavored 48x90 ml

For patients not managed by other formula on this List and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a metabolic modular product

4.50 - 41679008702 00041679087435 00041679087022 0.0369 0.0385 January 1, 2021 No Change

Specialized Modular Lipid Vitaflo, USA LLC; 1-888-548-2356

Betaquik, MCT emulsion, unflavored, 18x250ml

For patients 3+ years of age not managed by other formula on this List and require additional medium- chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a metabolic modular product

1.89 - 50600057853 none 812539020004 0.0200 0.0216 January 1, 2021 No Change

Specialized Modular Lipid Vitaflo, USA LLC; 1-888-548-2356

Lipistart powder, unflav, 400g

For patients 0-10 years of age not managed by other formula on this List and require additional medium- chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request.

4.50 0.14 50600050205 none 812539021339 0.0810 0.0826 January 1, 2021 Updated MAC and EAC amounts

Specialized Modular Protein Abbott Nutrition; 1-800-227-5767

Promod liquid protein, Fruit Punch, 32oz bottle, 6ct

For patients not effectively managed by other formula on the covered list and require additional protein; protein requirements (g/kg/day) must be documented on each prior authorization request.


Specialized Modular Protein Global Health Products, Inc.; 1-800-638-2870

LiquaCel, 1920 ml, liquid, concord grape

For patients not effectively managed by other enteral nutrition formula on the covered list and require additional protein; protein requirements (g/kg/day) must be documented on each prior authorization request

3.33 0.53 82028000294 782028001947 782028002944 0.0222 0.0238 January 1, 2021 Added


LiquaCel, 1920 ml, liquid, peach mango




LiquaCel, 960 ml, liquid, lemonade




LiquaCel, 960 ml, liquid, citrus orange




LiquaCel, 960 ml, liquid, concord grape




LiquaCel, 960 ml, liquid, peach mango




LiquaCel, 960 ml, liquid, watermelon



Specialized Modular Protein Nestlé HealthCare Nutrition; 1-888-240-2713

BENEPROTEIN, Unflavored Powder 6 x 8 oz canisters



12

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Specialized Modular Protein Nutricia North America; 1-800-365-7354

Pro-Stat Sugar Free, 887ml, citrus




Pro-Stat Sugar Free, 887ml, grape




Pro-Stat Sugar Free, 887ml, vanilla




Pro-Stat Sugar Free, 887ml, wild cherry punch



Specialized Modular Protein, Renal


Pro-Stat Renal Care, 887ml, tangerine

For patients on dialysis; AND For patients not effectively managed by other formula on the covered list and require additional protein; protein requirements (g/kg/day) must be documented on each prior authorization request


Specialized Pulmonary Abbott Nutrition; 1-800-227-5767

PULMOCARE 1L READY TO HANG

For patients with a diagnosis of COPD, cystic fibrosis, or respiratory failure


Specialized Pulmonary Abbott Nutrition; 1-800-227-5767

PULMOCARE VANILLA 8OZ RECLOSEABLE CARTON



Specialized Pulmonary Nestlé HealthCare Nutrition; 1-888-240-2713

Nutren Pulmonary, Spikeright Plus 6 X 1000 ml Ultrapak Bags



Specialized Pulmonary Nestlé HealthCare Nutrition; 1-888-240-2713

Nutren Pulmonary, Vanilla 24 X 250 ml Tetra Prisma



Specialized Renal Abbott Nutrition; 1-800-227-5767

NEPRO 1L READY TO HANG

For patients with a diagnosis of renal disease 1.77 0.08 70074062670 070074626703 070074626697 0.0111 0.0127 January 1, 2021 Added


NEPRO BUTTER PECAN 8OZ RECLOSEABLE CARTON

For patients with a diagnosis of renal disease 1.77 0.08 70074064797 070074647975 070074647982 0.0111 0.0127 January 1, 2021 Updated MAC and EAC amounts


NEPRO MIXED BERRY 8OZ RECLOSEABLE CARTON



NEPRO VANILLA 8OZ RECLOSEABLE CARTON



SUPLENA VANILLA 8OZ CAN



SUPLENA VANILLA 8OZ RECLOSEABLE CARTON


Specialized Renal Nestlé HealthCare Nutrition; 1-888-240-2713

Novasource Renal, Café Mocha, 27 X 8 Fl Oz Tetra Briks



Novasource Renal, Spikeright Plus 6 X 1000 ml Ultrapak Bags



Novasource Renal, Strawberry, 27 X 8 Fl Oz Tetra Briks



Novasource Renal, Vanilla 27 X 8 Fl Oz Briks



Renalcal, Unflavored 24 X 250 ml Tetra Prisma


13

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Specialized Renal Vitaflo, USA LLC; 1-888-548-2356

Renastart, 400 grams, powder, unflavored

For patients with a diagnosis of renal disease 4.94 0.02 50600054623 None 812539021490 0.0945 0.0961 January 1, 2021 Updated MAC and EAC amounts

Specialized Tube-fed, diabetic management formula


Diabetisource Ac, Spikeright Plus 4 X 1500 ml Ultrapak Bags

For patients with a diagnosis of diabetes or hyperglycemia; AND not effectively managed by a lower-calorie enteral nutrition formula on the covered list; documentation must be included on each request; AND must be tube-fed only




Diabetisource Ac, Spikeright Plus 6 X 1000 ml Ultrapak Bags





Diabetisource Ac, Unflavored 24 X 250 ml Tetra Brik



Metabolic Amino Acid Nutricia North America; 1-800-365-7354

Complete Amino Acid Mix powd, 200g



Essential Amino Acid Mix powd, 200g, unflavored



Glycine powder, 50g 4.00 0.10 00847001300 700847013002 none 0.4622 0.4638 January 1, 2021 Updated MAC and EAC amounts


L-Arginine powder, 50g

4.00 0.10 00847001200 700847012005 none 0.4580 0.4596 January 1, 2021 Updated MAC and EAC amounts


L-Isoleucine powder, 50g



L-Leucine powder, 50g 4.00 0.10 00847001500 700847015006 none 0.4600 0.4616 January 1, 2021 Updated MAC and EAC amounts


L-Tyrosine powder, 50g



L-Valine powder, 50g 4.00 0.10 00847001700 700847017000 none 0.4537 0.4553 January 1, 2021 Updated MAC and EAC amounts

Metabolic Amino Acid Solace Nutrition, LLC; 1-888-876-5223

Cytolline, 275g, unflavored, powder

4.00 1.00 57771000116 none 857771001169 0.1273 0.1289 January 1, 2021 No Change

Metabolic Amino Acid Vitaflo, USA LLC; 1-888-548-2356

Arginine2000 Amino Acid Supplement, powd, 30x4g sachets



Arginine500 Amino Acid Supplement, powd, 30x4g sachets



Citrulline 200 Amino Acid Supplement, unflav, 30X4g sachets



Citrulline1000 Amino Acid Supplement, powd, 30x4g sachets



Creatine5000 Amino Acid Supplement, powd, 30x6g sachets


14

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




Cystine500 Amino Acid Supplement, powd, 30x4g sachets



Glycine500 Amino Acid Supplement powder, 30x4g sachets



Isoleucine1000 Amino Acid Supplement powder, unflav, 30x4g sachets



Isoleucine50 Amino Acid Supplement powder, unflav, 30x4g sachets



Leucine100 Amino Acid Supplement powder, unflav, 30x4g sachets



Methionine100 Amino Acid Supplement, unflav, powder, 30x4g sachets



Phenylalanine50 Amino Acid Supplement powder, 30x4g sachets



Tyrosine1000 Amino Acid Supplement, powder, 30x4g sachets



Valine1000 Amino Acid Supplement, powder, 30x4g sachets



Valine50 Amino Acid Supplement, powder, 30x4g sachets


Metabolic Disaccharidase deficiencies


3232A powd, 454g Restricted to the use of infants and children with a clinical diagnosis of disaccharidase deficiencies.


Metabolic Extensively- hydrolyzed peptide and Ketogenic- based Formula

Ajinomoto Cambrooke, Inc.; 1-866-456-9776

KetoVie 4:1 Peptide, 30x250ml

For patients requiring a medically-necessary ketogenic diet; AND For patients requiring a peptide-based formula; AND Patients 1+ years of age


Metabolic Extensively- hydrolyzed peptide and Ketogenic- based Formula

Functional Formularies; 1-844-631-8365

Keto Peptide, unflavored, 227g

For patients requiring a medically-necessary ketogenic diet; AND For patients requiring a peptide-based formula; AND Patients 1+ years of age

2.69 0.08 57858000424 857858004243 00857858004298 0.0305 0.0321 January 1, 2021 Added

Metabolic Fat hydrolysis disorders


Portagen powd, 410g For patients with a clinical diagnosis of intraluminal hydrolysis of fat defects


Metabolic Glucomacropeptide (GMP)-containing formula for phenylketonuria


Glytactin 15 PE Bettermilk Powder, Orange Cream, 52g X 30 Packets

For use in individuals 1+ years of age with a clinical diagnosis of phenylketonuria AND patients who are compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record




Glytactin 15 PE Bettermilk Powder, Original, 49g X 30 Packets





Glytactin 15 PE Bettermilk Powder, Strawberry Cream, 52g X 30 Packets



15

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Glytactin 20PE Bettermilk Lite Powder, Unflavored, 51g X 30 Packets





Glytactin BUILD 10 Powder, 30 x 16g Packets, unflavored

For patients compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record; AND For patients 1+ years of age

3.35 0.67 24359035307 324359353076 324359353076 0.2639 0.2655 January 1, 2021 Added



Glytactin BUILD 20/20 Powder, 30 x 32g Packets, unflavored


3.35 0.67 24359053101 324359531016 324359531016 0.2639 0.2655 January 1, 2021 Added



Glytactin BURST 10 Powder Punch, 30 x 16g Packets


3.13 0.63 24359020507 324359205078 324359205078 0.2557 0.2573 January 1, 2021 Added



Glytactin BURST 20/20 Powder, Punch, 30 x 33g Packets


3.03 0.61 24359021501 324359215015 324359215015 0.2557 0.2573 January 1, 2021 Added



Glytactin RTD 10 PE Liquid, chocolate, 30x250ml





Glytactin RTD 10 PE Liquid, original, 30x250ml





Glytactin RTD 15 PE Liquid, chocolate, 30x250ml





Glytactin RTD 15 PE Liquid, original, 30x250ml





Glytactin RTD 15 PE Lite Liquid, Coffee Mocha, 30x250ml





Glytactin RTD 15 PE Lite Liquid, vanilla, 30x250ml





PhenylAde GMP Mix, powder, original unflavored, 16x33.3g packets

Restricted to patients who are compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record.




PhenylAde GMP Mix, powder, vanilla, 16x33.3g packets

For patients compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record.




PhenylAde GMP Mix, powder, vanilla, 400g





PhenylAde GMP Mix- In, unflavored, 200g powder





PhenylAde GMP Mix- In, unflavored, 20x12.5g powder packets



16

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





PhenylAde GMP Ready, 10PE, plain, 250ml




Vitaflo, USA LLC; 1-888-548-2356

PKU Sphere 15, powder, Red Berry 30x27g


3.37 0.56 12539002113 none 812539021131 0.3000 0.3016 January 1, 2021 Added



PKU Sphere 15, powder, Vanilla 30x27g





PKU Sphere 20, powder, Chocolate, 30x35g





PKU Sphere 20, powder, red berry, 30x35g





PKU Sphere 20, powder, vanilla, 30x35g



Metabolic Glucomacropeptide (GMP)-containing formula for Tyrosinemia I, II, III


Tylactin BUILD 20 Powder, Unflavored, 30 x 28g Packets

For patients with a clinical diagnosis of tyrosinemia; AND Patients who are compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record; AND Patient is 1+ years of age

3.57 0.71 24359054107 324359541077 324359541077 0.4287 0.4303 January 1, 2021 Added



Tylactin RTD 15 PE Liquid, original, 30x250ml

For patients with a clinical diagnosis of tyrosinemia; AND Patients who are compliant with their nutritional management plan and monitoring of phenylalanine blood concentrations as documented in their medical record; AND Patients 1+ years of age




TYR Lophex GMP Mix- In, unflavored, 20x12.5g powder





TYR Sphere 20 Red Berry, 30x35g



Metabolic Glutaric acidemia Type 1


GLUTAREX-1 14.1OZ (400G) PWD 6CT

For patients with a diagnosis of glutaric acidemia 4.80 0.15 70074051141 70074511412 70074511405 0.0796 0.0812 January 1, 2021 Updated MAC and EAC amounts



GLUTAREX-1 14.1OZ PWD 6CT




GLUTAREX-2 14.1OZ (400G) PWD 6CT




GLUTAREX-2 UNFL 14.1OZ (400G) PWD 6CT

For patients with a diagnosis of glutaric acidemia 4.10 0.30 70074067039 70074670393 70074670386 0.1713 0.1729 January 1, 2021 Added



GA powd, 454g For patients with a diagnosis of glutaric acidemia 5.00 0.15 00087510188 300875101889 300875101896 0.0813 0.0829 January 1, 2021 Updated MAC and EAC amounts



GA1 Anamix Early Years powd, 400g


17

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Metabolic glutaric acidemia Type 1


GlutarAde Essential GA-1 Drink Mix, unflavored, 454g




GlutarAde GA-1 Amino Acid Blend powd unflavored 454g




GlutarAde Junior GA-1 Drink Mix powd 400g




GA Express 15, unflav, powd, 30x25g sachets

For patients with a diagnosis of glutaric acidemia 2.97 0.60 50600051622 none 812539020103 0.3000 0.3016 January 1, 2021 Updated MAC and EAC amounts



GA Gel, unflav, powd, 30x24g sachets

For patients with a diagnosis of glutaric acidemia 3.38 0.42 50600053602 none 812539020059 0.2500 0.2516 January 1, 2021 Added

Metabolic Hepatic Glycogen Storage


Glycosade powder, lemon, 30x60g sachets

For patients with a diagnosis of Glycogen Storage Disease; AND For patients 3+ years of age

3.52 - 12539002476 none 812539024767 0.0650 0.0666 January 1, 2021 Added

Metabolic Hepatic Glycogen Storage


Glycosade powder, unflavored, 30x60g sachets

For patients with a diagnosis of Glycogen Storage Disease; AND For patients 3+ years of age

3.52 - 50600051400 none 812539021346 0.0650 0.0666 January 1, 2021 Updated MAC and EAC amounts

Metabolic Homocystinuria or Hypermethioninemia


HOMINEX-1 14.1OZ (400G) PWD 6CT

For patients with a diagnosis of Homoystinuria or hypermethioninemia; AND For patients 0-3 years of age


Metabolic Homocystinuria or hypermethioninemia


HOMINEX-1 14.1OZ PWD 6CT






For patients with a diagnosis of Homoystinuria or hypermethioninemia; AND For patients 1+ years of age






4.10 0.30 70074067043 70074670430 70074670423 0.1605 0.1621 January 1, 2021 Added



Homactin AA Plus, berry flavor, 30x250ml





HCY 1 powd, 454g For patients with a diagnosis of Homoystinuria or hypermethioninemia; AND For patients 0-3 years of age




HCY 2 powd, 454g For patients with a diagnosis of Homoystinuria or hypermethioninemia; AND For patients 1+ years of age




HCU Anamix Early Years powd, 400g





HCU Anamix Next, 400g,powder





HCU Lophlex LQ, liquid, 125ml, mixed berry





XMet Maxamum powd, 454g, unflavored





HCU Cooler 15 Orange, 30x130ml





HCU Cooler 15 Red, 30x130ml



18

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





HCU Express 15, powder, unflavored, 30x25g sachets





HCU Express 20 powder, unflav, 30x34g sachets





HCU Gel, powd, unflav, 30x24g sachets



Metabolic Hypercalcemia Abbott Nutrition; 1-800-227-5767

CALCILO XD CAL W/O VITD (375G) PWD 6CT

For patients 0-12 months of age 5.13 0.11 70074053329 070074533292 070074533285 0.0417 0.0433 January 1, 2021 Updated MAC and EAC amounts

Metabolic Isovaleric Acidemia Ajinomoto Cambrooke, Inc.; 1-866-456-9776

Isovactin AA Plus, berry flavor, 30x250ml

For patients with a diagnosis of Isovaleric Acidemia; AND For patients 1+ years of age


Metabolic Isovaleric Acidemia Nutricia North America; 1-800-365-7354

IVA Anamix Early Years powd, 400g

For patients with a diagnosis of Isovaleric Acidemia; AND For patients 1-3 years of age



IVA Anamix Next, 400g, powder




XLeu Maxamum Powd, 454g, unflavored



Metabolic Ketogenic Formula, LCFA and fat malabsorption disorders


SIM ISO RCF 13OZ CL 12CT

For patients 0-12 months of age with a clinial diagnosis of seizure disorder.




KetoVie 3:1 Unflavored, 30x250ml

For patients with conditions that require a ketogenic diet or have LCFA conditions; AND For patients 1+ years of age

1.04 0.03 24539050403 324359504034 324359504034 0.0181 0.0197 January 1, 2021 Added



KetoVie 4:1 Chocolate, 30x250ml





KetoVie 4:1 Vanilla, 30x250ml





Ketocal 2.5:1 Vanilla Liquid with MCT(New)


1.53 0.05 49735017246 749735072462 749735172469 0.0208 0.0224 January 1, 2021 Added



Ketocal 3:1 powder, 300g





Ketocal 4:1 liquid, 237ml, unflav





Ketocal 4:1 liquid, 240 237 ml, vanilla





KetoCal 4:1 powder, 300g, vanilla



19

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Monogen with DHA, 400g, powder





Betaquik, MCT emulsion, unflavored, 18x250ml

For patients 3+ years of age who require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions such as LCFAOD. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a specialized modular product.

1.89 - 50600057853 none 812539020004 0.0200 0.0216 January 1, 2021 No Change



MCT Procal, , unflav, 30x16g sachets



Metabolic Leucine Metabolism Disorders


I-VALEX-1 14.1OZ (400G) PWD 6CT

For patients with leucine metabolism disorders; AND For patients 1-3 years of age




I-VALEX-1 14.1OZ PWD 6CT

For patients with leucine metabolism disorders; AND For patients 1-3 years of age




I-VALEX-2 UNFL 14.1OZ (400G) PWD 6CT

For patients with leucine metabolism disorders; AND For patients 1+ years of age

4.10 0.30 70074067047 70074670478 70074670461 0.1605 0.1621 January 1, 2021 Added



I-VALEX-2 14.1OZ (400G) PWD 6CT

For patients with leucine metabolism disorders; AND For patients 1+ years of age




LMD powd, 454g For patients with leucine metabolism disorders 5.00 0.16 00087510196 300875101964 300875101971 0.1575 0.1591 January 1, 2021 Updated MAC and EAC amounts

Metabolic Maple Syrup Urine Disease (MSUD)


KETONEX-1 14.1OZ (400G) PWD 6CT

For patients with a clinical diagnosis of MSUD; AND For patients 0-3 years of age




KETONEX-1 14.1OZ PWD 6CT





KETONEX-2 14.1OZ (400G) PWD 6CT

For patients with a clinical diagnosis of MSUD; AND For patients 1+ years of age




KETONEX-2 UNFL 14.1OZ (400G) PWD 6CT


4.10 0.30 70074067051 70074670515 70074670508 0.1605 0.1621 January 1, 2021 Added



Vilactin AA Plus, berry flavor, 30x250ml





BCAD 1 powd, 454g For patients with a clinical diagnosis of MSUD; AND For patients 0-3 years of age




BCAD 2 powd, 454g For patients with a clinical diagnosis of MSUD; AND For patients 1+ years of age




Complex Essential MSD Mix powd vanilla 454g

For patients with a clinical diagnosis of MSUD 3.23 0.25 00847059722 700847059826 700847598226 0.1560 0.1576 January 1, 2021 Updated MAC and EAC amounts



Complex Junior MSD Drink Mix powd unflavored 400g




Complex MSUD Amino Acid Blend powd unflavored 454g




MSUD Anamix Early Years powd, 400g



20

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





MSUD Lophlex Liquid, mixed berry (30x125ml) pouches





MSUD Maxamum powd, orange 454g





MSUD Cooler 15 Orange, 30x130 ml





MSUD Cooler 15 Red, 30x130 ml





MSUD Express 20 powder, unflav, 30x34g sachets





MSUD Express15 powder,unflavored, 30x25g sachets





MSUD Gel, unflav, 30x24g sachets



Metabolic Methylmalonic/ Propionic acidemia


MMA/PA Anamix Early Years powd, 400g

For patients with organic acidemias disorders; AND For patients 0-3 years of age


Metabolic methylmalonic/ Propionic acidemia


MMA-PA Anamix Next, 400g, powder

For patients with organic acidemias disorders; AND For patients 1+ years of age




XMTVI Maxamum powd, 454g, unflavored





MMA/PA Gel, unflav, powder, 30x24g sachets

For patients with organic acidemias disorders; AND For patients 1-10 years of age




MMA-PA Cooler 15, red flavor, 130ml



Metabolic Modular Carbohydrate and Fat


Duocal powd, 400g For patients not managed by other products on the covered list and require additional calories; kcal (kca/kg/day) and fat (g/kg/day) requirements must be documented on each prior authorization request.


Metabolic Modular Lipid Nestlé HealthCare Nutrition; 1-888-240-2713

MCT OIL, Unflavored (946)

For patients not managed by other products on the covered list and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a metabolic modular product


Metabolic Modular Lipid Nestlé HealthCare Nutrition; 1-888-240-2713

MICROLIPID, Unflavored 48x90 ml

For patients not managed by other products on the covered list and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request. NOTE: Also listed as a metabolic modular product

4.50 - 41679008702 00041679087435 00041679087022 0.0369 0.0385 January 1, 2021 No Change

Metabolic Modular Lipid Nutricia North America; 1-800-365-7354

Liquigen MCT (3x4x250ml)



21

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Metabolic Modular Lipid Vitaflo, USA LLC; 1-888-548-2356

Lipistart powder, unflav, 400g

For patients not managed by other products on the covered list and require additional medium-chain triglycerides (MCT) such as ketogenic diet or metabolic conditions. Specific fat requirements (g/kg/day) and diagnosis are required to be documented on each prior authorization request; AND For patients 1-10 years of age


Metabolic Modular Lipid Nutricia North America; 1-800-365-7354

Liquigen MCT 3x4x250ML



Metabolic Modular Protein Abbott Nutrition; 1-800-227-5767

PROVIMIN 5.3OZ (400G) PWD 6CT

Clinical documentation is required justifying the need for a diet modified in carbohydrate, fat, and requiring increased protein related to a metabolic condition


Metabolic Phenylketonuria (PKU)


PHENEX-1 14.1OZ (400G) PWD 6CT

For patients with PKU; AND For patients 0-3 years of age




PHENEX-1 14.1OZ PWD 6CT





PHENEX-2 14.1OZ (400G) PWD 6CT

For patients with PKU; AND For patients 1+ years of age




PHENEX-2 UNFL 14.1OZ (400G) PWD 6CT


4.10 0.30 70074067055 70074670553 70074670546 0.0899 0.0915 January 1, 2021 Added



PHENEX-2 VAN (400G) PWD 6CT





PHENEX-2 VAN 14.1OZ (400G) PWD 6CT


4.10 0.30 70074067057 70074670577 70074670560 0.0899 0.0915 January 1, 2021 Added



Phenactin AA Plus, berry flavor, 30x250ml




Galen US, Inc.; 1-855-425-3646

PKU Easy Microtabs, tablets, unflavored, 110 grams


3.96 0.71 50059034100 350059341009 none 0.4700 0.4716 January 1, 2021 Added



Phenyl-Free 1 powd, 454g





Phenyl-Free 2 powd, 454g





Phenyl-Free 2HP powd, 454g





Lanaflex powd, 40x15.8g sachets

Limited to non-pregnant patients, 18 years of age or older




Lophlex Liquid, tropical (30x125ml) pouches





Lophlex, berry powder, 30x14.3g sachets





Lophlex, orange powder, 30x14.3g sachets



22

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





Periflex Advance powd, orange 454g





Periflex Advance powd, unflav 454g





Periflex Junior Plus powd, berry, 400g





Periflex Junior Plus powd, orange, 400g





Periflex Junior Plus powd, plain, 400g





Periflex Junior Plus powd, vanilla, 400g





Periflex LQ (berry cream), RTF 250ml





Periflex LQ (orange cream), RTF 250ml





PhenylAde Amino Acid Blend powd unflavored 454g





PhenylAde Amino Acid Blend powd unflavored, 30x12.8g sachets





PhenylAde Essential Drink Mix, powd, chocolate, 16x40g sachets





PhenylAde Essential Drink Mix, powd, chocolate, 454g





PhenylAde Essential Drink Mix, powd, orange crème, 16x40g sachets





PhenylAde Essential Drink Mix, powd, orange crème, 454g





PhenylAde Essential Drink Mix, powd, strawberry, 16x40g sachets





PhenylAde Essential Drink Mix, powd, strawberry, 454g





PhenylAde Essential Drink Mix, powd, unflav, 16x40g sachets





PhenylAde Essential Drink Mix, powd, unflav, 454g





PhenylAde Essential Drink Mix, powd, vanilla, 16x40g sachets



23

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





PhenylAde Essential Drink Mix, powd, vanilla, 454g





PhenylAde MTE Amino Acid Blnd powd, unflav, 30x12.8g sachets





PhenylAde MTE Amino Acid Blnd powd, unflav, 454g





PhenylAde PheBloc LNAA Powd, unflav, 110x3g sachets





PhenylAde PheBloc LNAA Tablets, unflavored, 550 each





PhenylAde40 Drink Mix powd, citrus, 20x25g sachets





PhenylAde40 Drink Mix powd, unflav, 20x25g sachets





Phenylade60 Drink Mix Powd, unflav, 30x16.7g sachets





Phenylade60 Drink Mix powd, unflav, 454g





Phenylade60 Drink Mix powd, vanilla, 30x16.7g sachets





PhenylAde60 Drink Mix powd, vanilla, 454g





Phlexy-10 Drink Mix Powd, 30x20g sachet, blackcurrant/apple





Phlexy-10 Drink Mix powd, 30x20g sachet, tropical surprise





Phlexy-10 Tablets, 75 each

Restricted to individuals 8 years of age and older. 3.80 0.83 49735001951 749735019511 none 0.4700 0.4716 January 1, 2021 Updated MAC and EAC amounts



PKU Lophlex Liquid, mixed berry blast (30x125ml) pouches





PKU Lophlex LQ Liquid,juicy orange (30x125ml) pouches





PKU Periflex Early Years powd, 400g





XPhe Maxamum powd, orange, 454g





XPhe Maxamum powd, unflav, 30x50g sachets



24

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





XPhe Maxamum powd, unflav, 454g





XPhe Maxamum powd,orange, 30x50g sachets





MMA/PA Express15, powder, unflav, 30x25g sachets





PKU Air20 Gold (coffee fusion), 30 x 174ml





PKU Air20 Green (citris twist), 30 x 174ml





PKU Air20 Yellow (mango breeze), 30 x 174ml





PKU Cooler 10 Orange, 30x87ml





PKU Cooler 10 Purple, 30x87ml





PKU Cooler 10 Red, 30x87ml





PKU Cooler 10 White, 30x87ml















PKU Cooler 15 Red, 30x130ml

























PKU Cooler 20, Red, 30x174ml





PKU Express 20 powder, lemon, 30x34g sachet



25

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





PKU Express 20 powder, orange, 30x34g sachet





PKU Express 20 powder, tropical, 30x34g sachet





PKU Express 20 powder, unflavored, 30x34g sachet





PKU Express15 Lemon, powder, 30x25g sachets





PKU Express15 Orange, powder, 30x25g sachets





PKU Express15 Tropical, powder, 30x25g sachets





PKU Express15 Unflavored, powder, 30x25g sachets





PKU Gel Orange, powd, 30x24g sachets





PKU Gel Raspberry, powd, 30x24g sachets





PKU Gel, powder, Unflavored, 30x24g sachets





PKU Trio, powd, unflavored, 400g





PKU Trio, powd, vanilla, 400g



Metabolic Propionic and methylmalonic acidemias


PROPIMEX-1 14.1OZ (400G) PWD 6CT

For patients with organic acidemia disorders; AND For patients 0-3 years of age




PROPIMEX-1 14.1OZ PWD 6CT

For patients with organic acidemia disorders; AND For patients 0-3 years of age




PROPIMEX-2 14.1OZ (400G) PWD 6CT

For patients with organic acidemia disorders; AND For patients 1+ years of age




PROPIMEX-2 UNFL 14.1OZ (400G) PWD 6CT

For patients with organic acidemia disorders; AND For patients 1+ years of age

4.10 0.30 70074067061 70074670614 70074670607 0.1626 0.1642 January 1, 2021 Added



Promactin AA Plus, berry flavor, 30x250ml

For use in individuals 1+ years of age with a clinical diagnosis of organic acidemias




OA 1 powd, 454g For patients with organic acidemia disorders; AND For patients 0-12 months of age




OA 2 powd, 454g For patients with organic acidemia disorders; AND For patients 1+ years of age


Metabolic Protein-free diet Abbott Nutrition; 1-800-227-5767

PRO-PHREE 14.1OZ (400G) PWD 6CT

For patients with a metabolic condition requiring additional calories, minerals, and vitamins and protein free diet; AND For patients 0-3 years of age


Metabolic Protein-free diet Abbott Nutrition; 1-800-227-5767

PRO-PHREE 14.1OZ PWD 6CT

For patients with a metabolic condition requiring additional calories, minerals, and vitamins and protein free diet; AND For patients 0-3 years of age


26

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml



Metabolic Protein-free diet Mead Johnson & Company, LLC; 1-800-457-3550

PFD 2 powd, 454g For patients with an amino acid metabolic disorder requiring a protein-free diet.


Metabolic Protein-free diet Mead Johnson & Company, LLC; 1-800-457-3550

PFD Toddler powd, 454g

For patients with an amino acid metabolic disorder requiring a protein-free diet.


Metabolic Sulphite oxidase deficiency


SOD Anamix Early Years powd, 400g

For patients with suphite oxidase deficiency; AND For patients 0-3 years of age


Metabolic Tyrosinemia Abbott Nutrition; 1-800-227-5767

TYREX-1 14.1OZ (400G) PWD 6CT

For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 0-12 months of age



TYREX-1 14.1OZ PWD 6CT

For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 0-12 months of age



TYREX-2 14.1OZ (400G) PWD 6CT

For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 1+ years of age



TYREX-2 UNFL 14.1OZ (400G) PWD 6CT


4.10 0.30 70074067065 70074670652 70074670645 0.1626 0.1642 January 1, 2021 Added

Metabolic Tyrosinemia Mead Johnson & Company, LLC; 1-800-457-3550

TYROS 1 powd, 454g For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 0-12 months of age


Metabolic Tyrosinemia Mead Johnson & Company, LLC; 1-800-457-3550

TYROS 2 powd, 454g For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 1+ years of age


Metabolic Tyrosinemia Nutricia North America; 1-800-365-7354

TYR Anamix Early Years powd, 400g

For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 0-3 years of age



TYR Anamix Next, 400g, powder




TYR Lophlex LQ, mixed berry, (30x125ml)



Metabolic Tyrosinemia Vitaflo, USA LLC; 1-888-548-2356

TYR Cooler 15 Orange, 30x130ml




TYR Cooler 15 Red, 30x130ml




TYR Express 20 powder, unflavored, 30x34g sachet




TYR Express15, powder, unflavored, 30x25g sachets




TYR Gel , powder, unflavored, 30x24g sachets

For patients with a diagnosis of Tyrosinemia or PKU; AND For patients 1-10 years of age


Metabolic Urea cycle disorders (UCD)


CYCLINEX-1 14.1OZ (400G) PWD 6CT

For patients 0-12 months with a diagnosis of UCD 5.10 0.08 70074051145 70074511450 70074511443 0.0388 0.0404 January 1, 2021 Updated MAC and EAC amounts



CYCLINEX-1 14.1OZ PWD 6CT

For patients 0-12 months with a diagnosis of UCD 5.10 0.08 70074067033 070074670331 070074670324 0.0388 0.0404 January 1, 2021 Updated MAC and EAC amounts



CYCLINEX-2 14.1OZ (400G) PWD 6CT

For patients 1+ years of age with a diagnosis of UCD 4.40 0.15 70074051147 070074511474 070074511467 0.0907 0.0923 January 1, 2021 Updated MAC and EAC amounts

27

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml





CYCLINEX-2 UNFL 14.1OZ (400G) PWD 6CT

For patients 1+ years of age with a diagnosis of UCD 4.40 0.15 70074067035 70074670355 70074670348 0.0907 0.0923 January 1, 2021 Added



WND 1 powd, 454g For patients 0-3 years of age with a diagnosis of UCD 5.00 0.07 00087510205 300875102053 300875102060 0.0381 0.0397 January 1, 2021 Updated MAC and EAC amounts



WND 2 powd, 454g For patients 1+ years of age with a diagnosis of UCD 4.10 0.08 00087510029 300875100295 300875101155 0.0882 0.0898 January 1, 2021 Updated MAC and EAC amounts



UCD Anamix Junior powder, Unflavored, 400g




UCD Anamix Junior powder, Vanilla, 400g




UCD Trio, powd, unflavored, 400g

For patients 1+ years of age with a diagnosis of UCD 3.93 0.15 50600051820 none 5060014051820 0.1365 0.1381 January 1, 2021 Updated MAC and EAC amounts

Metabolic Urea cycle disorders (UCD) or protein metabolism disorder


EAA Supplement, powd, tropical, 50x12.5g sachets

For patients 3+ years of age with a diagnosis of UCD or protein metabolism disorders


Elemental and Semi-Elemental

Peptide-based, calorie-dense, GI intolerance


Vital 1.5 Cal, 1L ready to hang

For patients demonstrating they require specialized omega-3 fatty acids





Vital 1.5 Cal, 8 oz recloseable container




Amino acid- based pediatric formula, impaired GI function, low fat


Vivonex Pediatric,unflavored, 36x 48.5g

Patient must try and fail two other peptide-based products on the covered list or has a contraindication to all age-appropriate peptide-based products on the covered list; AND Patient has impaired GI function and requires a specialized formula with lower fat; AND Patients 1-13 years of age



Amino acid-based pediatric formula


EleCare Junior 400g, Unflavored, powder

Patient must try and fail two other peptide-based products on the covered list or has a contraindication to all age-appropriate peptide-based products on the covered list; AND Patient is 1+ years of age





EleCare Junior, Banana 400g powder






EleCare Junior, Chocolate 400g powder






EleCare Junior, Vanilla, 400g powder






EquaCare Jr 400g, Choc, Powder


4.69 0.14 24359081308 324359813082 324359813105 0.0652 0.0668 January 1, 2021 Added




EquaCare Jr 400g, Unflavored, Powder


4.69 0.14 24359081108 324359811088 324359801101 0.0652 0.0668 January 1, 2021 Added




EquaCare Jr 400g, Vanilla, Powder


4.69 0.14 24359081208 324359812085 324359812108 0.0652 0.0668 January 1, 2021 Added

28

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml






Essential Care Jr, 400g, Citrus, Powder


4.76 0.19 24359080408 324359804080 324359804103 0.0869 0.0885 January 1, 2021 Added




Essential Care Jr, 400g, Unflavored, Powder


4.76 0.19 24359080108 324359801089 324359801102 0.0869 0.0885 January 1, 2021 Added




Essential Care Jr, 400g, Vanilla, Powder


4.76 0.19 24359080208 324359802086 324359802109 0.0869 0.0885 January 1, 2021 Added




Essential Care Jr, 400g, White Chocolate, Powder


4.76 0.19 24359080308 324359803083 324359803106 0.0869 0.0885 January 1, 2021 Added




PurAmino Jr Powder, 400g, unflavored






PurAmino Jr Powder, 400g, vanilla






Alfamino Junior, unflav powder, 6x400g

Patient must try and fail two other peptide-based products on the covered list or has a contraindication to all age-appropriate peptide-based products on the covered list; AND Patient has tried and failed other amino-acid based pediatric formulas on this covered list; AND Patient is 1+ years of age





Neocate Junior with Prebiotics, strwbry 400g powder






Neocate Junior with Prebiotics, unflav 400g






Neocate Junior with Prebiotics, vanilla 400g






Neocate junior without Prebiotics, unflavored 400g powder






Neocate junior, with Prebiotics, chocolate 400g, powder






Neocate junior, with Prebiotics, tropical 400g powder






Neocate Splash, 237ml, Grape

For patients 1+ years of age 1.00 0.03 49735012435 749735024355 749735124352 0.0219 0.0235 January 1, 2021 Updated MAC and EAC amounts




Neocate Splash, 237ml, Orange Pineapple





Neocate Splash, 237ml, Tropical Fruit


29

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml






Neocate Splash, unflav, 237ml



Amino acid-based formula, impaired GI function, low fat


Tolerex, unflavored, 60x 80g packets

Patient must try and fail two other peptide-based products on the covered list or has a contraindication to all age-appropriate peptide-based products on the covered list; AND Patient has impaired GI function and requires a specialized formula with lower fat





Vivonex Plus, unflavored, 36x 79.5g

Patient must try and fail two other peptide-based products on this List OR has a contraindication to all age-appropriate peptide-based products; AND Patient has impaired GI function and requires a specialized formula with lower fat





Vivonex RTF 250ml, unflavored, 24x250ml

Patient has impaired GI function and requires a specialized formula with lower fat





Vivonex RTF 6x1000ml

Patient has impaired GI function and requires a specialized formula with lower fat





Vivonex T.E.N.unflavored, 60x 80.5g

Patient must try and fail two other peptide-based products on the covered list or has a contraindication to all age-appropriate peptide-based products on the covered list; AND Patient has impaired GI function and requires a specialized formula with lower fat



Peptide based, GI intolerance


Vital 1.0 Cal, 8 oz recloseable container






Vital 1.0 Cal, 1L ready to hang






Vital AF 1.2 Cal, 1L ready to hang






Vital AF 1.2 Cal, 8 oz recloseable container






Peptamen AF Unflav 24x250ml






Peptamen AF, 6x1000ml ultrapak bags




Peptide based, high protein, low fat, GI intolerance


Vital HP 1L ready to hang, unflavored




Peptide based, high protein, low fat, GI intolerance


Vital HP, unflavored, 8 ozl recloseable container




Peptide-based formula


Peptamen Unflav 24x250ml





Peptamen with Prebio, 6x1000ml Ultrapak bags

Patient is tube-fed only 1.00 0.04 98716012804 00798716128049 10798716228043 0.0233 0.0249 January 1, 2021 Updated MAC and EAC amounts




Peptamen with Prebio, Vanilla, 24x 250ml


30

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




Peptide-based formula for BMI>30


Peptamen Intense VHP, 6x1000ml ultrapak bags

For patients with a BMI >30, critically ill, tube-fed only; AND A two-month maximum authorization term applies.



Peptide-based formula for BMI>30


Peptamen Intense VHP, unflavored, 24x 250ml

For patients with a BMI >30, critically ill, tube-fed only; AND A two-month maximum authorization term applies.



Peptide-based pediatric formula


PediaSure Peptide 1.0 Cal 1000ml, unflavored, ready to hang





PediaSure Peptide 1.0 Cal 1000ml, Unflavored, ready to hang





PediaSure Peptide 1.0 Cal 237ml, Strawberry btl





PediaSure Peptide 1.0 Cal 237ml, unflavored btl





PediaSure Peptide 1.0 Cal 237ml, Vanilla btl





PediaSure Peptide 1.0 Cal, 237ml Strawberry, Btl





PediaSure Peptide 1.0 Cal, 237ml Vanilla, Btl





PediaSure Peptide 1.0 Cal, 237ml, Unflavored, Btl





Peptamen Junior Fiber Van 24x250ml





Peptamen Junior Strawb 24x 250ml





Peptamen Junior Unflav 24x 250ml





Peptamen Junior Van 24x 250ml





Peptamen Junior with Prebio, Vanilla, 24x250ml



Peptide-based pediatric formula with probiotics


Nutramigen Enflora LGG Toddler Powder,357 g

For patients 1-3 years of age 4.80 0.12 00087510734 300875107348 300875107355 0.0788 0.0804 January 1, 2021 Added


Peptide-based, calorie-dense formula


Peptamen 1.5 Unflav, 24x250ml

For patients not effectively managed by lower-calorie peptide-based products on the covered list.





Peptamen 1.5 Vanilla, 24x 250ml

For patients not effectively managed by lower-calorie peptide-based products on the covered list; AND For patients 1-13 years of age.





Peptamen 1.5 with Prebio, 6x 1000ml






Peptamen 1.5 with Prebio, Vanilla, 24x 250ml



31

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml






Peptamen 1.5, 6x1000ml Ultrapak bags






Vital Peptide 1.5, vanilla, 8 oz recloseable container

For patients 14-18 years of age transitioning from PediaSure Peptide 1.0



Peptide-based, calorie-dense, pediatric formula


PediaSure Peptide 1.5 Cal 1000ml, vanilla, ready to hang






PediaSure Peptide 1.5 Cal 1000ml, Vanilla, ready to hang






PediaSure Peptide 1.5 Cal, 237ml Vanilla, Btl






PediaSure Peptide 1.5 Cal, Vanilla, 237ml btl






Peptamen Junior 1.5 Unflav 24x250ml






Peptamen Junior 1.5 Vanilla 24x250ml


1.50 0.05 98716070482 0098716704824 00098716855359 0.0320 0.0336 January 1, 2021 Added




Peptamen Junior HP, Very Vanilla, 24x 250ml

For patients 1-13 years of age. 1.20 0.05 43900046768 00043900467689 00043900544588 0.0276 0.0292 January 1, 2021 No Change


Peptide-based, plant- based formula


Liquid Hope Peptide, unflavored, 341g

1.47 0.07 57858000428 857858004281 10857858004288 0.0301 0.0317 January 1, 2021 Added


Peptide-based, plant- based pediatric formula

Kate Farms, Inc.; 1-805-845-2446

Kate Farms Pediatric Peptide 1.0, vanilla, 250ml

For patients 1-13 years of age 1.00 0.04 11112003052 811112030522 811112030539 0.0227 0.0243 January 1, 2021 Added


Peptide-based, plant- based, calorie-dense formula

Kate Farms, Inc.; 1-805-845-2446

Kate Farms Peptide 1.5 plain, 325ml




Peptide-based, plant- based, calorie-dense formula


COMPLEAT® PEPTIDE 1.5 Cal, Unflavored 24 x 250mL carton


1.50 0.05 43900040722 00043900407227 00043900762838 0.0308 0.0324 January 1, 2021 Added


Peptide-based, plant- based, calorie-dense pediatric formula


Nourish Peptide, unflavored, 341g

For patients 1-13 years of age. 1.52 0.05 57858000427 857858004274 10857858004271 0.0301 0.0317 January 1, 2021 Added



Kate Farms, Inc.; 1-805-845-2446

Kate Farms Pediatric Peptide 1.5 vanilla, 250ml






COMPLEAT® PEDIATRIC PEPTIDE 1.5 Cal, Unflavored 24 x 250mL carton


1.50 0.05 43900076469 00043900764696 00043900131351 0.0308 0.0324 January 1, 2021 Added


Peptide-based, tube- fed formula for acute care


Impact Peptide 1.5 1000ml

For tube-fed patients not effectively managed by lower calorie peptide-based products on the covered list; AND are immediate post-surgery, are recently post- trauma, or metabolic stressed



Peptide-based, tube- fed formula for acute care


Impact Peptide 1.5, unflavored, 24x 250ml

For tube-fed patients not effectively managed by lower calorie peptide-based products on the covered list; AND are immediate post-surgery, are recently post- trauma, or metabolic stressed



Tube-fed Only, peptide-based


Perative, unflavored, 1L ready to hang

Patient is tube-fed only 1.30 0.07 70074062724 070074627243 070074627236 0.0123 0.0139 January 1, 2021 No Change


Tube-fed Only, peptide-based


Perative, unflavored, 8oz, recloseable carton

Patient is tube-fed only 1.30 0.07 70074064815 070074648156 070074648163 0.0123 0.0139 January 1, 2021 No Change

32

Product Category


Protein per g or

ml)

NDC Billing Code


Only)


MAC per gm or ml

EAC per gm or ml




Tube-fed Only, peptide-based, calorie-dense, high protein formula


Pivot 1.5 Cal, unflavored, 1L ready to hang

Patient requires higher protein; AND Patient is metabolically stressed, tube-fed only



Tube-fed Only, peptide-based, calorie-dense, high protein formula


Pivot 1.5 Cal, unflavored, 8oz, recloseable container

Patient requires higher protein; AND Patient is metabolically stressed, tube-fed only


33

Deletions

Manufacturer Product Label Name NDC Billing Code UPC Number per Item (For Reference Only)


Effective Date of Deletion

Mead Johnson Nutrition EnfaCare powder 22cal, 363g 00087001944 300870019448 300870019042 1/1/2021 Mead Johnson Nutrition Enfamil EnfaCare Nursette 22cal, 59ml 00087139041 300871390416 300871390010 1/1/2021 Mead Johnson Nutrition Nutramigen RTU liquid, 237ml 00087510246 300875102466 300875102473 1/1/2021 Mead Johnson Nutrition Enfamil EnfaCare RTU 22cal, 237ml 00087510298 300875102985 300875102992 1/1/2021 Mead Johnson Nutrition PurAmino Toddler Powder, 400g 00087511732 300875117323 300875117330 1/1/2021 Cambrooke Therapeutics Camino Pro PKU, Pina Colada, 28x140ml 24359030103 804795310012 none 1/1/2021 Cambrooke Therapeutics Camino Pro PKU, fruit punch, 28x140ml 24359030203 804795310029 none 1/1/2021 Cambrooke Therapeutics Camino Pro MSUD, fruit punch, 28x140ml 24359060203 804795610020 None 1/1/2021 Nestlé HealthCare Nutrition Boost Compact Complete, Rich Chocolate, 24x120ml 41679051571 041679515716 00043900100036 1/1/2021 Nestlé HealthCare Nutrition Boost Compact Complete, Very Vanilla, 24x120ml 41679051663 00041679516638 00043900100043 1/1/2021 Nutricia North America EO28 Splash, orange pineapple 237ml 49735011050 749735010501 749735110508 1/1/2021 Nutricia North America Pepdite Junior, Unflavored 51g each 49735011766 749735017661 749735117668 1/1/2021 Nutricia North America EO28 Splash, tropical fruit 237ml 49735012666 749735026663 749735126660 1/1/2021 Nutricia North America EO28 Splash, grape 237ml 49735012670 749735026700 749735126707 1/1/2021 Nutricia North America Monogen, 400g 49735017097 749735097083 749735170977 1/1/2021 Nutricia North America XLys, XTrp Maxamaid powd, 454g 49735017780 749735023594 749735177808 1/1/2021 Nutricia North America MSUD Maxamaid powd, orange 454g 49735017781 749735023600 749735177815 1/1/2021 Nutricia North America XMTVI Maxamaid powd, 454g 49735017785 749735023617 749735177853 1/1/2021 Nutricia North America XPhe, XTyr Maxamaid powd, 454 g 49735017786 749735023624 749735177860 1/1/2021 Nutricia North America XMet Maxamaid powd, 454 g 49735017787 749735023631 749735177877 1/1/2021 Nutricia North America XPhe Maxamaid powd, orange, 454g 49735017792 749735023570 749735177921 1/1/2021 Nutricia North America XPhe Maxamaid powd, unflav, 454g 49735017793 749735023587 749735177938 1/1/2021 Vitaflo PKU Gel, powder, Unflavored, 30x24g sachets 50600051448 none 812539020226 1/1/2021 Vitaflo PKU Gel Raspberry, powd, 30x24g sachets 50600051455 none 812539020264 1/1/2021 Vitaflo PKU Gel Orange, powd, 30x24g sachets 50600051462 none 812539020240 1/1/2021 Vitaflo HCU Gel, powd, unflav, 30x24g sachets 50600051486 none 812539020035 1/1/2021 Vitaflo MSUD Gel, unflav, 30x24g sachets 50600051493 none 812539020042 1/1/2021 Vitaflo TYR Gel , powder, unflavored, 30x24g sachets 50600051509 none 812539020691 1/1/2021 Vitaflo GA Gel, unflav, powd, 30x24g sachets 50600051516 none 812539020059 1/1/2021 Vitaflo MMA/PA Gel, unflav, powder, 30x24g sachets 50600051523 none 812539020066 1/1/2021 Vitaflo Lysine4000 Amino Acid Supplement, unflav, powser, 30x5.6g sachets 50600054449 none 812539021056 1/1/2021 Vitaflo Carbzero, unflavored, 18x250mL 50600057845 none 812539021643 1/1/2021 Kate Farms, Inc. Core Essentials Pediatric Peptide 1.5 plain, 250ml 51823000686 851823006867 811112030089 1/1/2021 Kate Farms, Inc. Core Essentials Pediatric Peptide 1.5 chocolate, 250ml 51823000688 851823006881 811112030096 1/1/2021 Kate Farms, Inc. Core Essentials Pediatric Standard Formula 1.2, plain, 250ml 51823000689 851823006898 811112030102 1/1/2021 Kate Farms, Inc. Core Essentials Pediatric Standard Formula 1.2, chocolate, 250ml 51823000691 851823006911 811112030119 1/1/2021 Solace Nutrition, LLC CYTO ARG, 300g, unflavored, powder 57771000118 none 857771001183 1/1/2021 Abbott Nutrition Jevity 1 Cal, unflavored, 237ml 70074040143 070074401430 070074001432 1/1/2021 Abbott Nutrition Pulmocare 237mL - Vanilla 70074040699 70074406992 70074006994 1/1/2021 Abbott Nutrition Osmolite 1 Cal, unflavored, 237ml 70074040735 070074407357 070074007359 1/1/2021 Abbott Nutrition Glucerna 1.0 Cal 237mL, Ready-to-Drink, Vanilla 70074050241 70074502410 70074502403 1/1/2021 Abbott Nutrition Ensure Original, vanilla, 237ml 70074050461 070074504612 070074504605 1/1/2021 Abbott Nutrition Ensure Original, chocolate, 237ml 70074050463 070074504636 070074504629 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, vanilla, 237ml 70074050465 070074504650 070074504643 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, chocolate, 237ml 70074050467 070074504674 070074504667 1/1/2021 Abbott Nutrition Perative, unflavored, 237ml 70074050629 070074506296 070074506289 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, strawberry, 237ml 70074050647 070074506470 070074506463 1/1/2021 Abbott Nutrition Ensure Original, strawberry, 237ml 70074050649 070074506494 070074506487 1/1/2021 Abbott Nutrition Promote, vanilla, 237ml 70074050775 070074507750 070074507743 1/1/2021 Abbott Nutrition Promote Fiber, vanilla, 237ml 70074051873 070074518732 070074518725 1/1/2021 Abbott Nutrition Ensure Original, butter pecan, 237ml 70074051893 070074518930 070074518923 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, butter pecan, 237ml 70074051895 070074518954 070074518947 1/1/2021 Abbott Nutrition Jevity 1.2 Cal, unflavored, 237ml 70074053119 070074531199 070074531182 1/1/2021 Abbott Nutrition Osmolite 1.2 Cal, unflavored, 237ml 70074053121 070074531212 070074531205 1/1/2021

34




Abbott Nutrition PediaSure, vanilla, 237ml 70074053582 070074535821 070074535814 1/1/2021 Abbott Nutrition PediaSure Fiber, vanilla, 237ml 70074053586 070074535869 070074535853 1/1/2021 Abbott Nutrition PediaSure, chocolate, 237ml 70074053588 070074535883 070074535876 1/1/2021 Abbott Nutrition PediaSure, strawberry, 237ml 70074053590 070074535906 070074535890 1/1/2021 Abbott Nutrition Glucerna Therapeutic nutrition shake 237mL - Butter Pecan 70074054327 70074543277 70074543260 1/1/2021 Abbott Nutrition Glucerna Therapeutic nutrition shake 237mL - Vanilla 70074054329 70074543291 70074543284 1/1/2021 Abbott Nutrition Glucerna Therapeutic nutrition shake 237mL - Chocolate 70074054545 70074545455 70074545448 1/1/2021 Abbott Nutrition Glucerna Therapeutic nutrition shake 237mL- Strawberry 70074056053 70074560533 70074560526 1/1/2021 Abbott Nutrition Vital 1.0 Cal, vanilla, 237ml 70074056278 070074562780 070074562773 1/1/2021 Abbott Nutrition Vital 1.5 Cal ,vanilla, 237ml 70074056280 070074562803 070074562797 1/1/2021 Abbott Nutrition Vital AF 1.2 Cal, vanilla, 237ml 70074056543 070074565439 070074565422 1/1/2021 Abbott Nutrition Jevity 1.5 Cal, unflavored, 237ml 70074057334 070074573342 070074573335 1/1/2021 Abbott Nutrition Similac NeoSure 946 mL liquid 70074057455 070074574561 070074574554 1/1/2021 Abbott Nutrition Osmolite 1.5, unflavored, 237ml 70074057470 070074574707 070074574691 1/1/2021 Abbott Nutrition Similac Alimentum 946 mL liquid 70074057512 070074575131 070074575124 1/1/2021 Abbott Nutrition Similac Expert Care Alimentum 454 g pwdr) 70074057664 070074576640 070074576633 1/1/2021 Abbott Nutrition Pivot 1.5 Cal, unflavored, 237ml 70074058014 070074580142 070074580135 1/1/2021 Abbott Nutrition Ensure Original, chocolate, 237ml 70074058294 070074582948 070074582931 1/1/2021 Abbott Nutrition Ensure Original, strawberry, 237ml 70074058296 070074582962 070074582955 1/1/2021 Abbott Nutrition Ensure Original, vanilla, 237ml 70074058298 070074582986 070074582979 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, chocolate, 237ml 70074058300 070074583006 070074582993 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, strawberry, 237ml 70074058302 070074583020 070074583013 1/1/2021 Abbott Nutrition Ensure Plus 1.5cal, vanilla, 237ml 70074058304 070074583044 070074583037 1/1/2021 Abbott Nutrition Nepro with Carb Steady 237mL can) - Butter Pecan 70074062091 70074620916 70074620909 1/1/2021 Abbott Nutrition Nepro with Carb Steady 237mL can) - Mixed Berry 70074062093 70074620930 70074620923 1/1/2021 Abbott Nutrition Nepro with Carb Steady 237mL, Vanilla 70074062095 70074620954 70074620947 1/1/2021 Abbott Nutrition Nepro with Carb Steady 1000mL 70074062669 70074626703 70074626697 1/1/2021 Abbott Nutrition Glucerna 1.0 Cal 1000mL Cross Cap Ready-To-Hang 70074062671 70074626727 70074626710 1/1/2021 Abbott Nutrition Glucerna 1.0 Cal 1500mL Cross Cap Ready-To-Hang 70074062673 70074626741 70074626734 1/1/2021 Abbott Nutrition Glucerna 1.2 Cal1500mL Cross Cap Ready-To-Hang 70074062675 70074626765 70074626758 1/1/2021 Abbott Nutrition Glucerna 1.2 Cal 1000mL Cross Cap Ready-To-Hang 70074062677 70074626789 70074626772 1/1/2021 Abbott Nutrition Glucerna 1.5 cal 1000mL) Cross Cap Ready-To-Hang 70074062679 70074626802 70074626796 1/1/2021 Abbott Nutrition Vital 1.0 Cal, vanilla, 1000ml 70074062711 70074627120 70074627113 1/1/2021 Abbott Nutrition Vital 1.5 Cal, vanilla, 1000ml 70074062713 70074627144 70074627137 1/1/2021 Abbott Nutrition Vital AF 1.2 Cal, vanilla, 1000ml 70074062715 70074627168 70074627151 1/1/2021 Abbott Nutrition Pivot 1.5 Cal, unflavored, 1000ml 70074062719 70074627205 70074627199 1/1/2021 Abbott Nutrition Perative, unflavored, 1500ml 70074062721 70074627229 70074627212 1/1/2021 Abbott Nutrition Perative, unflavored, 1500ml 70074062722 70074627229 70074627212 1/1/2021 Abbott Nutrition Perative, unflavored, 1000ml 70074062723 70074627243 70074627236 1/1/2021 Abbott Nutrition Pulmocare 1000mL 70074062725 70074627267 70074627250 1/1/2021 Abbott Nutrition Vital High Protein 237 ml, unflavored 70074063120 70074631202 70074631196 1/1/2021 Abbott Nutrition Ensure High Protein for Muscle Health, chocolate, 237ml 70074064135 070074641355 070074641348 1/1/2021 Abbott Nutrition Ensure High Protein , vanilla, 237ml 70074064137 070074641379 070074641362 1/1/2021 Abbott Nutrition TwoCal HN, butter pecan, 237ml recloseable container 70074064804 070074648040 070074648064 1/1/2021 Abbott Nutrition Ensure High Protein for Muscle Health, chocolate, 237 ml recloseable container 70074064894 070074648941 070074648958 1/1/2021 Abbott Nutrition Ensure High Protein for Muscle Health, vanilla, 237 ml recloseable container 70074064896 070074648965 070074648989 1/1/2021 Abbott Nutrition PediaSure Grow & Gain with Fiber, vanilla, 237ml Bottle 70074067532 70074675329 70074675312 1/1/2021 Abbott Nutrition PediaSure Grow & Gain, vanilla, 237ml Bottle 70074067534 70074675343 70074675336 1/1/2021 Abbott Nutrition PediaSure Grow & Gain, chocolate, 237ml Bottle 70074067536 70074675367 70074675350 1/1/2021 Abbott Nutrition PediaSure Grow & Gain, strawberry, 237ml Bottle 70074067538 70074675381 70074675374 1/1/2021 Global Health Products, Inc. ProCel, 285 grams, powder, unflavored 82028000680 082028000803 082028006803 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 30 each, peach mango 82028003086 782028000862 782028030862 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 30 each, citrus orange 82028003091 782028000916 782028030916 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 30 each, concord grape 82028003095 782028000954 782028030954 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 30 each, watermelon 82028003097 782028000978 782028030978 1/1/2021 Global Health Products, Inc. ProCel, 750 grams, powder, vanilla 82028006100 782028001009 782028061009 1/1/2021

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Global Health Products, Inc. ProCel, 750 grams, powder, chocolate 82028006101 782028001012 782028061012 1/1/2021 Global Health Products, Inc. ProCel, 6.6 grams packet, powder, unflavored 82028010082 782028000824 782028100824 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 100 each, peach mango 82028010086 782028000862 782028100862 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 100 each, citrus orange 82028010091 782028000916 782028100916 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 100 each, concord grape 82028010095 782028000954 782028100954 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 100 each, watermelon 82028010097 782028000978 782028100978 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 100 each, lemonade 82028010116 782028001166 782028101166 1/1/2021 Global Health Products, Inc. LiquaCel, 30 ml, liquid packet x 30 each, lemonade 82028030116 782028001160 782028301160 1/1/2021 Nestlé HealthCare Nutrition Peptamen Junior 1.5 Unflav 6x 1000ml 98716008543 00798716085434 00798716185431 1/1/2021 Nestlé HealthCare Nutrition Peptamen Junior with Prebio,Chocolate, 24x 250ml 98716036415 798716364157 00798716364164 1/1/2021 Nestlé HealthCare Nutrition Peptamen Junior Unflav 6x1000ml ultrapak bags 98716067350 798716673501 00798716773607 1/1/2021

Documents

Medi-Cal Rx List of Covered Enteral Nutrition Products ......1.00 0.04 70074064632 070074646329 070074646336 0.0049 0.0065 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction;