Medi-Cal Rx List of Covered Enteral Nutrition Products - California
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.
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 Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Manufacturer Product Label Name
Product-Specific Criteria
Abbott Nutrition; JEVITY 1 CAL 1500 For tube-fed only patients 1-800-227-5767 ML READY TO HANG
Abbott Nutrition; 1-800-227-5767 Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
JEVITY 1 CAL 1L READY TO HANG
JEVITY 1.0 CAL 8OZ RECLOSEABLE CARTON JEVITY 1.2 CAL 1.5L READY TO HANG
For tube-fed only patients
For patients who are tube-fed only or have altered taste perception For tube-fed only patients
Caloric density kcal/g or ml)
1.05
Protein per g or
ml)
NDC Billing Code
0.04 70074062688
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
070074626888
070074626871
1.05
0.04 70074062686 070074626864
1.05
0.04 70074064758 070074647586
070074626857 070074647593
1.20
0.06 70074062668 070074626680
070074626673
Abbott Nutrition; JEVITY 1.2 CAL 1L 1-800-227-5767 READY TO HANG
For tube-fed only patients
1.20
0.06 70074062684 070074626840
070074626833
Abbott Nutrition; JEVITY 1.2 CAL 8OZ For patients who are tube-fed only or have altered
1.20
1-800-227-5767 RECLOSEABLE
taste perception
CARTON
Nestl? HealthCare Fibersource HN
For tube-fed only patients
1.20
Nutrition;
SpikeRight Plus
1-888-240-2713 UltraPak 4x1500ml
Nestl? HealthCare Fibersource HN
For tube-fed only patients
1.20
Nutrition;
SpikeRight Plus
1-888-240-2713 UltraPak 6x1000ml
Nestl? HealthCare Fibersource HN,
For tube-fed only patients
1.20
Nutrition;
unflavored, 24x250ml
1-888-240-2713 Tetra Prisma
Nestl? HealthCare Nutren 1.0 Fiber
For tube-fed only patients
1.00
Nutrition;
unflavored, 24x250ml
1-888-240-2713 Tetra Prisma
Nestl? HealthCare Nutren 1.0, unflavored, For tube-fed only patients
1.00
Nutrition;
24x250ml Tetra
1-888-240-2713 Prisma
Nestl? HealthCare Replete Fiber
For tube-fed only patients
1.00
Nutrition;
SpikeRight 4x1500ml
1-888-240-2713
Nestl? HealthCare Replete Fiber
For tube-fed only patients
1.00
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 6x1000ml
Nestl? HealthCare Replete Fiber,
1.00
Nutrition;
unflavored, 24x250ml
1-888-240-2713 Tetra Prisma
Nestl? HealthCare Replete SpikeRight For tube-fed only patients
1.00
Nutrition;
PLUS UltraPak 6
1-888-240-2713 x1000ml
Nestl? HealthCare Replete, unflavored, For tube-fed only patients
1.00
Nutrition;
24x250ml Tetra
1-888-240-2713 Prisma
Caloric-restriction; high protein tubefeeding formula
Abbott Nutrition; 1-800-227-5767
OSMOLITE 1 CAL 1.5L READY TO HANG
For tube-fed patients requiring less than 2000 calories 1.00 per day or increased protein requirements
Caloric-restriction; Abbott Nutrition; OSMOLITE 1 CAL 1L For tube-fed patients requiring less than 2000 calories 1.00 high protein tube- 1-800-227-5767 READY TO HANG per day or increased protein requirements feeding formula
0.06 70074064624 070074646244
070074646251
0.05 43900018582 00043900185828 10043900185832
0.05 43900018588 00043900185880 10043900185887
0.05 43900018555 00043900185552 10043900185504
0.04 98716006056 00798716060561 00798716160568
0.04 98716006210 00798716062107 00798716162104
0.06 98716016359 00798716163590 10798716263594
0.06 98716016358 000798716163583 10798716263587
0.06 98716006245 00798716062459 00798716162456
0.06 98716016356 00798716163569 10798716263563
0.06 98716006249 00798716062497 00798716162494
0.04 70074062696 070074626963
070074626956
0.04 70074062692 070074626925
070074626918
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0048
0.0064 January 1, 2021 No Change
0.0048 0.0048
0.0064 0.0064
January 1, 2021 No Change January 1, 2021 No Change
0.0057 0.0057 0.0057 0.0060 0.0060 0.0058 0.0061
0.0073 0.0073 0.0073 0.0076 0.0076 0.0074 0.0077
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
0.0050 0.0060 0.0060 0.0057 0.0063 0.0061 0.0049 0.0049
0.0066 0.0076 0.0076 0.0073 0.0079 0.0077 0.0065 0.0065
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
1
Product Category Standard Standard Standard Standard Standard Standard Standard
Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Caloric-restriction; high protein tubefeeding formula Caloric-restriction; high protein tubefeeding formula Caloric-restriction; high protein tubefeeding formula Caloric-restriction; high protein tubefeeding formula Caloric-restriction; high protein tubefeeding formula Caloric-restriction; high protein tubefeeding formula Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Manufacturer
Abbott Nutrition; 1-800-227-5767
Product Label Name
Product-Specific Criteria
Caloric
density
kcal/g or ml)
OSMOLITE 1 CAL
For patients requiring less than 2000 calories per day
1.00
8OZ RECLOSEABLE or increased protein requirements
CARTON
Protein per g or
ml)
NDC Billing Code
0.04 70074064632
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
070074646329
070074646336
Abbott Nutrition; OSMOLITE 1.2 CAL For tube-fed patients requiring less than 2000 calories 1.20
1-800-227-5767 1.5L READY TO
per day or increased protein requirements
HANG
0.06 70074062694 070074626949
070074626932
Abbott Nutrition; OSMOLITE 1.2 CAL For tube-fed patients requiring less than 2000 calories 1.20 1-800-227-5767 1L READY TO HANG per day or increased protein requirements
0.06 70074062698 070074626987
070074626970
Abbott Nutrition; OSMOLITE 1.2 CAL For patients requiring less than 2000 calories per day
1.20
1-800-227-5767 8OZ RECLOSEABLE or increased protein requirements
CARTON
Abbott Nutrition; OSMOLITE 1.5 CAL For patients requiring less than 2000 calories per day
1.50
1-800-227-5767 1L READY TO HANG or increased protein requirements; AND
documentation showing patient is not maintained on a lower kcal/g or ml product
Abbott Nutrition; OSMOLITE 1.5 CAL For patients requiring less than 2000 calories per day
1.50
1-800-227-5767 8OZ RECLOSEABLE or increased protein requirements; AND
CARTON
documentation showing patient is not maintained on a lower kcal/g or ml product
Abbott Nutrition; ENSURE PLUS
For patients with documentation they have tried and
1.50
1-800-227-5767 BUTTER PECAN 8OZ failed lower kcal/ g or ml standard products on this List
RECLOSEABLE
OR require a calorie-dense, volume restricted diet
CARTON
Abbott Nutrition; ENSURE PLUS
For patients with documentation they have tried and
1.50
1-800-227-5767 CHOCOLATE 8OZ failed lower kcal/ g or ml standard products on this List
RECLOSEABLE CARTON
OR require a calorie-dense, volume restricted diet
Abbott Nutrition; ENSURE PLUS
For patients with documentation they have tried and
1.50
1-800-227-5767 STRAWBERRY 8OZ failed lower kcal/ g or ml standard products on this List
RECLOSEABLE CARTON
OR require a calorie-dense, volume restricted diet
Abbott Nutrition; ENSURE PLUS
For patients with documentation they have tried and
1.50
1-800-227-5767 VANILLA 8OZ
failed lower kcal/ g or ml standard products on this List
RECLOSEABLE CARTON
OR require a calorie-dense, volume restricted diet
Abbott Nutrition; JEVITY 1.5 CAL 1.5L For tube-fed only patients with documentation they
1.50
1-800-227-5767 READY TO HANG have tried and failed lower kcal/ g or ml standard
products on this List OR require a calorie-dense, volume restricted diet
Abbott Nutrition; JEVITY 1.5 CAL 1L For tube-fed only patients with documentation they
1.50
1-800-227-5767 READY TO HANG have tried and failed lower kcal/ g or ml standard
products on this List OR require a calorie-dense, volume restricted diet
Abbott Nutrition; JEVITY 1.5 CAL 8OZ For tube-fed OR taste-altered patients with
1.50
1-800-227-5767 RECLOSEABLE
documentation they have tried and failed lower kcal/ g
CARTON
or ml standard products on this List OR require a calorie-dense, volume restricted
Nestl? HealthCare Boost Plus Creamy For patients with documentation they have tried and
1.50
Nutrition;
Strawberry 27x237ml failed lower kcal/ g or ml standard products on this List
1-888-240-2713 Tetra Brik
OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Boost Plus Rich
For patients with documentation they have tried and
1.50
Nutrition;
Chocolate 27x237ml failed lower kcal/ g or ml standard products on this List
1-888-240-2713 Tetra Brik
OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Boost Plus, Creamy For patients with documentation they have tried and
1.50
Nutrition;
Strawberry 24x 237ml failed lower kcal/ g or ml standard products on this List
1-888-240-2713
OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Boost Plus, Rich
For patients with documentation they have tried and
1.50
Nutrition;
Chocolate, 24x 237ml failed lower kcal/ g or ml standard products on this List
1-888-240-2713
OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Boost Plus, Very
Nutrition;
Vanilla 27x237ml
1-888-240-2713 Tetra Brik
For patients with documentation they have tried and
1.50
failed lower kcal/ g or ml standard products on this List
OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Boost Plus, Very
For patients with documentation they have tried and
1.50
Nutrition;
Vanilla, 24x 237ml failed lower kcal/ g or ml standard products on this List
1-888-240-2713
OR require a calorie-dense, volume restricted diet
0.06 70074064634 070074646343
070074646350
0.06 70074062700 070074627007
070074626994
0.06 70074064835 070074648354
070074648378
0.05 70074064908 070074649085
070074649092
0.05 70074064910 070074649108
070074649115
0.05 70074064906 070074649061
070074649078
0.05 70074064904 070074649047
070074649054
0.06 70074062690 070074626901
070074626895
0.06 70074062682 070074626826
070074626819
0.06 70074064626 070074646268
070074646282
0.06 43900093338 00043900933382 10043900933310
0.06 43900093239 00043900932392 10043900932382
0.06 41679093366 00041679933008 00041679933367
0.06 41679093266 00041679932001 00041679932360
0.06 43900093139 00043900931395 10043900931385
0.06 41679093166 00041679931004 00041679931363
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0049 0.0058 0.0058 0.0058 0.0059 0.0059 0.0062
0.0065 0.0074 0.0074 0.0074 0.0075 0.0075 0.0078
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
0.0062 0.0062 0.0062 0.0063 0.0063 0.0063 0.0063 0.0063 0.0063 0.0063 0.0063 0.0063
0.0078 0.0078 0.0078 0.0079 0.0079 0.0079 0.0079 0.0079 0.0079 0.0079 0.0079 0.0079
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
2
Product Category Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense pediatric formula
Calorie-dense, high protein formula
Manufacturer Product Label Name
Product-Specific Criteria
Caloric
density
kcal/g or ml)
Nestl? HealthCare Nutren 1.5 SpikeRight For tube-fed only patients with documentation they
1.50
Nutrition;
PLUS UltraPak
have tried and failed lower kcal/ g or ml standard
1-888-240-2713 6x1000ml
products on this List OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Nutren 1.5, unflavored, For tube-fed only patients with documentation they
1.50
Nutrition;
24x250ml Tetra
have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Prisma
products on this List OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Nutren 2.0 SpikeRight For tube-fed only patients with documentation they
2.00
Nutrition;
PLUS UltraPak
have tried and failed lower kcal/ g or ml standard
1-888-240-2713 6x1000ml
products on this List OR require a calorie-dense, volume restricted diet
Nestl? HealthCare Nutren 2.0, unflavored, For tube-fed only patients with documentation they
2.00
Nutrition;
24x250ml Tetra
have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Prisma
products on this List OR require a calorie-dense, volume restricted diet
Abbott Nutrition; PEDIASURE 1.5 CAL For patients 1-13 years of age that have documented
1.50
1-800-227-5767 VANILLA 8OZ CAN they have tried and failed lower kcal/ g or ml standard
products on this List or require a calorie-dense, volume restricted diet;
Abbott Nutrition; PEDIASURE 1.5 CAL For patients 1-13 years of age that have documented
1.50
1-800-227-5767 VANILLA 8OZ CAN they have tried and failed lower kcal/ g or ml standard
products on this List or require a calorie-dense, volume restricted diet;
Abbott Nutrition; PEDIASURE FIBER For tube-fed patients 1-13 years of age with
1.50
1-800-227-5767 1.5 CAL 1L READY documentation they have tried and failed lower kcal/ g
TO HANG
or ml standard products on this List OR require a calorie-dense, volume restricted diet
Abbott Nutrition; PEDIASURE FIBER For tube-fed patients 1-13 years of age with
1.50
1-800-227-5767 1.5 CAL VANILLA 1L documentation they have tried and failed lower kcal/ g
READY TO HANG
or ml standard products on this List OR require a calorie-dense, volume restricted diet
Abbott Nutrition; PEDIASURE FIBER For patients 1-13 years of age that have documented
1.50
1-800-227-5767 1.5 CAL VANILLA 8OZ they have tried and failed lower kcal/ g or ml standard
CAN
products on this List or require a calorie-dense, volume restricted diet;
Abbott Nutrition; PEDIASURE FIBER For patients 1-13 years of age that have documented
1.50
1-800-227-5767 1.5 CAL VANILLA 8OZ they have tried and failed lower kcal/ g or ml standard
CAN
products on this List or require a calorie-dense, volume restricted diet;
Nestl? HealthCare Boost Kid Essentials For patients 1-13 years of age that have documented
1.52
Nutrition;
1.5, Creamy
they have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Strawberry Splash, products on this List or require a calorie-dense,
27x8fl oz, 237ml Tetra volume restricted diet; Brik
Nestl? HealthCare Boost Kid Essentials For patients 1-13 years of age that have documented
1.52
Nutrition;
1.5, Rich Chocolate they have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Craze, 27x8fl oz, 237ml Tetra Brik
products on this List or require a calorie-dense, volume restricted diet;
Nestl? HealthCare Boost Kid Essentials For patients 1-13 years of age that have documented
1.52
Nutrition;
1.5, Very Vanilla
they have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Vortex, 27x8fl oz, 237ml Tetra Brik
products on this List or require a calorie-dense, volume restricted diet;
Nestl? HealthCare Boost Kid Essentials For patients 1-13 years of age that have documented
1.52
Nutrition;
1.5, Very Vanilla
they have tried and failed lower kcal/ g or ml standard
1-888-240-2713 Vortex, Fiber 27x 8fl products on this List or require a calorie-dense, oz 237ml Tetra Brik volume restricted diet;
Nestl? HealthCare Boost VHC Very
For patients with documentation they have tried and
2.25
Nutrition;
Vanilla, 27x237ml
failed lower kcal/ g or ml standard products on this List
1-888-240-2713 Tetra Brik
OR require a calorie-dense, volume restricted diet
Protein per g or
ml)
NDC Billing Code
0.06 98716016354
0.06 98716006220
0.08 98716033147
0.08 98716006230
0.06 70074056410
0.06 70074067386
0.06 70074062750
0.06 70074067377
0.06 70074056412
0.06 70074067375
0.04 43900033590
0.04 43900033588 0.04 43900033540 0.04 43900033500 0.09 43900018215
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
00798716163545 10798716263549
00798716062206 00798716162203
00798716331470 00798716441469
00798716062305 00798716162302
070074564104
070074564098
070074673868
070074673783
070074627502
070074627496
070074673776
070074673769
070074564128
070074564111
070074673752
070074673745
00043900335902 10043900335992
00043900335889 10043900335886 00043900335407 10043900335442 00043900335001 10043900335008 00043900182155 10043900182169
Calorie-dense, high protein formula
Calorie-dense, high protein formula
Calorie-dense, high protein formula
Calorie-dense, high protein formula
Nestl? HealthCare Isosource 1.5 Cal
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 4x1500ml
Nestl? HealthCare Isosource 1.5 Cal
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 6x1000ml
Nestl? HealthCare Isosource 1.5
Nutrition;
unflavored, 24x250ml
1-888-240-2713 Tetra Prisma
Nestl? HealthCare Isosource HN
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 4x1500ml
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
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
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 For tube-fed only patients
1.50
0.07 43900018182 00043900181820 10043900281824
1.50
0.07 43900018181 00043900181813 10043900181810
1.50
0.07 43900018150 00043900181509 10043900181506
1.20
0.05 43900018466 00043900184661 10043900284665
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0066 0.0063 0.0069 0.0066 0.0085 0.0085 0.0086 0.0086 0.0085 0.0085 0.0085
0.0085 0.0085 0.0085 0.0073 0.0069 0.0069 0.0066 0.0060
0.0082 0.0079 0.0085 0.0082 0.0101 0.0101 0.0102 0.0102 0.0101 0.0101 0.0101
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
0.0101 0.0101 0.0101 0.0089 0.0085 0.0085 0.0082 0.0076
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
3
Product Category Standard Standard Standard
Standard
Standard
Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Manufacturer Product Label Name
Product-Specific Criteria
Calorie-dense, high Nestl? HealthCare Isosource HN
protein formula
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 6x1000ml
For tube-fed only patients
Caloric density kcal/g or ml)
1.20
Protein per g or
ml)
NDC Billing Code
0.05 43900018480
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
00043900184807 10043900184804
Calorie-dense, high Nestl? HealthCare Isosource HN,
protein formula
Nutrition;
unflavored, 24x250ml
1-888-240-2713 Tetra Prisma
For tube-fed only patients
1.20
0.05 43900018457 00043900184579 10043900184507
Calorie-dense, high Nestl? HealthCare Resource 2.0 Very
For patients with clinical documentation demonstrating
2.00
protein formula
Nutrition;
Vanilla Creme 27x they are not effectively managed by other formula on
1-888-240-2713 237ml
this List and require additional calories and protein;
kcal requirements (kcal/kg/day) must be documented
on each prior authorization request.
0.08 43900018010 00043900180106 10043900180103
Critical care formula Nestl? HealthCare IMPACT, SpikeRight For tube-fed patients with clinical documentation
1.00
Nutrition;
PLUS 6 x 1000 mL demonstrating they are not effectively managed by all
1-888-240-2713 UltraPak bags
other medically appropriate standard products on the
List AND who are immediate post-surgery or recently
post-trauma, or critical care
0.06 43900035818 00043900358185 10043900358182
Critical care formula Nestl? HealthCare IMPACT, Unflavored For tube-fed patients with clinical documentation
1.00
Nutrition;
24 x 250 mL Tetra demonstrating they are not effectively managed by all
1-888-240-2713 Prisma
other medically appropriate standard products on the
List AND who are immediate post-surgery or recently
post-trauma, or critical care
0.06 43900035810 00043900358109 10043900358106
High Protein
Abbott Nutrition; 1-800-227-5767
ENSURE ENLIVE CHOCOLATE 8OZ BTL
For patients requiring high protein diet. Clinical justification is required.
1.50
0.08 70074064284 070074642840
070074642833
High Protein
Abbott Nutrition; 1-800-227-5767
ENSURE ENLIVE STRAWBERRY 8OZ BTL
For patients requiring high protein diet. Clinical justification is required.
1.50
0.08 70074064282 070074642826
070074642819
High Protein
Abbott Nutrition; ENSURE ENLIVE 1-800-227-5767 VANILLA 8OZ BTL
For patients requiring high protein diet. Clinical justification is required.
1.50
0.08 70074064290 070074642901
070074642864
High Protein
Abbott Nutrition; PROMOTE 1500 ML For tube-fed patients; AND
1.00
1-800-227-5767 READY TO HANG Clinical documentation is required justifying the need
for a -very-high-protein formula
High Protein
Abbott Nutrition; PROMOTE 1L READY For tube-fed patients; AND
1.00
1-800-227-5767 TO HANG
Clinical documentation is required justifying the need
for a -very-high-protein formula
High Protein
Abbott Nutrition; PROMOTE FIBER For tube-fed patients; AND
1.00
1-800-227-5767 1.5L READY TO
Clinical documentation is required justifying the need
HANG
for a -very-high-protein formula
High Protein
Abbott Nutrition; PROMOTE FIBER 1L For tube-fed patients; AND
1.00
1-800-227-5767 READY TO HANG Clinical documentation is required justifying the need
for a -very-high-protein formula
High Protein
Abbott Nutrition; PROMOTE FIBER For patients with clinical documentation justifying the
1.00
1-800-227-5767 8OZ RECLOSEABLE need for a -very-high-protein formula
CARTON
High Protein
Abbott Nutrition; PROMOTE VANILLA For patients with clinical documentation justifying the
1.00
1-800-227-5767 8OZ RECLOSEABLE need for a -very-high-protein formula
CARTON
Plant-based formula Kate Farms, Inc.; Kate Farms Standard For patients with documentation they have tried and
1.40
1-805-845-2446 1.4, Plain, 325ml
failed lower kcal/ g or ml standard products on this List
OR require a calorie-dense, volume restricted diet
Plant-based formula Kate Farms, Inc.; Kate Farms Standard For patients with documentation they have tried and
1.40
1-805-845-2446 1.4, vanilla, 325ml failed lower kcal/ g or ml standard products on this List
OR require a calorie-dense, volume restricted diet
Plant-based formula Kate Farms, Inc.; Kate Farms Standard
1.00
1-805-845-2446 Liquid 1.0, chocolate, 325ml
Plant-based formula Kate Farms, Inc.; Kate Farms Standard
1.00
1-805-845-2446 Liquid 1.0, vanilla, 325ml
0.06 70074062708 070074627083 0.06 70074062702 070074627021 0.06 70074062706 070074627069 0.06 70074062704 070074627045 0.06 70074064629 070074646299 0.06 70074064833 070074648330 0.06 11112003001 811112030010 0.06 11112003042 811112030423 0.05 51823000664 851823006645 0.05 51823000663 851823006638
070074627076 070074627014 070074627052 070074627038 070074646312 070074648347 811112030027 811112030430 851823006690 851823006683
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0060 0.0058 0.0066
0.0076 0.0074 0.0082
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
0.0325
0.0341
January 1, 2021 Updated MAC and EAC amounts
0.0313
0.0329
January 1, 2021 Updated MAC and EAC amounts
0.0066 0.0066 0.0066 0.0052 0.0053 0.0052 0.0052 0.0052 0.0053 0.0085
0.0082 0.0082 0.0082 0.0068 0.0069 0.0068 0.0068 0.0068 0.0069 0.0101
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Added
0.0085
0.0101 January 1, 2021 Added
0.0061 0.0061
0.0077 0.0077
January 1, 2021 Updated Product Label Name
January 1, 2021 Updated Product Label Name
4
Product Category Standard Standard
Standard
Standard
Standard
Standard
Standard
Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Standard
Standard
Sub-Category Plant-based pediatric formula Tube-fed Only
Tube-fed Only
Tube-fed Only
Tube-fed Only
Tube-fed Only
Tube-fed Only
Volume-limited Volume-limited Volume-limited
Manufacturer Product Label Name
Product-Specific Criteria
Kate Farms, Inc.; Kate Farms Pediatric For patients 1-13 years of age 1-805-845-2446 Standard Formula 1.2,
vanilla, 250ml
Caloric density kcal/g or ml)
1.20
Protein per g or
ml)
NDC Billing Code
0.05 51823000690
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
851823006904
851823006997
Functional Formularies; 1-844-631-8365
Liquid Hope, unflavored, 341g
For patients who are tube-fed only and do not receive 1.32 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
0.07 57858000411 857858004113
10857858004110
Functional
Nourish, unflavored, For patients 1-13 years of age who are tube-fed only
1.17
Formularies;
341g
and do not receive ANY oral nutrition; AND
1-844-631-8365
documented failure to two other standard products on
this List; AND Not used as a convenience or alternative to blended food
Nestl? HealthCare Compleat Pediatric For patients 1-13 years of age who are tube-fed only
0.60
Nutrition;
Reduced Calorie,
and do not receive ANY oral nutrition; AND
1-888-240-2713 unflavored, 24x250ml documented failure to two other standard products on
Tetra Prisma
this List; AND Not used as a convenience or alternative to blended food
Nestl? HealthCare Compleat Pediatric, For patients 1-13 years of age who are tube-fed only
1.00
Nutrition;
unflavored, 24x250ml and do not receive ANY oral nutrition; AND
1-888-240-2713 Tetra Prisma
documented failure to two other standard products on
this List; AND Not used as a convenience or alternative to blended food
Nestl? HealthCare Compleat SpikeRight For patients who are tube-fed only and do not receive 1.06
Nutrition;
PLUS UltraPak
ANY oral nutrition; AND have documented failure to
1-888-240-2713 6x1000ml
two other standard products on this List; AND Not
used as a convenience or alternative to blended food
0.04 57858000412 857858004120
10857858004127
0.04 43900038074 00043900380742 10043900380749
0.04 43900014240 00043900142401 10043900142408
0.05 43900014180 00043900141800 10043900141807
Nestl? HealthCare Compleat, unflavored, For patients who are tube-fed only and do not receive 1.06
Nutrition;
24x250ml Tetra
ANY oral nutrition; AND have documented failure to
1-888-240-2713 Prisma
two other standard products on this List; AND Not
used as a convenience or alternative to blended food
0.05 43900014010 00043900140100 10043900140107
Abbott Nutrition; 1-800-227-5767
ENSURE COMPACT For patients requiring a volume-limited diet. Clinical
4OZ BOTTLE
justification is required.
CHOCOLATE
1.86
0.08 70074064363 070074643632
070074643625
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
ENSURE COMPACT 4OZ BOTTLE VANILLA
TWOCAL HN 1L READY TO HANG
For patients requiring a volume-limited diet. Clinical justification is required.
For tube-fed patients with clinical documentation justifying the need for a volume-restricted diet
1.86
0.08 70074064357 070074643571
2.00
0.08 70074062710 070074627106
070074643564 070074627090
Volume-limited Volume-limited Volume-limited
Abbott Nutrition; TWOCAL HN
For patients with clinical documentation justifying the
2.00
1-800-227-5767 BUTTER PECAN 8OZ need for a volume-restricted diet CAN
Abbott Nutrition; TWOCAL HN
For patients with clinical documentation justifying the
2.00
1-800-227-5767 VANILLA 8OZ CAN need for a volume-restricted diet
Abbott Nutrition; TWOCAL HN 1-800-227-5767 VANILLA 8OZ
For patients with clinical documentation justifying the
2.00
need for a volume-restricted diet
RECLOSEABLE CARTON
Abbott Nutrition; ENSURE ORIGINAL
4.39
1-800-227-5767 POWDER, 14.1OZ,
VANILLA
Abbott Nutrition; ENSURE ORIGINAL
4.39
1-800-227-5767 POWDER, 14.1OZ,
CHOCOLATE
Abbott Nutrition; ENSURE ORIGINAL
4.39
1-800-227-5767 POWDER, VANILLA
14OZ PWD 6CT
Abbott Nutrition; ENSURE ORIGINAL
0.93
1-800-227-5767 SHAKE, BUTTER
PECAN 8OZ
RECLOSEABLE CARTON
Abbott Nutrition; ENSURE ORIGINAL
0.93
1-800-227-5767 SHAKE, CHOCOLATE
8OZ RECLOSEABLE CARTON
Abbott Nutrition; ENSURE ORIGINAL
0.93
1-800-227-5767 SHAKE,
STRAWBERRY 8OZ
RECLOSEABLE CARTON
0.08 70074054065 070074540658 0.08 70074040729 070074407296 0.08 70074064807 070074648071 0.16 70074066854 070074668543 0.16 70074066850 070074668505 0.16 70074060750 070074607504 0.04 70074064934 070074649344
0.04 70074064936 070074649368
0.04 70074064932 070074649320
070074540641 070074007298 070074648095 070074668536 070074668499 070074007502 070074649351
070074649375
070074649337
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0073 0.0156
0.0089 0.0172
January 1, 2021 Updated Product Label Name
January 1, 2021 Added
0.0123
0.0139 January 1, 2021 Added
0.0109 0.0109 0.0130 0.0128 0.0110
0.0125
January 1, 2021 Updated MAC and EAC amounts
0.0125
January 1, 2021 Updated MAC and EAC amounts
0.0146
January 1, 2021 Updated MAC and EAC amounts
0.0144
January 1, 2021 Updated MAC and EAC amounts
0.0126 January 1, 2021 Added
0.0110 0.0062
0.0062 0.0062 0.0062
0.0126 January 1, 2021 Added
0.0078 0.0078
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
0.0078 0.0078
January 1, 2021 No Change January 1, 2021 No Change
0.0200 0.0200 0.0200 0.0050
0.0050
0.0050
0.0216 January 1, 2021 No Change
0.0216 January 1, 2021 No Change
0.0216 January 1, 2021 No Change
0.0066
January 1, 2021 Updated MAC and EAC amounts
0.0066
January 1, 2021 Updated MAC and EAC amounts
0.0066
January 1, 2021 Updated MAC and EAC amounts
5
Product Category Standard
Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Manufacturer Product Label Name
Product-Specific Criteria
Abbott Nutrition; 1-800-227-5767
ENSURE ORIGINAL SHAKE, VANILLA 8OZ RECLOSEABLE CARTON
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
PEDIASURE 1 CAL For patients 1-13 years of age VANILLA 8OZ CAN
PEDIASURE BANANA For patients 1-13 years of age 8OZ CAN
Abbott Nutrition; PEDIASURE BANANA For patients 1-13 years of age 1-800-227-5767 8OZ CAN
Abbott Nutrition; 1-800-227-5767
PEDIASURE CHOCOLATE 8OZ CAN
For patients 1-13 years of age
Abbott Nutrition; 1-800-227-5767
PEDIASURE CHOCOLATE 8OZ CAN
For patients 1-13 years of age
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
PEDIASURE ENT
For patients 1-13 years of age
VANILLA 8OZ CAN
PEDIASURE FIBER 1 For patients 1-13 years of age CAL 1L READY TO
HANG
Abbott Nutrition; 1-800-227-5767
PEDIASURE FIBER 1 For patients 1-13 years of age CAL VANILLA 1L READY TO HANG
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767 Abbott Nutrition; 1-800-227-5767 Abbott Nutrition; 1-800-227-5767
PEDIASURE FIBER 1 For patients 1-13 years of age
CAL VANILLA 8OZ CAN
PEDIASURE FIBER 1 For patients 1-13 years of age
CAL VANILLA 8OZ
CAN 24CT INST PEDIASURE FIBER
For patients 1-13 years of age
VANILLA 8OZ CAN
PEDIASURE FIBER For patients 1-13 years of age
VANILLA 8OZ CAN
PEDIASURE
For patients 1-13 years of age
REDUCED CALORIE
8OZ BOTTLES
Abbott Nutrition; 1-800-227-5767
Abbott Nutrition; 1-800-227-5767
PEDIASURE SIDEKICK VANILLA 8OZ BTL
PEDIASURE STRAWBERRY 8OZ CAN
For patients 1-13 years of age For patients 1-13 years of age
Abbott Nutrition; 1-800-227-5767
PEDIASURE STRAWBERRY 8OZ CAN
For patients 1-13 years of age
Abbott Nutrition; PEDIASURE VANILLA For patients 1-13 years of age 1-800-227-5767 8OZ CAN
Abbott Nutrition; PEDIASURE VANILLA For patients 1-13 years of age 1-800-227-5767 8OZ CAN
Nestl? HealthCare Boost High Protein,
Nutrition;
Rich Chocolate, 27x
1-888-240-2713 237ml
Nestl? HealthCare Boost High Protein,
Nutrition;
Very Vanilla, 24x
1-888-240-2713 237ml
Nestl? HealthCare Boost High Protein,
Nutrition;
Very Vanilla, 24x8fl
1-888-240-2713 oz, 237ml
Caloric density kcal/g or ml)
0.93
Protein per g or
ml)
NDC Billing Code
0.04 70074064930
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
070074649306
070074649313
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0050
0.0066
January 1, 2021 Updated MAC and EAC amounts
1.00
0.03 70074067402 070074674025
1.00
0.03 70074051885 070074518855
070074674018 070074518848
1.00
0.03 70074067528 070074675282
070074675275
1.00
0.03 70074051883 070074518831
070074518824
1.00
0.03 70074067524 070074675244
070074675237
1.00
0.03 70074051805 070074518053
1.00
0.03 70074062728 070074627281
070074518046 070074627274
1.00
0.03 70074067406 070074674063
070074674056
1.00
0.03 70074051807 070074518077
070074518060
0.0061 0.0061 0.0061 0.0061 0.0061 0.0061 0.0066 0.0066 0.0061
0.0077 0.0077 0.0077 0.0077 0.0077 0.0077 0.0082 0.0082 0.0077
January 1, 2021 No Change
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
1.00
0.03 70074067404 070074674049
070074674032
0.0061
0.0077 January 1, 2021 No Change
1.00
0.03 70074058221 070074582214
1.00
0.03 70074067530 070074675305
0.63
0.30 70074067613 070074676135
070074582207 070074675299 070074676128
0.0061 0.0061 0.0062
0.0077 0.0077 0.0078
January 1, 2021 No Change January 1, 2021 No Change January 1, 2021 No Change
0.63
0.03 70074056524 070074565248
1.00
0.03 70074051881 070074518817
070074565231 070074518800
1.00
0.03 70074067526 070074675268
070074675251
1.00
0.03 70074055898 070074558981
070074558974
1.00
0.03 70074067185 070074671857
070074675220
1.01
0.06 41679094066 00041679940006 00041679940365
1.01
0.06 41679094166 00041679941003 00041679941362
1.01
0.06 43900094139 00043900941394 10043900941391
0.0062 0.0061 0.0061 0.0061 0.0061 0.0061 0.0061 0.0061
0.0078 January 1, 2021 No Change
0.0077 0.0077 0.0077 0.0077 0.0077 0.0077 0.0077
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
6
Product Category Standard
Standard
Standard
Standard Standard
Standard Standard Standard Standard Standard Standard Standard Standard Standard Standard
Sub-Category
Manufacturer Product Label Name
Product-Specific Criteria
Nestl? HealthCare Boost Kid Essentials,
Nutrition;
Chocolate, Tetra
1-888-240-2713 Prisma 4-4 packs x
244ml
For patients 1-13 years of age
Nestl? HealthCare Boost Kid Essentials,
Nutrition;
Creamy Strawberry
1-888-240-2713 Splash, 27x8fl oz
237ml Tetra Brik
For patients 1-13 years of age
Nestl? HealthCare Boost Kid Essentials, For patients 1-13 years of age
Nutrition;
Rich Chocolate Craze,
1-888-240-2713 27x8fl oz 237ml Tetra
Brik
Nestl? HealthCare Boost Kid Essentials, For patients 1-13 years of age
Nutrition;
Vanilla, Tetra Prisma 4-
1-888-240-2713 4 packs x 244ml
Nestl? HealthCare Boost Kid Essentials,
Nutrition;
Very Vanilla Vortex,
1-888-240-2713 27x8fl oz 237ml Tetra
Brik
For patients 1-13 years of age
Nestl? HealthCare Boost Original
Nutrition;
Nutritional Drink Rich
1-888-240-2713 Chocolate 8oz 237ml
Nestl? HealthCare Boost Original
Nutrition;
Nutritional Drink
1-888-240-2713 Creamy Strawberry 8oz 237ml
Nestl? HealthCare Boost Original
Nutrition;
Nutritional Drink Very
1-888-240-2713 Vanilla 8oz 237ml
Nestl? HealthCare Boost, Creamy
Nutrition;
Strawberry, 27x237ml
1-888-240-2713 Tetra Brik
Nestl? HealthCare Boost, Rich Chocolate,
Nutrition;
27x237ml, Tetra Brik
1-888-240-2713
Nestl? HealthCare Boost, Very Vanilla,
Nutrition;
27x237ml Tetra Brik
1-888-240-2713
Nestl? HealthCare Nutren Junior Fiber
Nutrition;
unflav SpikeRight
1-888-240-2713 PLUS UltraPak 6x1000ml
Nestl? HealthCare Nutren Junior Fiber
Nutrition;
Vanilla 24x250ml
1-888-240-2713 Tetra Prisma
For tube-fed only patients 1-13 years of age For tube-fed only patients 1-13 years of age
Nestl? HealthCare Nutren Junior unflav
Nutrition;
SpikeRight PLUS
1-888-240-2713 UltraPak 6x1000ml
For tube-fed only patients 1-13 years of age
Nestl? HealthCare Nutren Junior Vanilla For tube-fed only patients 1-13 years of age
Nutrition;
24x250ml Tetra
1-888-240-2713 Prisma
Caloric density kcal/g or ml)
1.00
Protein per g or
ml)
NDC Billing Code
0.03 41679033261
UPC Number per Item (For Reference
Only)
UPC Number per Case (For Reference Only)
00041679332610 00041679339787
MAC per gm EAC per gm Effective Date of Description
or ml
or ml
Change
of Change
0.0061
0.0077
January 1, 2021 Updated MAC and EAC amounts
1.00
0.03 43900033530 043900335308
10043900335336
0.0061
0.0077
January 1, 2021 Updated MAC and EAC amounts
1.00
0.03 43900033520 00043900335209 10043900335220
0.0061
0.0077
January 1, 2021 Updated MAC and EAC amounts
1.00
0.03 41679033251 00041679332511 00041679339688
1.00
0.03 43900033511 00043900335117 10043900335114
0.0061 0.0061
0.0077 0.0077
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
1.00
0.04 41679067566 00041679675007 00041679675366
1.00
0.04 41679067666 00041679676004 00041679676363
1.00
0.04 41679067466 00041679674000 00041679674369
1.00
0.04 43900067638 00043900676388 10043900676392
1.00
0.04 43900067539 00043900675398 10043900675388
1.00
0.04 43900067439 00043900674391 10043900674381
1.00
0.03 98716067390 00798716673907 00798716774000
1.00
0.03 98716006063 00798716060639 00798716160636
0.0050 0.0050 0.0050 0.0050 0.0050 0.0050 0.0063 0.0061
0.0066 0.0066 0.0066 0.0066 0.0066 0.0066 0.0079 0.0077
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
1.00
0.03 98716067370 00798716673709 00798716773805
1.00
0.03 98716006062 00798716060622 00798716160629
0.0063 0.0061
0.0079 0.0077
January 1, 2021 Updated MAC and EAC amounts
January 1, 2021 No Change
Specialty Infant Amino Acid-based Nutricia North Neocate Syneo Infant, For patients 0-12 months of age with clinical
4.75
(100 percent)
America;
400g, powder,
documentation demonstrating they are not effectively
powder formula
1-800-365-7354 unflavored
managed by peptide-based formula
containing probiotics
Specialty Infant Amino Acid-based Abbott Nutrition; ELECARE IN 14.1OZ For patients 0-12 months of age with clinical
4.75
(100 percent)
1-800-227-5767 POWDER
documentation demonstrating they are not effectively
powder formula
managed by peptide-based formula
without probiotics
Specialty Infant Amino Acid-based Mead Johnson & PurAmino Powder, For patients 0-12 months of age with clinical
4.90
(100 percent)
Company, LLC; 400gm
documentation demonstrating they are not effectively
powder formula
1-800-457-3550
managed by peptide-based formula
without probiotics
0.14 49735011436 749735114360 0.15 70074053511 070074535111 0.14 00087510480 300875104804
749735014363 070074552514 300875104811
0.0963 0.0938 0.0912
0.0979
January 1, 2021 Updated MAC and EAC amounts
0.0954
January 1, 2021 Updated MAC and EAC amounts
0.0928
January 1, 2021 Updated MAC and EAC amounts
7
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