ENTERAL PRODUCT CLASSIFICATION LIST DME Policy …

ENTERAL PRODUCT CLASSIFICATION LIST

The following list of enteral formulae is provided as a guideline for prescribers and dispensers. This is not an all-inclusive list, but is meant to assist providers in prescribing and determining the correct item code for billing.

For products not listed below, dispensers are to use their judgment in selecting the appropriate product coding classification based upon the prescriber's order, general categorical descriptions, and Medicaid coverage criteria (see DME Policy Guidelines at for coverage criteria).

Powdered, liquid, fiber-added, calcium-added and high protein forms of the same formula are billed under the same code. Special metabolic formulas categorized under B4157 should be billed using B4162 if provided to a pediatric patient.

Bolded Italicized products are subject to coverage by the Women, Infants and Children (WIC) program. WIC must be accessed prior to requests for Medicaid reimbursement.

PRODUCT 80056 Advera Alimentum Alitraq Powder Analog Formulas Arginine Amino Acid BCAD-1 BCAD-2 Boost Boost Kids Essentials Boost Diabetic(Glucose Control) Boost Plus Boost Pudding Bright Beginnings Soy Calcio XD

CODE B4155 B4154 B4161 B4153 B4162 B4155 B4162 B4157 B4150 B4160 B4154 B4152 B4150 B4160 B4162

PRODUCT CIB Lactose Free CIB Lactose Free Plus Casec Powder Choice DM Citrulline 1000 Amino Acid Compleat Compleat Pediatric Complete Amino Acid Comply Complex Essential MSD Complex MSUD AA Blend Complex MSUD Drink Mix Criticare-HN Crucial Cyclinex-1

CODE B4152 B4152 B4155 B4154 B4155 B4149 B4149 B4155 B4152 B4157 B4155 B4157 B4153 B4153 B4162

Revised 1/22/18

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PRODUCT Cyclinex-2 Cystine Amino Acid Deliver 2.0 Diabetisource AC Duocal EAA Egg/Pro EleCare Elemental 028 Extra Enfamil AR Ensure Ensure Plus Ensure Pudding Essential Amino Acid Fibersource HN GA GA Gel Glucerna Select/Shake Gluco-Pro Glutapak-10 Glutarex-1 Glutarex-2 Glutasolve Glutasorb Glytrol Good Start Soy

Revised 1/22/18

ENTERAL PRODUCT CLASSIFICATION LIST

CODE B4157 B4155 B4152 B4154 B4155 B4155 B4155 B4161 B4154 B4158 B4150 B4152 B4150 B4155 B4150 B4157 B4157 B4154 B4154 B4155 B4162 B4157 B4155 B4153 B4154 B4159

PRODUCT HCU Cooler HCU Express HCU Gel HCY 1 HCY 2 Hepatic-Aid Hominex-1 Hominex-2 HOM 1 HOM 2 Immunocal Imu-Plus Impact Impact 1.5 Impact Glutamine IntensiCal Isocal Isocal-HN Isoleucine Amino Acid Isoleucine 1000 Amino Acid Isomil Isosource 1.5 Isosource VHN Isosource-HN I-Valex-1 I-Valex-2

CODE B4157 B4157 B4155 B4162 B4157 B4154 B4162 B4157 B4155 B4155 B4155 B4155 B4154 B4154 B4153 B4153 B4150 B4150 B4155 B4155 B4159 B4152 B4154 B4150 B4162 B4157

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PRODUCT Jevity 1 Cal Jevity 1.2 Cal Jevity 1.5 Cal Juven K-PAX (tube feedings only) KetoCal Ketonex 1 Ketonex 2 Kindercal LactAid tablets Lactofree L-Emental L-Emental Pediatric Leucine Lipistart Lofenelac Lophlex LMD LPS 15/30 Magnacal Renal Maximaid formulas Maximum formulas MCT Oil MCT Procal Microlipid Modulen IBD

ENTERAL PRODUCT CLASSIFICATION LIST

CODE B4150 B4150 B4152 B4155 B4155 B4154 B4162 B4157 B4160 B9998 B4158 B4161 B4161 B4155 B4158 B4154 B4157 B4157 B4155 B4154 B4162 B4157 B4155 B4155 B4155 B4154

PRODUCT Monogen MMA/PA Gel MMA/PA Express MSUD Express MSUD Gel MSUD-2 Neocate Nepro Novasource Renal Nutramigen Nutra Pro Nutrassist Nutren Junior Nutren-1 Nutren-1.5 Nutren-2 Nutren Pulmonary NutriHeal Nutrihep NutriRenal Optimental OA 1 OA 2 OS 2 Osmolite Osmolite 1.2

Revised 1/22/18

CODE B4150 B4162 B4157 B4157 B4162 B4155 B4161 B4154 B4154 B4161 B4154 B4152 B4160 B4150 B4152 B4152 B4154 B4150 B4154 B4154 B4153 B4162 B4157 B4155 B4150 B4150

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PRODUCT Optimental OA 1 OA 2 OS 2 Osmolite Osmolite 1.2 Osmolite 1.5 Pediatric E028 Pediasure Pepdite One + Peptamen Peptamen 1.5 Diet Peptamen Jr Peptinex DT Peptinex Pediatric DT Perative Periflex PFD-1 PFD-2 Phenex 1 Phenex 2 PhenylAde Amino Acid PhenylAde Drink Mix PhenylAde Essential PhenylAde 40 PhenylAde 60

Revised 1/22/18

ENTERAL PRODUCT CLASSIFICATION LIST

CODE B4153 B4162 B4157 B4155 B4150 B4150 B4152 B4161 B4160 B4161 B4153 B4153 B4161 B4153 B4161 B4153 B4162 B4155 B4155 B4162 B4157 B4155 B4157 B4157 B4157 B4157

PRODUCT Phenylalalanine AA Phenylene Phenyl-Free 1 Phenyl-Free 2 Phenylfree 2HP Phlexy-10 Pivot 1.5 PKU PKU2 PKU3 PKU Cooler 10, 15, 20 PKU Express PKU Gel Polycose Portagen Pregestimil ProBalance ProCell Product 3232A ProMod Promote Pro-Phree Propimex 1 Propimex 2 Prosobee Pro-Stat

CODE B4155 B4157 B4162 B4157 B4157 B4157 B4153 B4155 B4155 B4155 B4157 B4162 B4162 B4155 B4158 B4161 B4150 B4155 B4161 B4155 B4150 B4155 B4162 B4157 B4159 B4155

Page 4 of 6

ENTERAL PRODUCT CLASSIFICATION LIST

PRODUCT Pro-Stat (Sugar Free) + AWC ProSource ProSure Protain XL Proteinex ProViMin Pulmocare Re-Gen Re-Gen Sugar-free Renalcal Replete Resource Arginaid Resource Diabetic Resource Glutasolve Resource Plus Resource 2.0 Respalor Ross Carbohydrate Free Scandi Shake Similac PM 60/40 Subdue Suplena Sustacal Sustagen Powder Sympt-X Glutamine Tolerex Traumacal

Revised 1/22/18

CODE B4155 B4155 B4155 B4154 B4155 B4155 B4154 B4154 B4154 B4154 B4150 B4155 B4154 B4155 B4152 B4152 B4154 B4155 B4152 B4154 B4153 B4154 B4150 B4150 B4155 B4153

B4154

PRODUCT TYR 1 TYR 2 TYR Cooler TYR Express TYR gel Tyrosine Tyrex-1 Tyrex-2 TYROS 2 UCD-1 UCD-2 Ultracal Ultracal HN Plus Valine Amino Acid Valine 1000 Amino Acid Vitaflo Flavor Packets Vital Jr Vital-HN Vitaneed Vivonex Pediatric Vivonex Plus Vivonex RTF Vivonex-TEN Sustagen Powder Sympt-X Glutamine Tolerex WND 1

CODE B4155 B4155 B4157 B4157 B4162 B4155 B4162 B4157 B4157 B4155 B4155 B4150 B4150 B4155 B4155 B9998 B4161 B4153 B4149 B4161 B4153 B4153 B4153 B4150 B4155 B4153 B4162

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TwoCal-HN

ENTERAL PRODUCT CLASSIFICATION LIST

B4152

WND 2

B4157

Use code B4100 #Food thickener, administered orally, per ounce for products such as Thick-It, Thick-n-Easy and Thicken-Up. A Dispensing Validation System (DVS) authorization number is required, obtained through the Medicaid Eligibility Verification System (MEVS). (For questions on obtaining a DVS authorization through MEVS, call Computer Science Corporation at 1-800-343-9000.)

Enteral formula requires voice interactive telephone prior authorization (1-866-211-1736). Only the prescriber can initiate an authorization. Dispensers are responsible for validating the prescriber's authorization matches the fiscal order and for correctly coding the product in the authorization system.

The Prescriber Worksheet is available by clicking the link below and choosing the Physician Manual, and then clicking the Provider Communications link. The Dispenser Worksheet is available by clicking the link below and choosing DME Manual, it is located at the bottom of P. 30.

Paper prior approval is required for code B9998, when the prescriber orders greater than 2000 calories per day for any combination of formula(s), or if over 1000 calories per day for code B4155 is needed.

Questions may be referred to the Division of OHIP Operations at 1-800-342-3005.

Revised 1/22/18

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