Enteral Nutrition List of Contracted Products enteral by jennyyingdi

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									                                                                                                               enteral
Enteral Nutrition: List of Available Products                                                                        1
This section contains information about enteral nutrition products and program coverage (Welfare &
Institutions Code, [W&I Code] Section 14105.8, and Section 14132 (ab))

Program Coverage                             Enteral nutrition products are separately covered for outpatients only,
                                             when supplied by a pharmacy provider upon the prescription of a
                                             licensed practitioner within the scope of his or her practice.
                                             Authorization is required for all products. Authorization is given when
                                             a patient is both Medi-Cal and medically eligible, and the product is
                                             used as a therapeutic regimen to prevent serious disability or death in
                                             patients with medically diagnosed conditions that preclude the full use
                                             of regular food.

                                             Enteral nutrition products provided to inpatients receiving inpatient
                                             hospital services are included in the hospital’s reimbursement made
                                             under California Code of Regulations (CCR), Title 22, Section 51536.
                                             These products are not separately reimbursable.

                                             Enteral nutrition products provided to inpatients receiving Nursing
                                             Facility Level A (NF-A) services or Nursing Facility Level B (NF-B)
                                             services are not separately reimbursable.

                                             Enteral nutrition products and infusion nutrients that are provided to
                                             patients during chronic outpatient hemodialysis in renal dialysis
                                             centers and community hemodialysis units, or for use during home
                                             dialysis, are not separately reimbursable. Pharmacies that furnish
                                             enteral nutrition or infusion nutrition products to these providers should
                                             bill the provider directly. See the section entitled Drugs Provided to
                                             Physicians, Hospital Emergency Rooms, Outpatient Clinics, or
                                             Nursing Facilities, for Dispensing or Administering, in the
                                             Reimbursement section of the Pharmacy Provider Manual.



Non-Coverage                                 The following items are not covered by Medi-Cal:

                                                     Regular food including solid, semi-solid, blenderized, and
                                                      pureed foods
                                                     Household items
                                                     Regular infant formula defined in the Federal Food, Drug and
                                                      Cosmetic Act (FD&CA) to meet the normal needs of healthy
                                                      infants, regardless of the route of administration, or reduced
                                                      iron content, or thickened form.
                                                     Shakes, cereals, thickened products, puddings, bars, gels, and
                                                      other non-liquid products
                                                     Thickeners
                                                     Tablets, caplets, gel caps, or thickened products for tube fed
                                                      patients
                                                     Any products for assistance with weight loss
                                                     Vitamin and/or mineral supplements, except for pregnancy, and
                                                      birth-5 years of age (See the Contract Drugs List section of this
                                                      manual for more information)


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Recipient Eligibility                        To receive authorization for reimbursement, a recipient must be
                                             eligible for Medi-Cal and meet other program and medical criteria on
                                             the date of service. Providers should verify a recipient’s eligibility for
                                             the date of service before dispensing products. Authorization
                                             requests for services to ineligible patients will be denied.



Other Health Coverage                        Refer to the Other Health Coverage (OHC) section of this manual for
                                             OHC billing information.



Medicare Covered Services                    Medicare covers some enteral nutrition products. When Medicare
                                             covers an item and the recipient is eligible for Medicare, providers
                                             must not bill Medi-Cal before billing Medicare. Additional information
                                             is included in Medicare/Medi-Cal Crossover Claims sections of this
                                             manual.

                                             Providers should contact the Medicare carrier for coverage and billing
                                             instructions.



Authorization                                All enteral nutrition products require Treatment Authorization
                                             Requests (TARs) or Service Authorization Requests (SARs). Product
                                             numbers approved on a TAR or SAR shall be the same product
                                             number dispensed and billed. Authorization for all enteral nutrition
                                             products is limited to a 31-day supply.

                                             Refer to the TAR Completion section of this manual for additional TAR
                                             information. TARs for Medi-Cal only patients must be submitted to the
                                             appropriate Medi-Cal field office. Refer to the TAR Field Office
                                             Addresses section in this manual for details.



Medical Criteria                             Pursuant to W&I Code, Section 14132, coverage is limited to
                                             products administered through a feeding tube (patients under
                                             Early Periodic Screening, Diagnosis, and Treatment Program
                                             (EPSDT) are exempt).

                                             Feeding tubes include a gastric, nasogastric, or jejunostomy tube.
                                             Only products solely administered through a feeding tube are covered.
                                             Products administered through a syringe or other device into the
                                             mouth or esophagus is not covered. See the Medical Supply
                                             Products: Miscellaneous section of the Pharmacy and Allied Health
                                             Provider Manuals for the feeding tubes codes and claim information.

                                             The Department deems an enteral nutrition product, not administered
                                             through a feeding tube a benefit for patients with diagnoses of
                                             malabsorption or inborn errors of metabolism (IEM) when published in
                                             this section, and if the product has been shown to be neither
                                             investigational nor experimental when used as part of a therapeutic
                                             regimen to prevent serious disability or death.

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Inborn Error of                              An IEM diagnosis must be documented by a licensed prescriber in the
Metabolism (IEM)                             medical record and limited to the following diagnosis codes. Only
                                             products included on the Metabolic Enteral Nutrition list are applicable
                                             for patients with a documented IEM.
                                             Note: Patients with documented, diagnosed Cystic Fibrosis
                                                   (diagnosis code 277.0 through 277.09) may be authorized for
                                                   medically necessary, oral enteral nutrition products other than
                                                   those on the Metabolic List, when the product is applicable to a
                                                   morbidity related to cystic fibrosis. All other inborn errors of
                                                   metabolism diagnoses eligible for oral enteral nutrition products
                                                   are restricted to the Metabolic Enteral Nutrition list in this
                                                   section.

       CODE             DIAGNOSIS: Inborn Errors of Metabolism (IEM)
       270              Disorders of amino-acid transport and metabolism
       270.0            Disturbances of amino-acid transport
       270.1            Phenylketonuria [PKU]
                        Definition: inherited metabolic condition causing excess phenylpyruvic and other acids in
                        urine; results in mental retardation, neurological manifestations, including spasticity and
                        tremors, light pigmentation, eczema, and mousy odor.
       270.2            Other disturbances of aromatic amino-acid metabolism
       270.3            Disturbances of branched-chain amino-acid metabolism
       270.4            Disturbances of sulphur-bearing amino-acid metabolism
       270.5            Disturbances of histidine metabolism
       270.6            Disorders of urea cycle metabolism
       270.7            Other disturbances of straight-chain amino-acid metabolism
       270.8            Other specified disorders of amino-acid metabolism
       270.9            Unspecified disorder of amino-acid metabolism
       271              Disorders of carbohydrate transport and metabolism
       271.0            Glycogenosis
                        Definition: excess glycogen storage; rare inherited trait affects liver, kidneys; causes various
                        symptoms depending on type, though often weakness and muscle cramps.
       271.1            Galactosemia
                        Definition: any of three genetic disorders due to defective galactose metabolism; symptoms
                        include failure to thrive in infancy, jaundice, liver and spleen damage, cataracts, and mental
                        retardation.
       271.8            Other specified disorders of carbohydrate transport and metabolism (lactose intolerance alone,
                        excluded)
       277              Other unspecified disorders of metabolism
       277.0            Cystic Fibrosis
                        Definition: genetic disorder of infants, children, and young adults marked by exocrine gland
                        dysfunction; characterized by chronic pulmonary disease with excess mucus production,
                        pancreatic deficiency, and high levels of electrolytes in the sweat.
       277.00           Without mention of meconium ileus
       277.01           With meconium ileus
       277.02           With pulmonary manifestations
       277.03           With gastrointestinal manifestations
       277.09           With other manifestations
       277.8            Other specified disorders of metabolism
       277.82           Carnitine deficiency due to inborn errors of metabolism
       277.85           Disorders of fatty acid oxidation
       277.86           Peroxisomal disorders
       277.87           Disorders of mitochondrial metabolism


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Intestinal Malabsorption                     An intestinal malabsorption diagnosis must be documented by a
                                             licensed prescriber in the medical record and is limited to the following
                                             diagnosis codes. Only elemental and semi-elemental products are
                                             applicable for patients with documented intestinal malabsorption, for
                                             the purposes of this policy.
                                             Note: Products not published to the list, but available for
                                                   consideration as benefits in the electronic payment system,
                                                   must contain primarily semi-elemental and elemental
                                                   macronutrients. For the purposes of this policy, no standard
                                                   enteral nutrition products nor other product categories
                                                   containing intact proteins, carbohydrates, and fats are indicated
                                                   for use in intestinal malabsorption.

                     CODE           DIAGNOSIS (Malabsorption)
                     579            Intestinal Malabsorption
                     579.0          Celiac disease
                                              crisis
                                              infantilism
                                              rickets
                                    Gee(-Herter) disease
                                    Gluten enteropathy
                                    Idiopathic steatorrhea
                                    Nontropical sprue
                                    Definition: Malabsorption syndrome due to gluten consumption; symptoms include
                                    fetid, bulky, frothy, oily stools; distended abdomen, gas, asthenia, electrolyte
                                    depletion and vitamin B, D and K deficiency.
                     579.1          Tropical sprue
                                             Sprue
                                             NOS
                                             Tropical
                                    Definition: Diarrhea, occurs in tropics; may be due to enteric infection and
                                    malnutrition.
                     579.2          Blind loop syndrome
                                    Postoperative blind loop syndrome
                                    Definition: Obstruction or impaired passage in small intestine due to alterations,
                                    from strictures or surgery; causes stasis, abnormal bacterial flora, diarrhea, weight
                                    loss, multiple vitamin deficiency, and megaloblastic anemia.
                                    TIP: do not assign additional code 997.4 Digestive system complications.
                     579.3          Other and unspecified postsurgical nonabsorption
                                    Hypoglycemia or Malnutrition {following gastrointestinal surgery}
                     579.4          Pancreatic Steatorrhea
                                    Definition: Excess fat in feces due to absence of pancreatic juice in intestine.
                     579.8          Other specified intestinal malabsorption
                                    Enteropathy:
                                             Exudative
                                             Protein-losing
                                    Steatorrhea (chronic)
                     579.9          Unspecified intestinal malabsorption (lactose intolerance alone, excluded)
                                    Malabsorption syndrome NOS (lactose intolerance alone, excluded)




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Documentation                                Authorization is required for all enteral nutrition products and must be
                                             accompanied by all of the following (no exceptions):

                                                     Patient diagnosis, related to the request for product coverage, as
                                                      documented in the medical record by the licensed prescriber

                                                      Note: Detailed description of patient diagnosis is required for
                                                            ICD-9-CM diagnosis codes that are unspecified.

                                                     Licensed prescriber’s expectation for patient duration of need
                                                     Patient age, height (or length) and weight
                                                     Patient’s other additional anthropometric, biochemical, clinical
                                                      and/or dietary indicators, related to the request for product
                                                      coverage
                                                     Patient specific caloric requirement, for one day of product intake
                                                     If tube fed, licensed prescriber’s rationale for the tube feeding
                                                      and type of tube used
                                                     Product 11-digit Medi-Cal identification number
                                                     Caloric density of product requested (kcal/ml or kcal/gm)
                                                     Package size of product requested (in milliliters or grams, must
                                                      match the 11-digit product number package size information in
                                                      the electronic payment system)



Quantity Restrictions                        Each dispensing of authorized enteral nutrition product benefit is
                                             limited to a 31-day supply. A 31-day supply is defined as the patient’s
                                             daily caloric requirement for product (specified by licensed prescriber
                                             on the prescription), multiplied by 31 days, divided by caloric density
                                             of product (kcal/milliliter of liquid product, or kcal/gram of powdered
                                             product), and rounded up to the smallest available package size (can,
                                             bottle, bag, or brikpak) size. Rounding up does not include rounding
                                             up to full cases of product. See documentation requirements in the
                                             previous section to establish 31-day supply.




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Contracted Products                          The Department of Health Care Services (DHCS), pursuant to Welfare
                                             and Institutions Code (W&I Code), Section 14105.8 negotiates non-
                                             exclusive contracts for a maximum acquisition cost (MAC) for
                                             specified enteral nutrition products, with interested distributors,
                                             manufacturers and re-labelers. The contracts guarantee to Medi-Cal
                                             pharmacy providers, the contracted products at or below the MAC,
                                             upon request, for dispensing to eligible Medi-Cal outpatients.

                                             Items contracted for specified enteral nutrition product categories are
                                             listed with a Medi-Cal specific, 11 digit billing code, with corresponding
                                             Universal Product Codes (UPC) or Universal Product Numbers (UPN)
                                             at case level and/or item level. Billing for these products is restricted
                                             to the published items in the Enteral Nutrition Product section of this
                                             manual and must be identical to the product approved on the
                                             authorization request. Listing items is not a guarantee of availability of
                                             an item.

                                             MAC price suppliers may be contacted for identification of routes for
                                             obtaining MAC prices at:

                                             MAC Price Supplier              Telephone Number
                                             Abbott                          1-800-558-7677
                                             Applied Nutrition               1-800-605-0410
                                             Mead Johnson                    1-800-457-3550
                                             Nestle                          1-800-422-ASK2
                                             Nutricia North America          1-800-365-7354
                                             Vitaflo USA                     1-773-255-2223



Other Listed Products                        The Department of Health Care Services (DHCS), pursuant to Welfare
                                             and Institutions Code (W&I Code), Section 14105.8, also lists products
                                             that meet enteral nutrition category types for which there are no
                                             negotiated contracts, and therefore no MAC. These products are
                                             similarly available for prior authorization consideration. Listing items is
                                             not a guarantee of availability of an item.




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Reimbursement                                Enteral nutrition product reimbursement guidelines are as follows:


Upper Billing Limit                          Claims submitted pursuant to CCR, Title 22, Section 51008 for enteral
                                             nutrition products shall not exceed an amount that is the lesser of:

                                                    (1) The usual charges made to the general public, or
                                                    (2) The net purchase price of the item (including all discounts and
                                                        rebates), plus no more than 100 percent markup.
                                                        Documentation shall include, but not be limited to, evidence of
                                                        purchase such as invoices or receipts.
                                                        a. Net purchase price is defined as the actual cost to the
                                                           provider to purchase the item from the seller, including
                                                           refunds, rebates, discounts or any other price reducing
                                                           allowances, known by the provider at the time of billing
                                                           the Medi-Cal program for the item, that reduce the item’s
                                                           invoice amount.
                                                        b. The net purchase price shall reflect price reductions
                                                           guaranteed by any contract to be applied to the item(s)
                                                           billed to the Medi-Cal program.
                                                        c.   The net purchase price shall not include provider costs
                                                             associated with late payment penalties, interest, inventory
                                                             costs, taxes, or labor.
                                                        d. Providers shall not submit bills for items obtained at no
                                                           cost.


Maximum Reimbursement                        The maximum amount reimbursed to providers will be the lesser of:

                                               (1) The usual charges made to the general public;
                                               (2) The net purchase price of the item (including all discounts and
                                                   rebates), plus no more than 100 percent markup;
                                               (3) The price on file (Estimated Acquisition Cost [EAC] which equals
                                                   either the Average Wholesale Price [AWP] minus 10%) for non-
                                                   contracted items, or the published EAC for contracted items, plus
                                                   the 23 percent markup.




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DIABETIC ENTERAL NUTRITION (Authorization always required)

Abbott: 1-800-558-7677
                                       Medi-Cal     UPC number (case)      MAC per   EAC per
 Product Label Name                Billing Number   (for reference only)   g or ml   g or ml
 Glucerna 1.0 (8 oz)                70074050241        070074502403         0.0065    0.0065
 van
 Glucerna 1.0                       70074051207       070074512068         0.0080    0.0080
 (1000 ml)
 Glucerna 1.0                       70074052603       070074526027         0.0080    0.0080
 (1500 ml)
 Glucerna 1.2 can                   70074050905       070074509044         0.0100    0.0100
 (8 oz) van
 Glucerna 1.2                       70074050907       070074509068         0.0100    0.0100
 (1000 ml)
 Glucerna 1.2                       70074050903       070074509020         0.0100    0.0100
 (1500 ml)
 Glucerna 1.5 (8 oz)                70074053535       070074535340         0.0110    0.0110
 van
 Glucerna 1.5                       70074053537       070074535364         0.0110    0.0110
 (1000 ml)
 Glucerna Select can                70074057702       070074577012         0.0090    0.0090
 (8 oz) van
 Glucerna Select                    70074057704       070074577036         0.0100    0.0100
 (1000 ml)
 Glucerna Select                    70074057706       070074577050         0.0100    0.0100
 (1500 ml)


Nestle: 1-800-422-ASK2
                                       Medi-Cal     UPC number (case)      MAC per   EAC per
 Product Label Name                Billing Number   (for reference only)   g or ml   g or ml
 Nutren Glytrol                     00065908570     0079871616275300       0.00650    0.0065
 (250 ml) van
 Nutren Glytrol                     98716016376     1079871622390100       0.00800   0.0080
 UltraPak SpikeRight
 (1000 ml)
 Nutren Glytrol                     98716016377     0079871632391800       0.00800   0.0080
 UltraPak SpikeRight
 (1500 ml)
 Boost Glucose                      00212360162      10043900360109        0.00650   0.0065
 Control (237 ml) van
 Boost Glucose                      00212360262      10043900360208        0.00650   0.0065
 Control (237 ml) choc
 Boost Glucose                      00212360362      10043900360307        0.00650   0.0065
 Control (237 ml) strw
 Diabetisource AC                   00212365051      10043900365005        0.01000   0.0100
 (250 ml) unflav
 Diabetisource AC                   00212365142      10043900365012        0.01000   0.0100
 (1000 ml)
 Diabetisource AC                   00212365244      10043900365029        0.01000   0.0100
 (1500 ml)
 Diabetisource AC                   43900036508      10043900365081        0.01000   0.0100
 SpikeRight (1000 ml)
 Diabetisource AC                   43900036582      10043900365821        0.01000   0.0100
 SpikeRight (1500 ml)




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STANDARD ENTERAL NUTRITION (Authorization always required)

Abbott: 1-800-558-7677
                                       Medi-Cal     UPC number (case)      MAC per   EAC per
 Product Label Name                Billing Number   (for reference only)   g or ml   g or ml
 Ensure® Powder                     70074060750        070074007502        0.02000   0.0216
 (397 g can) van
 Ensure® (8 oz can)                 70074050461       070074504605         0.00470   0.0063
 van
 Ensure® Immune                     70074050461       070074504605         0.00470   0.0063
 Health (8 oz can) van
 Ensure® (8 oz can)                 70074050463       070074504629         0.00470   0.0063
 choc
 Ensure® Immune                     70074050463       070074504629         0.00470   0.0063
 Health (8 oz can)
 choc
 Ensure® (8 oz can)                 70074050649       070074506487         0.00470   0.0063
 strw
 Ensure® Immune                     70074050649       070074506487         0.00470   0.0063
 Health (8 oz can) strw
 Ensure® (8 oz can)                 70074051739       070074517384         0.00470   0.0063
 coff
 Ensure® (8 oz can) btr             70074051893       070074518923         0.00470   0.0063
 pcn
 Ensure® Immune                     70074051893       070074518923         0.00470   0.0063
 Health (8 oz can) btr
 pcn
 Ensure® Fiber w/FOS                70074050651       070074506500         0.00480   0.0064
 (8 oz) van
 Ensure® Fiber w/FOS                70074055315       070074553146         0.00480   0.0064
 (8 oz) choc
 Ensure® High Protein               70074052099       070074520988         0.00490   0.0065
 (8 oz) choc
 Ensure® High Protein               70074052101       070074521008         0.00490   0.0065
 (8 oz) van
 Ensure® High Protein               70074052105       070074521046         0.00490   0.0065
 (8 oz) berry
 Ensure® Plus 1.5                   70074050465       070074504643         0.00580   0.0074
 (8 oz) van
 Ensure® Plus 1.5                   70074050467       070074504667         0.00580   0.0074
 (8 oz) choc
 Ensure® Plus 1.5                   70074050647       070074506463         0.00580   0.0074
 (8 oz) strw
 Ensure® Plus 1.5                   70074051741       070074517407         0.00580   0.0074
 (8 oz) coff
 Ensure® Plus 1.5                   70074051895       070074518947         0.00580   0.0074
 (8 oz) btr pcn
 Jevity® 1.0 (8 oz can)             70074040143       070074001432         0.00480   0.0064
 unflav
 Jevity® 1.0 (1000 ml)              70074080682       070074006826         0.00480   0.0064
 Jevity® 1.0 (1500 ml)              70074052605       070074526041         0.00480   0.0064
 Jevity® 1.2 (8 oz)                 70074053119       070074531182         0.00540   0.0070
 unflav
 Jevity® 1.2 (1000 ml)              70074053125       070074531243         0.00540   0.0070
 Jevity® 1.2 (1500 ml)              70074053115       070074531144         0.00540   0.0070
 Jevity® 1.5 (8 oz)                 70074057334       070074573335         0.00590   0.0075
 unflav
 Jevity® 1.5 (1000 ml)              70074057330       070074573298         0.00590   0.0075
 Jevity® 1.5 (1500 ml)              70074057332       070074573311         0.00590   0.0075




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                                       Medi-Cal     UPC number (case)      MAC per   EAC per
 Product Label Name                Billing Number   (for reference only)   g or ml   g or ml
 Osmolite® 1.0 (8 oz)               70074040735        070074007359        0.00470    0.0063
 unflav
 Osmolite® 1.0                      70074080668       070074006680         0.00470   0.0063
 (1000 ml)
 Osmolite® 1.0                      70074052601       070074526003         0.00470   0.0063
 (1500 ml)
 Osmolite® 1.2 (8 oz)               70074053121       070074531205         0.00550   0.0071
 unflav
 Osmolite® 1.2                      70074053123       070074531229         0.00550   0.0071
 (1000 ml)
 Osmolite® 1.2                      70074053117       070074531168         0.00550   0.0071
 (1500 ml)
 Osmolite® 1.5                      70074057470       070074574691         0.00580   0.0074
 (8 oz) unflav
 Osmolite® 1.5                      70074057472       070074574714         0.00580   0.0074
 (1000 ml)
 PediaSure® (8 oz can)              70074051805       070074518046         0.00470   0.0074
 van
 PediaSure® (8 oz can)              70074051881       070074518800         0.00470   0.0074
 strw
 PediaSure® (8 oz can)              70074051883       070074518824         0.00470   0.0074
 choc
 PediaSure® (8 oz can)              70074051885       070074518848         0.00470   0.0074
 ban
 PediaSure® (8 oz can)              70074055898       070074558974         0.00470   0.0074
 van
 PediaSure® (8 oz can)              70074057842       070074578415         0.00470   0.0074
 orng
 PediaSure® w/Fiber                 70074051807       070074518060         0.00500   0.0077
 (8 oz can) van
 PediaSure® w/Fiber                 70074058221       070074582207         0.00500   0.0077
 (8 oz can) van
 PediaSure® 1.5 Cal                 70074056410       070074564098         0.00750   0.0102
 (van 8 oz can)
 PediaSure® 1.5 Cal                 70074056412       070074564111         0.00780   0.0105
 w/Fiber (van 8 oz can)
 Promote® (8 oz can)                70074050775       070074507743         0.00520   0.0068
 van
 Promote® (1000 ml)                 70074051617       070074516165         0.00520   0.0068
 Promote® (1500 ml)                 70074057632       070074576312         0.00520   0.0068
 Promote® w/Fiber                   70074051873       070074518725         0.00510   0.0067
 (8 oz can) van
 Promote® w/Fiber                   70074051875       070074518749         0.00510   0.0067
 (1000 ml)
 Promote® w/Fiber                   70074057634       070074576336         0.00510   0.0067
 (1500 ml)
 TwoCal® HN                         70074040729       070074007298         0.00620   0.0078
 (8 oz can) van
 TwoCal® HN                         70074054065       070074540641         0.00620   0.0078
 (8 oz can) btr pcn
 TwoCal® HN                         70074057048       070074570471         0.00620   0.0078
 (1000 ml)




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Nestle: 1-800-422-ASK2
                                                        UPC number
                                           Medi-Cal      (item) (for     UPC number        MAC         EAC
                                            Billing      reference         (case) (for     per g       per g
 Product Label Name                        Number           only)       reference only)    or ml       or ml
 Boost (237 ml) strw                     00212067613   043900676302    10043900676392     0.00470     0.0063
 Boost Tetra Brik (237 ml)               00212067613   043900676388    10043900676392     0.00470    0.0063 *
 strw
 Boost Tetra Brik (237 ml) van           00212674313   043900674391    10043900674381     0.00470     0.0063
 Boost Tetra Brik (237 ml)               00212675313   043900675398    10043900675388     0.00470     0.0063
 choc
 Boost Original Nutritional              41679067466   041679674000    00041679674369     0.00470     0.0063
 Drink (8 oz) van
 Boost Original Nutritional              41679067566   041679675007    00041679675366     0.00470     0.0063
 Drink (8 oz) choc
 Boost Original Nutritional              41679067666   041679676004    00041679676363     0.00470     0.0063
 Drink (8 oz) strw
 Boost Energy Drink                      41679067766                   00041679677360     0.00470    0.0063 **
 (8 oz bottle) choc mocha
 Boost Energy Drink                      41679098766                   00041679987360     0.00470    0.0063 **
 (8 oz bottle) btr pcn
 Boost Energy Drink (8 oz) van           41679067417   041679674185    00041679674178     0.00470     0.0063
 Boost Energy Drink (8 oz)               41679067517   041679675182    00041679675175     0.00470     0.0063
 choc
 Boost Energy Drink (8 oz) strw          41679067617   041679676189    00041679676172     0.00470     0.0063
 Boost w/Benefiber Liquid                41679015721                   00041679157206     0.00500    0.0066 **
 (8 oz) van
 Boost w/Benefiber Liquid                41679015801                   00041679158005     0.00500    0.0066 **
 (8 oz) choc
 Boost High Protein (237 ml)             00212941313   043900941394    10043900941301     0.00530     0.0069
 van
 Boost High Protein Tetra                00212941313   043900941394    10043900941391     0.00530    0.0069 *
 Brik (237ml) van
 Boost High Protein (8 oz) choc          41679094066   041679940006    00041679940365     0.00530     0.0069
 Boost High Protein (8 oz) van           41679094166   041679941003    00041679941362     0.00530     0.0069
 Boost High Protein Liquid               41679094466                   00041679944363     0.00530    0.0069 **
 (8 oz bottle) strw
 Boost High Protein Liquid               41679004007                   00041679040072     0.00530    0.0069 **
 (8 oz can) choc
 Boost High Protein (8 oz) van           41679094107   041679941096    00041679941072     0.00530     0.0069
 Boost High Protein Liquid               41679094407                   00041679944073     0.00530    0.0069 **
 (8 oz can) strw




* Effective February 1, 2012
** Effective March 1, 2012




2 – Enteral Nutrition: List of Available Products
                                                                                                    February 2012
enteral
12
                                                        UPC number
                                           Medi-Cal      (item) (for     UPC number        MAC        EAC
                                            Billing      reference         (case) (for     per g      per g
 Product Label Name                        Number           only)       reference only)    or ml      or ml
 Boost Kid Essentials (237 ml)           43900033511   043900335117    10043900335114     0.00470    0.0074
 van
 Boost Kid Essentials (237 ml)           43900033520   043900335209    10043900335220     0.00470    0.0074
 choc
 Boost Kid Essentials (244 ml)           41679033281   041679332818    00041679332801     0.00470    0.0074
 strw
 Boost Kid Essentials                    43900033500   043900335001    10043900335008     0.00650    0.0092
 1.5 w/Fiber (237 ml) van
 Boost Kid Essentials 1.5                43900033540   043900335407    10043900335442     0.00620    0.0089
 (237 ml) van
 Boost Kid Essentials (237 ml)           43900033530   043900335308    10043900335336     0.00470    0.0074
 strw
 Boost Kid Essentials (244 ml)           41679033251   041679332511    00041679332504     0.00470    0.0074
 van
 Boost Kid Essentials (244 ml)           41679033261   041679332610    00041679332603     0.00470    0.0074
 choc
 Boost Kid Essentials 1.5 Tetra          43900033588   043900335889    10043900335886     0.00620    0.0089
 Brik (237 ml) choc
 Boost Kid Essentials 1.5 Tetra          43900033590   043900335902    10043900335992     0.00620    0.0089
 Brik (237 ml) strw
 Boost Plus 1.52 Tetra Brik              00212931313   043900931395    10043900931385     0.00590    0.0075
 (237 ml) van
 Boost Plus 1.52 Tetra Brik              00212932313   043900932392    10043900932382     0.00590    0.0075
 (237 ml) choc
 Boost Plus 1.52 Tetra Brik              00212933313   043900933382    10043900933310     0.00590    0.0075
 (237 ml) strw
 Boost Plus 1.52 (8 oz) van              41679093166   041679931004    00041679931363     0.00590    0.0075
 Boost Plus 1.52 (8 oz) choc             41679093266   041679932001    00041679932360     0.00590    0.0075
 Boost Plus 1.52 (8 oz) strw             41679093366   041679933008    00041679933367     0.00590    0.0075
 Boost Plus 1.52 (8 oz) van              41679093111   041679931127    00041679931110     0.00590    0.0075
 Boost Plus 1.52 (8 oz) choc             41679093211   041679932124    00041679932117     0.00590    0.0075
 Boost Plus 1.52 (8 oz) strw             41679093304   041679933053    00041679933046     0.00590    0.0075
 Boost VHC Tetra Brik                    43900018215   043900182155    10043900182169     0.00700   0.0086 *
 (237 ml) van
 CIB Lactose Free (250 ml)               00065905070   798716709019    0079871670902600   0.00470    0.0063
 van
 CIB Lactose Free (250 ml)               00065905071   798716709033    0079871670904000   0.00470    0.0063
 choc
 CIB Lactose Free (250 ml)               00065905072   798716038935    0079871633892900   0.00470    0.0063
 strw
 CIB PLUS Lactose Free 1.5               00065905073   798716038959    79871638940200     0.00590    0.0075
 (250 ml) van
 CIB PLUS Lactose Free 1.5               00065905074   798716038973    79871633896700     0.00590    0.0075
 (250 ml) choc
 CIB PLUS Lactose Free 1.5               00065905075   798716038997    0079871633898100   0.00590    0.0075
 (250 ml) strw
 CIB VHC Lactose Free 2.25               00065905076   798716039017    0079871633900100   0.00700    0.0086
 (250 ml) van




* Effective February 1, 2012




2 – Enteral Nutrition: List of Available Products
                                                                                                    January 2012
                                                                                                                            enteral
                                                                                                                                    13
                                                           UPC number
                                           Medi-Cal         (item) (for           UPC number              MAC             EAC
                                            Billing         reference               (case) (for           per g           per g
 Product Label Name                        Number              only)             reference only)          or ml           or ml
 * Compleat SpikeRight                   43900014180      043900141800          10043900141807           0.01166         0.0133
 (1000 ml)
 * Compleat SpikeRight                43900014182            043900141824            10043900141821           0.01166    0.0133
 (1500 ml)
 * Compleat Modified (250 ml)         00212140151            043900140100            10043900140107           0.01166    0.0133
 * Compleat Modified (1000 ml)        00212141442            043900141411            10043900141418           0.01166    0.0133
 * Compleat Modified (1500 ml)        00212141444            043900141428            10043900141425           0.01166    0.0133
 * Compleat Pediatric Formula         00212142451            043900142401            10043900142408           0.01000    0.0127
 (250 ml)
    * All Compleat products are limited to:
         Patients with documented medical intolerance to all other standard enteral products on the list, and
         Documented intolerance shall include consideration of hospitalization experience when medical need for a Compleat brand
           product was previously established, and
         Shall not include a requirement for the patient to have first attempted blenderized food.
 Fibersource 1.2 (250 ml)            00212183551            043900183572             10043900183500           0.00520    0.0068
 Fibersource HN 1.2 (250 ml)         00212185551            043900185552             10043900185504           0.00520    0.0068
 Fibersource HN 1.2 (250 ml)         43900018556            043900185569             10043900185566           0.00520    0.0068
 Isosource 1.2 (250 ml)              00212182551            043900182506             10043900182503           0.00500    0.0066
 Isosource 1.2 (1000 ml)             00212182642            043900182605             10043900182619           0.00500    0.0066
 Isosource 1.2 (1500 ml)             00212182644            043900182629             10043900182626           0.00500    0.0066
 Isosource HN 1.2 (250 ml)           00212184551            043900184579             10043900184507           0.00500    0.0066
 Isosource HN 1.2 (1000 ml)          00212184642            043900184678             10043900184613           0.00500    0.0066
 Isosource HN 1.2 (1500 ml)          00212184644            043900184623             10043900184620           0.00500    0.0066
 Isosource HN SpikeRight             43900018480            043900184807             10043900184804           0.00500    0.0066
 (1000 ml)
 Isosource HN SpikeRight             43900018466            043900184661             10043900184668           0.00500    0.0066
 (1500 ml)
 Isosource 1.5 (250 ml)              00212181551            043900181509             10043900181506           0.00620    0.0078
 Isosource 1.5 (1000 ml)             00212181642            043900181608             10043900181612           0.00620    0.0078
 Isosource 1.5 (1500 ml)             00212181644            043900181622             10043900181629           0.00620    0.0078
 Isosource 1.5 SpikeRight            43900018181            043900181813             10043900181810           0.00620    0.0078
 (1000 ml)
 Isosource 1.5 SpikeRight            43900018182            043900181820             10043900181827           0.00620    0.0078
 (1500 ml)




2 – Enteral Nutrition: List of Available Products
                                                                                                                        January 2012
enteral
14
                                         Medi-Cal      UPC number        UPC number        MAC        EAC
                                          Billing       (item) (for        (case)(for      per g      per g
 Product Label Name                      Number      reference only)    reference only)    or ml      or ml
 Nutren 1.0 (250 ml) van               00065902470    798716062107     00798716162104     0.00470    0.0063
 Nutren 1.0 w/Fiber (250 ml)           00065902570    798716060561     00798716160568     0.00500    0.0066
 van
 Nutren 1.0 (250 ml) unflav            00065903070   798716062190      0079871616219700   0.00470    0.0063
 Nutren 1.0 w/Fiber (250 ml)           00065903170   798716060554      0079871616055100   0.00500    0.0066
 unflav
 Nutren 1.0 UltraPak                   00065915072   798716163507      1079871616350400   0.00470    0.0063
 (1000 ml)
 Nutren 1.0 UltraPak                   00065915073   798716163514      1079871616351100   0.00470    0.0063
 (1500 ml)
 Nutren 1.0 w/Fiber UltraPak           00065915272   798716163521      1079871616352800   0.00500    0.0066
 (1000 ml)
 Nutren 1.0 w/Fiber UltraPak           00065915273   798716163538      1079871616353500   0.00500    0.0066
 (1500 ml)
 Nutren 1.5 (250 ml) van               00065903270   798716062206       00798716162203    0.00590    0.0075
 Nutren 1.5 w/Fiber (250 ml)           00065903570   798716063814      0079871616381100   0.00620    0.0078
 van
 Nutren 2.0 (250 ml) van               00065904070    798716062305     0079871616230200   0.00620    0.0078
 Nutren 2.0 UltraPak                   00065904072   7987163314470     0079871633146300   0.00620    0.0078
 (1000 ml)
 Nutren 2.0 UltraPak                   98716033147   798716331470      0079871644146900   0.00620    0.0078
 SpikeRight (1000 ml)
 Nutren Junior (250 ml) van            00065904370   798716060622      0079871616062900   0.00470    0.0074
 Nutren Junior w/Fiber                 00065904570   798716060639       00798716160636    0.00500    0.0077
 (250 ml) van
 Nutren Junior SpikeRight              00065904390   798716673709      00798716773805     0.00470   0.0074 *
 Plus (1000 ml)
 Nutren Junior w/Fiber                 00065904590   798716673907      00798716774000     0.00500   0.0077 *
 SpikeRight Plus (1000 ml)
 Nutren Replete (250 ml) van           00065902270   798716062497       00798716162494    0.00530    0.0069
 Nutren Replete UltraPak               00065915672   798716163569      1079871616356600   0.00530    0.0069
 (1000 ml)
 Nutren Replete UltraPak               98716016356   798716163569      1079871626356300   0.00530    0.0069
 SpikeRight (1000 ml)
 Nutren Replete UltraPak               00065915673   798716163576      1079871616357300   0.00530    0.0069
 (1500 ml)
 Nutren Replete w/Fib                  00065902370   798716062459      00798716162456     0.00550    0.0071
 (250 ml) van
 Nutren Replete w/Fib                  00065915872   798716163583      10798716163580     0.00550    0.0071
 UltraPak (1000 ml)
 Nutren Replete w/Fib                  98716016358   798716163583      1079871626358700   0.00550    0.0071
 UltraPak SpikeRight
 (1000 ml)
 Nutren Replete w/Fib                  00065915873   798716163590      1079871616359700   0.00550    0.0071
 UltraPak (1500 ml)
 Nutren Replete w/Fib                  98716016359   798716163590      1079871626359400   0.00550    0.0071
 UltraPak SpikeRight
 (1500 ml)




* Effective February 1, 2012




2 – Enteral Nutrition: List of Available Products
                                                                                                    January 2012
                                                                                                         enteral
                                                                                                                15
                                         Medi-Cal      UPC number         UPC number        MAC        EAC
                                          Billing       (item) (for         (case)(for      per g      per g
 Product Label Name                      Number      reference only)     reference only)    or ml      or ml
 Nutren 1.5 w/Fiber UltraPak           00065903572    798716063821     0079871616382800    0.00620    0.0078
 (1000 ml)
 Nutren 1.5 w/Fiber UltraPak           00065903573   798716063838      0079871616383500    0.00620    0.0078
 (1500 ml)
 Nutren 1.5 (250 ml) Unflav            00065903870   798716062299      0079871616229600    0.00590    0.0075
 Nutren 1.5 UltraPak                   00065915472   798716163545      1079871626354200    0.00590    0.0075
 (1000 ml)
 Nutren 1.5 UltraPak                   98716016354   798716163545      1079871616354900    0.00590    0.0075
 SpikeRight (1000 ml)
 Nutren 1.5 UltraPak                   00065915473   798716163552      1079871616355900    0.00590    0.0075
 (1500 ml)
 Probalance 1.2                        00065916270                     0079871616204300    0.00560   0.0072 *
 (250 ml) van
 Probalance 1.2                        00065916672                     0079871661010000    0.00560   0.0072 *
 (1000 ml UltraPak)
 Probalance 1.2                        00065916673                     0079871641500200    0.00560   0.0072 *
 (1500 ml UltraPak)
 Resource JFK LIQ                      00212331162                      10043900331109     0.00470   0.0074 *
 (8 oz) van
 Resource JFK LIQ                      00212331262                      10043900331208     0.00470   0.0074 *
 (8 oz) choc
 Resource JFK LIQ                      00212331362                      10043900331307     0.00470   0.0074 *
 (8 oz) strw
 Resource JFK w/FIBER                  00212331462                      10043900331406     0.00500   0.0077 *
 LIQUID
 (8 oz) van
 Resource JFK LIQ 1.5                  00212331962                      10043900331901     0.00620   0.0089 *
 (237 ml) van
 Resource JFK LIQUID                   00212332062                      10043900332007     0.00650   0.0092 *
 1.5 w/Fib (237 ml) van
 Resource 2.0 (8 oz) van               00212180162   043900180106       10043900180103     0.00600    0.0076
 Resource 2.0 (8 oz) btr pcn           43900018040                      10043900180400     0.00600   0.0076 *




* Effective March 1, 2012




2 – Enteral Nutrition: List of Available Products
                                                                                                     January 2012
enteral
16
Other Standard Enteral Nutrition
                                       Medi-Cal     MAC per   EAC per
 Product Label Name                Billing Number   g or ml   g or ml
 Rite Aid BALANCED                  11822006540      None      0.0030
 NUTRITION DRINK
 Rite Aid BALANCED                  11822300530      None     0.0035
 NUTRIT PLUS
 DRINK
 Rite Aid BALANCED                  11822300550      None     0.0030
 NUTRITION DRINK
 Rite Aid BALANCED                  11822300560      None     0.0030
 NUTRITION DRINK
 Rite Aid BALANCED                  11822391920      None     0.0035
 NUTRITION PLUS
 DRINK
 Rite Aid BALANCED                  11822391950      None     0.0035
 NUTRITION PLUS
 DRINK
 Rite Aid BALANCED                  11822395210      None     0.0045
 NUTRITION PLUS
 DRINK
 Rite Aid BALANCED                  11822395220      None     0.0045
 NUTRITION PLUS
 DRINK
 Rite Aid BALANCED                  11822395230      None     0.0045
 NUTRITION PLUS
 DRINK
 CVS NUTRITION                      50428142158      None     0.0032
 PLUS LIQUID (8 oz)
 strw
 CVS NUTRITION                      50428142430      None     0.0032
 PLUS LIQUID (8 oz)
 van
 CVS NUTRITION                      50428142570      None     0.0032
 PLUS LIQUID (8 oz)
 choc
 CVS NUTRITION                      50428142695      None     0.0028
 LIQUID (8 oz) van
 CVS NUTRITION                      50428142737      None     0.0028
 LIQUID (8 oz) strw
 CVS NUTRITION                      50428142828      None     0.0028
 LIQUID (8 oz) choc
 CVS NUTRITIONAL                    50428560128      None     0.0036
 LIQUID
 CVS NUTRITIONAL                    50428560979      None     0.0036
 LIQUID
 CVS NUTRITIONAL                    50428561399      None     0.0036
 LIQUID
 CVS LIQUID                         50428702365      None     0.0031
 NUTRITION
 CVS LIQUID                         50428702423      None     0.0031
 NUTRITION




2 – Enteral Nutrition: List of Available Products
                                                                        December 2011
                                                                                                    enteral
                                                                                                        17
 METABOLIC ENTERAL NUTRITION (Authorization always required)

 Abbott: 1-800-558-7677
                                  Medi-Cal                                           MAC        EAC
                                   Billing            UPC number     UPC number      per g      per g
Product Label Name                Number                 (item)        (case)        or ml      or ml
Calcilo® XD                     70074053329          070074533292   070074533285   $ 0.0390    0.0415
Powder(375 g)
Cyclinex® – 1 Powder            70074051145          070074511450   070074511443   0.0363      0.0412
(400 g)
Cyclinex® – 2 Powder            70074051147          070074511474   070074511467   0.0840      0.0901
(400 g)
Glutarex® – 1 Powder            70074051141          070074511412   070074511405   0.0737      0.0819
(400 g)
Glutarex® – 2 Powder            70074051143          070074511436   070074511429   0.1601      0.1641
(400 g)
Hominex® – 2 Powder             70074051119          070074511191   070074511184   0.1500      0.1641
(400 g)
Hominex® – 1 Powder             70074051117          070074511177   070074511160   0.0799      0.0819
(400 g)
I-Valex® – 1 Powder             70074051137          070074511375   070074511368   0.0799      0.0819
(400 g)
I-Valex® – 2 Powder             70074051139          070074511399   070074511382   0.1500      0.1641
(400 g)
Ketonex® – 2 Powder             70074051115          070074511153   070074511146   0.1500      0.1641
(400 g)
Ketonex® – 1 Powder             70074051113          070074511139   070074511122   0.0768      0.0854
(400 g)
Phenex® – 2 Powder              70074055756          070074557564   070074557557   0.0840      0.0919
(400 g) van
Phenex® - 1 Powder              70074051121          070074511214   070074511207   0.0420      0.0468
(400 g)
Phenex® – 2 Powder              70074051123          070074511238   070074511221   0.0840      0.0919
(400 g) unflav
Pro-Phree® Powder               70074051149          070074511498   070074511481   0.0197      0.0201
(400 g) van
Propimex® – 2                   70074051135          070074511351   070074511344   0.1520      0.1641
Powder (400 g)
Propimex® – 1                   70074051133          070074511337   070074511320   0.0700      0.0819
Powder (400 g)
ProViMin® Powder                70074050260          070074502618   070074502601   0.0680      0.0784
(150 g)
RCF® (Liquid)                   70074040108          070074401089   070074001081   0.0109      0.0111
(384 ml)
Tyrex® –- 2 Powder              70074051127          070074511276   070074511269   0.1520      0.1641
(400 g)
Tyrex® – 1 Powder               70074051129          070074511290   070074511283   0.0727      0.0818
(400 g)




 2 – Enteral Nutrition: List of Available Products
                                                                                              December 2011
 enteral
 18
 Applied Nutrition: 1-800-605-0410
                                  Medi-Cal                                          MAC       EAC
                                   Billing            UPC number     UPC number     per g     per g
Product Label Name                Number                 (item)        (case)       or ml     or ml
Complex Junior MSD              00847059102          700847059109   700847591029   0.0625    0.0759
Drink Mix Powder
(400 g)
Complex MSUD                    00847059000          700847059000   700847590008   0.3444    0.3827
Amino Acid Blend,
Unfl Powder (454 g)
Complex MSUD Drink              00847059822          700847059826   700847598226   0.1200    0.1334
Mix, Van Powder
(454 g)
Complex MSUD                    00847059722          700847059727   700847597229   0.1200    0.1334
Essential Dr Mix Van
Powder (454 g)
PhenylAde Amino                 00847095000          700847095008   700847950000   0.2252    0.2283
Acid Blend Unflav
(454 g) Powder
PhenylAde Amino                 00847095004              none       700847950048   0.2252    0.3114
Acid Blend Unflav
Powder (13 g)
PhenylAde Drink Mix             00847095112          700847095114   700847951120   0.0720    0.0818
Choc Powder
(454 g)
PhenylAde Drink Mix             00847095332          700847095336   700847953322   0.0720    0.0818
Orange Creme
(454 g) Powder
PhenylAde Drink Mix             00847095442          700847095442   700847954428   0.0720    0.0818
Strawb (454 g)
Powder
PhenylAde Drink Mix             00847095222          700847095220   700847952226   0.0720    0.0818
Van (454 g) Powder
PhenylAde Essential             00847095022          700847095022   700847950222   0.0720    0.0818
Drink Mix Van
(454 g) Powder
PhenylAde Essential             00847095032          700847095039   700847950321   0.0720    0.0818
Drink Mix Orange
(454 g) Powder
PhenylAde Essential             00847095042          700847095046   700847950420   0.0720    0.0818
Drink Mix Strawb
(454 g) Powder
PhenylAde Essential             00847095012          700847095015   700847950123   0.0720    0.0818
Drink Mix Choc
(454 g) Powder
PhenylAde Essential             00847095014              none       700847950147   0.0720    0.0842
Drink Mix Choc
(40 g) Powder
PhenylAde Essential             00847095024              none       700847950246   0.0720    0.0842
Drink Mix Van
(40 g) Powder
PhenylAde Essential             00847095034              none       700847950345   0.0720    0.0842
Drink Mix Orange
(40 g) Powder
PhenylAde Essential             00847095044              none       700847950444   0.0720    0.0842
Drink Mix Strawb
(40 g) Powder




 2 – Enteral Nutrition: List of Available Products
                                                                                            December 2011
                                                                                                      enteral
                                                                                                           19
                                  Medi-Cal                                             MAC       EAC
                                   Billing            UPC number        UPC number     per g     per g
Product Label Name                Number                 (item)           (case)       or ml     or ml
PhenylAde MTE                   00847095960          700847095961      700847959607   0.2252    0.2283
Amino Acid Blnd
Unflav (454 g)
Powder
PhenylAde MTE                  00847095964                   none      700847959645   0.2252    0.3114
Amino Acid Blnd Unfl
(13 g) Powder
PhenylAde PheBloc              00847095501                   none      700847955012   0.2615/   0.3824/
LNAA Tablets                                                                            tab       tab
(550 tblts/jar)
PhenylAde PheBloc              00847095504                     one     700847955043   0.3333    0.3349
LNAA Powder (3 g)
   Limited to non-pregnant patients, 18 years of age or older.
PhenylAde40 Drink              00847095414                   none      700847954145   0.1000    0.1233
Mix Citrus (25 g)
Powder
PhenylAde40 Drink              00847095404                   none      700847954046   0.1000    0.1233
Mix Unflav (25 g)
Powder
PhenylAde60 Drink              00847095622              700847095626   700847956224   0.1093    0.1384
Mix Van (454 g)
Powder
Phenylade60 Drink              00847095602              700847095602   700847956028   0.1093    0.1384
Mix Unflav (454 g)
Powder
Phenylade60 Drink              00847095624                   none      700847956248   0.1093    0.1384
Mix Van (pouches)
Powder
Phenylade60 Drink              00847095604                   none      700847956040   0.1093    0.1384
Mix Powder Unflav
(pouches)


 Mead Johnson
 Metabolic: Find Mead Johnson suppliers at 1-800-457-3550
                                  Medi-Cal                                             MAC       EAC
                                   Billing            UPC number        UPC number     per g     per g
Product Label Name                Number                 (item)           (case)       or ml     or ml
3232A (454 g)                   00087042541          300870425416      300870425218   0.1230    0.1364
Powder
BCAD 1 (454 g)                  00087406042          300874060422      300874060026   0.0768    0.0773
Powder
BCAD 2 (454 g)                  00087510015          300875100158      300875101100   0.1200    0.1346 *
Powder
BCAD 2 (454 g)                  00087008341          300870083418      300870083012   0.1200    0.1346
Powder
GA (454 g) Powder               00087019841          300870198419      300870198013   0.0737    0.1029
HCY 1 (454 g)                   00087009541          300870095411      300870095015   0.0700    0.0773
Powder
HCY 2 (454 g)                   00087019941          300870199416      300870199010   0.1220    0.1346
Powder
HCY 2 (454 g)                   00087510027          300875100271      300875101148   0.1220    0.1346 *
Powder




 * Effective March 1, 2012


 2 – Enteral Nutrition: List of Available Products
                                                                                                 January 2012
 enteral
 20
                                  Medi-Cal                                            MAC       EAC
                                   Billing            UPC number     UPC number       per g     per g
Product Label Name                Number                 (item)        (case)         or ml     or ml
LMD (454 g) Powder              00087007841          300870078414   300870078018     0.0799    0.1029
OA 1 (454 g) Powder             00087008541          300870085412   300870085016     0.0700    0.0773
OA 2 (454 g) Powder             00087019141          300870191410   300870191014     0.1200    0.1287
OA 2 (454 g) Powder             00087510022          300875100226   300875101124     0.1200   0.1287 *
PFD 1 (454 g)                   00087099441          300870994417   300870994011     0.0197    0.0386
Powder
PFD 2 (454 g)                   00087007941          300870079411   300870079015     0.0171   0.0182
Powder
PFD 2 (454 g)                   00087510018          300875100189   300875101117     0.0171   0.0182 *
Powder
Phenyl-Free 1                   00087007447          300870074478   300870074072     0.0420   0.0566
(454 g) Powder
Phenyl-Free 2                   00087008041          300870080417   300870080011     0.0600   0.0654
(454 g) Powder
Phenyl-Free 2                   00087510003          300875100035   300875101087     0.0600   0.0654 *
(454 g) Powder
Phenyl-Free 2HP                 00087008141          300870081414   300870081018     0.0800   0.1176
(454 g) Powder
Phenyl-Free 2HP                 00087510010          300875100103   300875101094     0.0800   0.1176 *
(454 g) Powder
Portagen (454 g)                00087038701          300870387011   300870387219     0.0402   0.0427
Powder
TYROS 1 (454 g)                 00087019441          300870194411   300870194015     0.0727   0.0773
Powder
TYROS 2 (454 g)                 00087008241          300870082411   300870082015     0.1200   0.1346
Powder
TYROS 2 (454 g)                 00087510024          300875100240   300875101131     0.1200   0.1346 *
Powder
WND 1 (454 g)                   00087009241          300870092410   300870092014     0.0363   0.0386
Powder
WND 2 (454 g)                   00087009341          300870093417   300870093011     0.0500   0.0549
Powder
WND 2 (454 g)                   00087510029          300875100295   300875101155     0.0500   0.0549 *
Powder


 SHS/Nutricia North America: 1-800-365-7354
                                                                     UPC number
                                  Medi-Cal                              (case)        MAC      EAC
                                   Billing            UPC number    (for reference    per g    per g
Product Label Name                Number                 (item)          only)        or ml    or ml
Acerflex Powder                 49735010026          749735000267   749735100264     0.1047   0.1170
(454 g)
Acerflex Powder                 49735018842          749735000267   749735188422     0.1047   0.1170
(454 g) (pineapple)
Add-Ins (18.2 g)                49735012641          749735026410   749735126417     0.1810   0.1923
Complete Amino Acid             49735010124          749735001240   749735101247     0.3925   0.4304
Mix Powder (200 g)




 * Effective March 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                               January 2012
                                                                                                      enteral
                                                                                                          21
                                                                        UPC number
                                  Medi-Cal                                 (case)        MAC      EAC
                                   Billing            UPC number       (for reference    per g    per g
Product Label Name                Number                 (item)             only)        or ml    or ml
Duocal (unflav)                 49735010280          749735002803      749735102800     0.0481   0.0524
Powder (400 g)
Duocal (unflav)                 49735018262             749735002803   749735182628     0.0481   0.0524
Powder (400 g)
Essential Amino Acid            49735011490             749735014905   749735114902     0.3925   0.4304
Mix Powder (200 g)
Flavor Packet,                  49735010133             749735102497   749735102497     0.1200   0.1350
grapefruit (5 g)
Flavor Packet, lemon            49735010158             749735102497   749735102497     0.1200   0.1350
lime (5 g)
Flavor Packet, cherry           49735010249             749735102497   749735102497     0.1200   0.1350
vanilla (5 g)
Ketocal 3:1 (unflav)            49735016672             749735066720   749735166727     0.0788   0.0838
Powder (300 g)
KetoCal 4:1 Powder              49735016670             749735018422   749735166703     0.0784   0.0868
(300 g)
Ketocal 4:1 Liquid              49735018796             749735087961   749735187968     0.0162   0.0178
(van) (237 ml)
Lanaflex Powder                 49735012643             749735026434   749735126431     0.1646   0.1799
packet (15.8 g)
   Limited to non-pregnant patients, 18 years of age or older.
Lophlex (berry)                 49735012169             749735021699   749735121696     0.2284   0.2501
packet (14.3 g)
Lophlex (orange)                49735012167             749735021675   749735121672     0.2284   0.2501
packet (14.3 g)
Lophlex LQ (tropical)           49735019535                  none      749735195352     0.0432   0.0448
(125 ml)
Lophlex LQ (berry)              49735015096                  none      749735150962     0.0432   0.0448
(125 ml)
Methionaid Powder               49735010242             749735002421   749735002421     0.1365   0.1493
Milupa HOM-2                    81361093570             181361935702   181361935719     0.2760   0.3137
(500 g)
Milupa MSUD-2                   81361093510             181361935108   181361935115     0.2160   0.2453
(500 g)
Milupa OS-2 (500 g)             81361093490             181361934903   181361934910     0.2240   0.2553
Milupa PKU 2                    81361093460             181361934606   181361934613     0.1810   0.2055
(500 g)
Milupa PKU 2 Tomato             81361908701             181361930905   181361990879     0.0700   0.0706
(45 g)
Milupa PKU 3                    81361093470             181361934705   181361934712     0.1840   0.2100
(500 g)
Milupa TYR-2                    81361093530             181361935306   181361935313     0.2520   0.2873
(500 g)
Milupa UCD-2                    81361093610             181361936105   181361936112     0.2680   0.3050
(500 g)
Monogen (400 g)                 49735009708             749735097083   749735170977     0.0742   0.0824
Monogen (400 g)                 49735019708             749735097083   749735197080     0.0742   0.0824




 2 – Enteral Nutrition: List of Available Products
                                                                                                 January 2012
  enteral
  22
                                                                      UPC number
                                   Medi-Cal                              (case)        MAC      EAC
                                    Billing            UPC number    (for reference    per g    per g
Product Label Name                 Number                 (item)          only)        or ml    or ml
MSUD Aid Powder                  49735010143          749735001431   749735001431     0.1365   0.1493
(200 g)
MSUD Analog                      49735011886          749735018866   749735118863     0.1213   0.1329
(unflav) Powder
(400 g)
MSUD Analog                      49735018302          749735018866   749735183021     0.1213   0.1329
(unflav) Powder
(400 g)
MSUD Maxamaid                    49735012360          749735023600   749735123607     0.1322   0.1445
(orange) Powder
(454 g)
MSUD Maxamaid                    49735017781          749735023600   749735177815     0.1322   0.1445
(orange) Powder
(454 g)
MSUD Maxamum                     49735012340          749735023402   749735123409     0.1927   0.2287
(unflav) Powder
(454 g)
MSUD Maxamum                     49735017789          749735023402   749735177891     0.1927   0.2287
(unflav) Powder
(454 g)
Periflex Advance                 49735012650          749735026502   749735126509     0.1112   0.1193
(unflav) (454 g)
Periflex Advance                 49735018305          749735026502   749735183052     0.1112   0.1193
(unflav) (454 g)
Periflex Advance                 49735012651          749735026519   749735126516     0.1112   0.1193
(choc) (454 g)
Periflex Advance                 49735018306          749735026519   749735183069     0.1112   0.1193
(choc) (454 g)
Periflex Advance                 49735012652          749735026526   749735126523     0.1112   0.1193
(orange) PKU Powder
(454 g)
Periflex Advance                 49735018307          749735026526   749735183076     0.1112   0.1193
(orange) PKU Powder
(454 g)
Periflex Infant (unflav)         49735011880          749735018804   749735118801     0.0463   0.0511
former-XPhe Analog
(400 g)
Periflex Infant (unflav)         49735018326          749735018804   749735183267     0.0463   0.0511
former-XPhe Analog
(400 g)
Periflex Junior (choc)           49735012531          749735025314   749735125311     0.0716   0.0960
Powder (454 g)
Periflex Junior (choc)           49735018309          749735025314   749735183090     0.0716   0.0960
Powder (454 g)
Periflex Junior                  49735011401          749735014011   749735114018     0.0716   0.0960
(orange) Powder
(454 g)
Periflex Junior                  49735018310          749735014011   749735183106     0.0716   0.0960
(orange) Powder
(454 g)
Periflex Junior                  49735011402          749735014028   749735114025     0.0716   0.0960
(unflav) Powder
(454 g)
Periflex Junior                  49735018308          749735014028   749735183083     0.0716   0.0960
(unflav) Powder
(454 g)




  2 – Enteral Nutrition: List of Available Products
                                                                                               January 2012
                                                                                                   enteral
                                                                                                       23
                                                                     UPC number
                                  Medi-Cal                              (case)        MAC      EAC
                                   Billing            UPC number    (for reference    per g    per g
Product Label Name                Number                 (item)          only)        or ml    or ml
Phlexy-10 Drink Mix             49735011910          749735019108   749735119105     0.1533   0.1682
(trop surp) Powder
(20 g)
Phlexy-10 Drink Mix             49735011467          749735014677   749735114674     0.1533   0.1682
Powder (blckcur/appl)
(20 g)
XLeu Analog (unflav)            49735011888          749735018880   749735118887     0.1213   0.1329
Powder (400 g)
XLeu Analog (unflav)            49735018361          749735018880   749735183618     0.1213   0.1329
Powder (400 g)
XLeu Maxamaid                   49735012364          749735023648   749735106495     0.1322   0.1445
(orange) Powder
(454 g)
XLeu Maxamaid                   49735017791          749735023648   749735177914     0.1322   0.1445
(orange) Powder
(454 g)
XLeu Maxamum                    49735012343          749735023433   749735123430     0.2060   0.2253
(orange) Powder
(454 g)
XLeu Maxamum                    49735017790          749735023433   749735177907     0.2060   0.2253
(orange) Powder
(454 g)
XLys, XTrp Analog               49735011882          749735018828   749735118825     0.1160   0.1328
(unflav) Powder
(400 g)
XLys, XTrp Analog               49735018328          749735018828   749735183281     0.1160   0.1328
(unflav) Powder
(400 g)
XLys, XTrp Maxamaid             49735012359          749735023594   749735123591     0.1322   0.1445
(orange) Powder
(454 g)
XLys, XTrp Maxamaid             49735017780          749735023594   749735177808     0.1322   0.1445
(orange) Powder
(454 g)
XLys, XTrp Maxamum              49735012344          749735023440   749735123447     0.1746   0.2253
(orange) Powder
(454 g)
XLys, XTrp Maxamum              49735017788          749735023440   749735177884     0.1746   0.2253
(orange) Powder
(454 g)
XMet Analog (unflav)            49735011881          749735018811   749735118818     0.1213   0.1329
Powder (400 g)
XMet Analog (unflav)            49735018327          749735018811   749735183274     0.1213   0.1329
Powder (400 g)
XMet Maxamaid                   49735012363          749735023631   749735123638     0.1322   0.1445
Powder (orange)
(454 g)
XMet Maxamaid                   49735017787          749735023631   749735177877     0.1322   0.1445
Powder (orange)
(454 g)
XMet Maxamum                    49735012341          749735023419   749735123416     0.2060   0.2253
(orange) Powder
(454 g)
XMet Maxamum                    49735017795          749735023419   749735177952     0.2060   0.2253
(orange) Powder
(454 g)




 2 – Enteral Nutrition: List of Available Products
                                                                                              January 2012
 enteral
 24
                                                                     UPC number
                                  Medi-Cal                              (case)        MAC      EAC
                                   Billing            UPC number    (for reference    per g    per g
Product Label Name                Number                 (item)          only)        or ml    or ml
XPhe Maxamaid                   49735012357          749735023570   749735123577     0.0771   0.0842
(orange) Powder
(454 g)
XPhe Maxamaid                   49735017792          749735023570   749735177921     0.0771   0.0842
(orange) Powder
(454 g)
XPhe Maxamaid                   49735012371          749735023716   749735123713     0.0771   0.0842
(strawb) Powder
(454 g)
XPhe Maxamaid                   49735017794          749735023716   749735177945     0.0771   0.0842
(strawb) Powder
(454 g)
XPhe Maxamaid                   49735012358          749735023587   749735123584     0.0771   0.0842
(unflav) Powder
(454 g)
XPhe Maxamaid                   49735017793          749735023587   749735177938     0.0771   0.0842
(unflav) Powder
(454 g)
XPhe Maxamum                    49735012524          749735025246   749735125243     0.0300   0.0358
(berry) drink (250 ml)
XPhe Maxamum                    49735012551          749735025512   749735125519     0.0300   0.0358
(orange) drink
(250 ml)
XPhe Maxamum                    49735012312          749735023129   749735123126     0.1160   0.1268
(orange) packet
(50 g)
XPhe Maxamum                    49735012302          749735023020   749735123027     0.1156   0.1339
(orange) powder
(454 g)
XPhe Maxamum                    49735018324          749735023020   749735183243     0.1156   0.1339
(orange) powder
(454 g)
XPhe Maxamum                    49735012311          749735023112   749735123119     0.1160   0.1268
(unflav) packet
(50 g)
XPhe Maxamum                    49735012301          749735023013   749735123010     0.1156   0.1339
(unflav) Powder
(454 g)
XPhe Maxamum                    49735018323          749735023013   749735183236     0.1156   0.1339
(unflav) Powder
(454 g)
XPhe, XTyr Analog               49735011885          749735018859   749735118856     0.1213   0.1329
(unflav) Powder
(400 g)
XPhe, XTyr Analog               49735018301          749735018859   749735183014     0.1213   0.1329
(unflav) Powder
(400 g)
XPhe, XTyr                      49735012362          749735023624   749735123621     0.1322   0.1445
Maxamaid (orange)
Powder (454 g)
XPhe, XTyr                      49735017786          749735023624   749735177860     0.1322   0.1445
Maxamaid (orange)
Powder (454 g)
XPTM Analog (unflav)            49735011884          749735018842   749735118849     0.1213   0.1329
Powder (400 g)
XPTM Analog (unflav)            49735018843          749735018842   749735188439     0.1213   0.1329
Powder (400 g)




 2 – Enteral Nutrition: List of Available Products
                                                                                              January 2012
                                                                                             enteral
                                                                                                25
                                  Medi-Cal                                           MAC       EAC
                                   Billing            UPC number     UPC number      per g     per g
Product Label Name                Number                 (item)         (case)       or ml     or ml
XMet, XCys Analog               49735011653          749735016534   749735116531    0.1838    0.2031
powder (400 g)
XMet, XCys                      49735011457          749735014578   749735114575    0.2215    0.2408
Maxamaid powder
(500 g)
XMTVI Analog                    49735011887          749735018873   749735118870    0.1213    0.1329
(unflav) Powder
(400 g)
XMTVI Analog                    49735018303          749735018873   749735183038    0.1213    0.1329
(unflav) Powder
(400 g)
XMTVI Maxamaid                  49735012361          749735023617   749735123614    0.1322    0.1445
(orange) Powder
(454 g)
XMTVI Maxamaid                  49735017785          749735023617   749735177853    0.1322    0.1445
(orange) Powder
(454 g)
XMTVI Maxamum                   49735012342          749735023426   749735123423    0.1927    0.2253
(orange) Powder
(454 g)
XMTVI Maxamum                   49735017779          749735023426   749735177792    0.1927    0.2253
(orange) Powder
(454 g)


 Vitaflo USA (Authorization always required)
 Metabolic: Find Vitaflo MAC price suppliers at 1-773-255-2223
                                  Medi-Cal                                           MAC       EAC
                                   Billing           UPC number      UPC number      per g     per g
Product Label Name                Number               (item)           (case)       or ml     or ml
Arginine Amino Acid             50600054692             none        5060014054692   0.9688    0.9786
Supplement
Citrulline 1000                 50600055095              none       5060014055095   0.9688    0.9786
Supplement
Cystine Amino Acid              50600054777              none       5060014054777   0.9688    0.9786
Supplement
EAA Supplement                  50600054906              none       5060014054906   0.1996    0.2094
Powder
Flavour Pac Blk                 50600054159              none       5060014054159   0.1853    0.1869
Currant
Flavour Pac Lemon               50600054098             none        5060014054098   0.1853    0.1869
Flavour Pac Orange              50600054111             none        5060014054111   0.1853    0.1869
Flavour Pac Rasp                50600054135             none        5060014054135   0.1853    0.1869
Flavour Pac Trop                50600054173             none        5060014054173   0.1853    0.1869
GA Gel Powder                   50600053602             none        5060014053602   0.2589   0.2605 *
GA Gel Powder                   50600051516             none        5060014051516   0.2589   0.2605 *
Unflavored (24 g)
HCU Cooler                      50600053527             none        5060014053527   0.0583    0.0599
HCU Express Powder              50600053558             none        5060014053558   0.3498    0.3596
HCU Gel                         50600053503             none        5060014053503   0.2589    0.2605
HCU Gel Unflavored              50600051486             none        5060014051486   0.2589    0.2605
(24 g)




 * Effective March 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                              January 2012
 enteral
 26
                                  Medi-Cal                                         MAC      EAC
                                   Billing           UPC number    UPC number      per g    per g
Product Label Name                Number               (item)         (case)       or ml    or ml
Isoleucine 1000                 50600055118             none      5060014055118   0.9688   0.9786
Amino Acid
Supplement
Isoleucine Amino Acid           50600054302             none      5060014054302   0.7188   0.7286
Supplement
Leucine Amino Acid              50600054920             none      5060014054920   0.9688   0.9786
Supplement
Lipistart                       50600050205             none      5060014050205   0.0745   0.0843
MCT Procal Powder               50600050236             none      5060014050236   0.1406   0.1504
MMA/PA Express                  50600054371             none      5060014054371   0.3498   0.3596
Powder
MMA/PA Gel                      50600054355             none      5060014054355   0.2589    0.2605
MMA/PA Gel                      50600051523             none      5060014051523   0.2589   0.2605 *
Unflavored (24 g)
MSUD Cooler                     50600054654             none      5060014054654   0.0448   0.0464
MSUD Express                    50600053534             none      5060014053534   0.3498   0.3596
Powder (ages 1 – 8)
MSUD Gel (ages                  50600053404             none      5060014053404   0.2589   0.2605
1 – 8)
MSUD Gel (ages                  50600051493             none      5060014051493   0.2589   0.2605 *
1 – 8) Unflavored
(24 g)
Phenylalanine Amino             50600054944             none      5060014054944   0.9688   0.9786
Acid Supplement
PKU Cooler 10                   50600054852             none      5060014054852   0.0343   0.0359
Orange
PKU Cooler 10 Purple            50600054876             none      5060014054876   0.0343   0.0359
PKU Cooler 10 Red               50600051318             none      5060014051318   0.0343   0.0359
PKU Cooler 10 White             50600054999             none      5060014054999   0.0343   0.0359
PKU Cooler 15                   50600054500             none      5060014054500   0.0355   0.0371
Orange
PKU Cooler 15 Purple            50600054562             none      5060014054562   0.0355   0.0371
PKU Cooler 15 Red               50600151998             none      5060014051998   0.0355   0.0371
PKU Cooler 15 White             50600054975             none      5060014054975   0.0355   0.0371
PKU Cooler 20                   50600054814             none      5060014054814   0.0356   0.0372
Orange
PKU Cooler 20 Purple            50600054838             none      5060014054838   0.0356   0.0372
PKU Cooler 20 Red               50600052001             none      5060014052001   0.0356   0.0372
PKU Cooler 20 White             50600055019             none      5060014055019   0.0356   0.0372
PKU Express Lemon               50600053305             none      5060014053305   0.2390   0.2406
PKU Express Orange              50600053220             none      5060014053220   0.2390   0.2406
PKU Express Tropical            50600053336             none      5060014053336   0.2390   0.2406
PKU Express                     50600053206             none      5060014053206   0.2390   0.2406
Unflavored




 * Effective March 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                            January 2012
                                                                                           enteral
                                                                                              27
                                  Medi-Cal                                         MAC       EAC
                                   Billing           UPC number    UPC number      per g     per g
Product Label Name                Number               (item)         (case)       or ml     or ml
PKU Gel Orange                  50600051264             none      5060014051264   0.1614    0.1630
PKU Gel Orange                  50600051462             none      5060014051462   0.1614   0.1630 *
(24 g)
PKU Gel Raspberry               50600051233             none      5060014051233   0.1614    0.1630
PKU Gel Raspberry               50600051455             none      5060014051455   0.1614   0.1630 *
(24 g)
PKU Gel Unflavored              50600051202             none      5060014051202   0.1614    0.1630
PKU Gel Unflavored              50600051448             none      5060014051448   0.1614   0.1630 *
(24 g)
TYR Cooler                      50600053992             none      5060014053992   0.0448    0.0464
TYR Express Powder              50600053848             none      5060014053848   0.3498    0.3596
TYR Gel                         50600053800             none      5060014053800   0.2589    0.2605
TYR Gel Unflavored              50600051509             none      5060014051509   0.2589   0.2605 *
(24 g)
Tyrosine Amino Acid             50600054791             none      5060014054791   0.9688    0.9786
Supplement
Valine 1000 Amino               50600055132             none      5060014055132   0.9688    0.9786
Acid Supplement
Valine Amino Acid               50600054333             none      5060014054333   0.7187    0.7285
Supplement




 * Effective March 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                            January 2012
 enteral
 28
 SPECIALTY INFANT ENTERAL NUTRITION (Authorization always required and subject to limitations)

 Abbott: 1-800-558-7677
                                               Medi-Cal                                    MAC        EAC
                      Product Label             Billing     UPC number     UPC number     per g       per g
Type                       Name                Number          (item)        (case)       or ml       or ml
Extensively           Similac Expert         70074057664   070074576640   070074576633   0.0600 *   0.0616 **
hydrolyzed            Care
                      Alimentum
                      w/iron powd
                      (454 g)
Extensively           Similac Expert         70074057513   070074575131   070074575124   0.0097 *   0.0113 **
hydrolyzed            Care
                      Alimentum
                      w/iron RTF
                      (946 ml)
Extensively           Similac Expert         70074057509   070074575094   070074575087   0.0097 *   0.0113 **
hydrolyzed            Care
                      Alimentum
                      w/iron RTF
                      (237 ml)
Prem/LBW              Similac Expert         70074057431   070074574318   070074574301   0.0382 *   0.0398 **
                      Care Neosure
                      powd (371 g)
Prem/LBW              Similac Expert         70074057456   070074574561   070074574554   0.0075 *   0.0091 **
                      Care Neosure
                      RTF (946 ml)
Prem/LBW              Similac                70074059583   070074595832   070074595825   0.0150 *   0.0166 **
                      Special Care
                      24 (kcal)
                      w/iron RTF
                      (59 ml)
Prem/LBW              Similac                70074056295   070074562957   070074562940   0.0235 *   0.0251 **
                      Special Care
                      30 (kcal)
                      w/iron RTF
                      (59 ml)
Prem/LBW              Similac Human          70074054599   070074545998   070074545981   1.2271 *   1.2287 **
HMF                   Milk Fortifier
                      powd (0.9 g)
100% AA               Elecare                70074053511   070074535111   070074552514   0.0800 *   0.0816 **
                      Infant – powd
                      (400 g)
Renal/related         Similac PM             70074060850   070074608501   070074008509   0.0400 *   0.0416 **
                      60/40 powd
                      (400 g)




 * Effective January 1, 2012
 ** Effective April 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                                     January 2012
                                                                                                  enteral
                                                                                                      29
 Mead Johnson: 1-800-457-3550
                                               Medi-Cal                                   MAC        EAC
                      Product Label             Billing     UPC number     UPC number     per g     per g
Type                        Name               Number          (item)        (case)       or ml     or ml
Prem/LBW              Enfacare Lipil         00087001944   300870019448   300870019042   0.0385    0.0401 *
                      powd (363 g)
Prem/LBW              Enfacare Lipil         00087128741   300871287419   300871287013   0.0068    0.0084 *
                      RTU
                      22 kcal
                      (946 ml)
Prem/LBW              Enfamil                00087139241   300871392410   300871392014   0.0155    0.0171 *
                      Premature Lipil
                      with Iron 20 cal
                      (59 ml)
Prem/LBW              Enfamil                00087139441   300871394414   300871394018   0.0155    0.0171 *
                      Premature Lipil
                      Low Iron 20
                      cal
                      (59 ml)
Prem/LBW              Enfamil                00087139141   300871391413   300871391017   0.0155    0.0171 *
                      Premature Lipil
                      low iron 24 cal
                      (59 ml)
Prem/LBW              Enfamil                00087139341   300871393417   300871393011   0.0155    0.0171 *
                      Premature Lipil
                      w/iron 24 cal
                      (59 ml)
Extensively           Nutramigen             00087049901   300870499011   300870499110   0.0087    0.0103 *
hydrolyzed            Lipil RTU
                      (946 ml)
Extensively           Nutramigen             00087049801   300870498014   300870498113   0.0160    0.0176 *
hydrolyzed            Lipil Conc
                      Liquid
                      (384 ml)
Extensively           Nutramigen             00087033801   300870338013   300870338211   none      0.0616 *
hydrolyzed            Lipil Powder
                      (454 g)
Extensively           Nutramigen             00087123941   300871239418   300871239012   0.0602    0.0618 *
hydrolyzed            Enflora LGG
                      Lipil powd
                      (357 g)
100% AA               Nutramigen             00087129049   300871290495   300871290099   0.0722    0.0738 *
                      AA Lipil powd
                      (400 g)
Fat                   Pregestimil            00087036701   300870367013   300870367211   0.0604    0.0620 *
Malabsorption         Lipil Powder
                      (454 g)
Chylothorax/          Enfaport Lipil         00087128941   300871289413   300871289017   0.0104    0.0120 *
LCHAD                 RTU (237 ml)


 * Effective April 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                                   February 2012
 enteral
 30

 SHS/Nutricia North America: 1-800-365-7354
                                                                           UPC number
                                               Medi-Cal                       (case)        MAC
                      Product Label             Billing     UPC number    (for reference    per g   EAC per
Type                     Name                  Number          (item)          only)        or ml   g or ml
100% AA               Neocate Infant         49735012595   749735025956   749735125953     0.0744   0.0760 *
                      w/DHA ARA
                      powd (400 g)


 * Effective April 1, 2012




 2 – Enteral Nutrition: List of Available Products
                                                                                                    February 2012
                                                                                                                  enteral
                                                                                                                      31
Specialty infant nutrition products are subject to the following limitations *:
Premature or Low Birth Weight:
    20 or 22 kcal/ounce
    24 or 30 kcal/ounce
    Human Milk Fortifier (HMF)
Products                        Patients are limited to:                    And product is limited to:
Enfamil Premature Lipil            0 – 9 months current Corrected            Sole source nutrition provision
(20 or 24)                           Age * (CA), and                            only until the latter of 6 months
Enfacare Lipil (22)                Born prior to 37 weeks gestation,           Corrected Age or Actual Age, and
Similac Expert Care                  and                                      Two month maximum
Neosure Infant (22)                Birth weight < 3500 g, and                  authorization term (one month
Similac Expert Care                If HMF, patient may only receive            maximum authorization term for
Neosure Advance                      product until weight reaches               HMF), and
Similac Special Care                 3600 g. No product shall be              Authorization ends at 9 months
(24 or 30)                           authorized after 3600 g body               post-hospital discharge date for
Similac Human Milk                   weight is achieved (weight gain is         20 or 22 kcal products, or
Fortifier (HMF)                      presumed to be 33 – 34 g/day             If product is 24 kcal or 30 kcal,
                                     when calculating 31 day supply             infant shall be currently < 3500 g
                                     limits).                                   and maximum authorization term
                                                                                is one month per authorization;
                                                                                and
                                                                              If HMF, infant shall be fully breast
                                                                                fed and no other infant nutrition
                                                                                product is covered
                                                                                simultaneously.
Extensively Hydrolyzed (“hypo-allergenic,” “semi-elemental”)
Products                       Patients are limited to:                     And product is limited to:
Nutramigen Lipil (liquid           0 – 9 months Actual Age, and              Sole source nutrition provision
or powder, but not                 Diagnosed cow’s milk protein                only until the latter of 6 months
Nutramigen AA)                       allergy, or                                Corrected Age or Actual Age, and
Nutramigen Enflora                 Other diagnosed breast milk or            Powdered form only, or
LGG Lipil ** (contains               infant formula intolerance exists        Liquid form is permitted when
probiotic)                           and is documented in the medical           infant is born <34 weeks
Pregestimil                          record (see medical criteria in this       gestation or birth weight is
Similac Expert Care                  section).                                  < 1800 g, or infant is diagnosed
Alimentum                                                                       with immune function disorder,
                                                                                and
                                                                              Two month maximum
                                                                                authorization term, and
                                                                              Authorization ends at 12 months
                                                                                Actual Age, and
                                                                              ** Nutramigen Enflora LGG Lipil
                                                                                is not authorized for infants:
                                                                                a. With immune function
                                                                                    disorders. or
                                                                                b. < 3500 g at authorization, or
                                                                                c. Prior to documented medical
                                                                                    intolerance to Nutramigen Lipil
                                                                                    (ready to feed, concentrate, or
                                                                                    powder, not Nutramigen AA),
                                                                                    or Similac Expert Care
                                                                                    Alimentum.




2 – Enteral Nutrition: List of Available Products
                                                                                                                      March 2012
enteral
32
100% Amino Acid Based (entire protein content is in the form of AA)
Products                      Patients are limited to:                     And product is limited to:
Nutramigen AA Lipil              0 – 9 months Actual Age, and               Sole source nutrition provision
Elecare                          Only after extensively hydrolyzed            only until the latter of 6 months
Neocate                             protein products are medically             Corrected Age or Actual Age, and
                                    documented as tried, failed, and         Two month maximum
                                    unsafe for use, or in hospital use         authorization term, and
                                    established need for product at          Authorization ends at 12 months
                                    discharge, and                             Actual Age.
                                 Other diagnosed breast milk or
                                    infant formula intolerance exists
                                    and is documented in the medical
                                    record (see Medical Criteria in
                                    this section).
Fat Malabsorption Products
Products                      Patients are limited to:                     And product is limited to:
Elecare                          0 – 9 months Actual Age, and               Sole source nutrition provision
Neocate                          Diagnosed fat malabsorption not              only until the latter of 6 months
Pregestimil                         effectively addressed by breast            Corrected Age or Actual Age, and
                                    milk, regular infant formula, and        Two month maximum
                                    extensively hydrolyzed protein             authorization term, and
                                    products.                                Authorization ends at 12 months
                                                                               Actual Age.
Renal, Infant Product
Products                           Patients are limited to:                And product is limited to:
Similac PM 60/40                      0 – 9 months Actual Age, and          Sole source nutrition provision
                                      Diagnosed renal function                only until the latter of 6 months
                                        impairment, or hypercalcemia, or       Corrected Age or Actual Age, and
                                        hypocalcemia due to                  Two month maximum
                                        hyperphosphatemia.                     authorization term, and
                                                                             Authorization ends at 12 months
                                                                               Actual Age
Chylothorax or LCHAD Product
Products                     Patients are limited to:                      And product is limited to:
Enfaport Lipil                  0 – 9 months Actual Age, and                Sole source nutrition provision
                                Only for diagnosed chylothorax or             only until the latter of 6 months
                                  LCHAD deficiency (Long-chain 3-              Corrected Age or Actual Age, and
                                  hydroxyacyl-CoA dehydrogenase              Two month maximum
                                  deficiency)                                  authorization term, and
                                                                             Authorization ends at 12 months
                                                                               Actual Age


All specialty infant product types are authorized as sole source nutrition only for patients between birth
and 6 months of age because the introduction of solid foods begins at 6 months (per American Academy
of Pediatrics recommendation). Infant nutrition product in quantities that exceed the 6-month-old’s daily
caloric requirement is therefore not authorized beyond 6 months of age unless significant medical criteria
and documentation demonstrating complete intolerance to early solid foods accompanies a request for
authorization for any infant product, for the purposes of calculating 31-day supply quantity limits. See the
“Medical Criteria” and “Required Documentation” portions of the Enteral Nutrition overview for
requirements.

* Corrected Age (CA) example: If birth date is 36 weeks gestation (4 weeks early) then remove 4 weeks
  from Actual Age since birth to get CA. CA is always younger than Actual Age when infant is born prior
  to 37 weeks gestation. Infants born after 37 weeks gestation are not premature by definition.




2 – Enteral Nutrition: List of Available Products
                                                                                                                   February 2012

								
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