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25.4.2.2 Medical Nutritional Products Formulary
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Product Name
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Local Code
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The following products are billed with procedure code A9150:
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Isoleucine, any strength
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Not applicable
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L-arginine or L-arginine MCH, powder, 1000 g
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5491X
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L-citrulline, 500 mg caps, per 50
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5246X
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L-citrulline, powder, any strength
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Not applicable
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Valine, any strength
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Not applicable
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The following products are billed with procedure code B4100:
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Nutra-thick, 8 oz. can, each, concentrated
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5328X
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Nutra-thick, single portion packets, each, concentrated
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5329X
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Simply Thick, all sizes
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Not applicable
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Thick-it, 240 g, administered orally, per ounce
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184NS
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Thick-it, powder, 240 g, each, concentrated
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5139X
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Thick-it, powder, 900 g, administered orally, per ounce
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143NS
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The following products are billed with procedure code B4150:
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Boost high protein (Sustacal), 946 mL
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152NS
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Boost with fiber (Sustacal with fiber), 237 mL
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153NS
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Boost, 237 mL
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151NS
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Ensure bottles, 8 oz., each
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5082X
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Ensure fiber with nutraflora FOS
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5140X
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Ensure, liquid, 240 mL, each
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5079X
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Ensure, liquid, 960 mL, each
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5080X
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Ensure, powder, 420 g, each
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5081X
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Entrition 0.5, 1,000 mL
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106NS
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Entrition HN, 1,000 mL
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107NS
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Fibersource HN, 250 mL, per can
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5006X
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Fibersource, 250 mL, per can
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5001X
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Forta drink, powder, 428 g
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108NS
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Forta shake, 470 g
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158NS
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Forta shake, 530 g
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159NS
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Isocal HN, 237 mL
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163NS
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Isocal, 355 mL
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111NS
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Isocal, liquid, 237 mL, each
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5084X
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Isocal, liquid, 946 mL, each
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5085X
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Isomil SF, liquid, concentrate, 390 mL, each
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5369X
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Isomil-DF, liquid, 960 mL, each
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5335X
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Isosource HN, 250 mL, per can
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5013X
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Isosource, 250 mL, per can
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5009X
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Jevity plus, ready-to-hang, 1,000 mL, each
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5088X
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Jevity, liquid, 240 mL, each
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5086X
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Jevity, liquid, 960 mL, each
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5087X
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Kindercal ready-to-use, liquid, 237 mL, each
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5393X
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Lacto-free, liquid, concentrate, 390 mL, each
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5360X
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Lacto-free, powder, 420 g, each
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5342X
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Lacto-free, ready-to-use, liquid, 960 mL, each
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5361X
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Meritene, powder, 2,160 g
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115NS
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Meritene, powder, 480 g
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114NS
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Nursoy, concentrate, 390 mL
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5369X
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Nursoy, powder, 453 g
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5398X
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Nursoy, ready-to-use, 960 mL
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5397X
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Nutra shake with fiber, 180 mL
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122NS
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Nutra shake, 120 mL
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117NS
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Nutra shake, 120 mL, chocolate
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167NS
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Nutra shake, 120 mL, lemon
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164NS
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Nutra shake, 120 mL, strawberry
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165NS
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Nutra shake, 120 mL, vanilla
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166NS
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Nutra shake, 180 mL
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118NS
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Nutra shake, 180 mL, chocolate
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171NS
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Nutra shake, 180 mL, lemon
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168NS
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Nutra shake, 180 mL, strawberry
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169NS
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Nutra shake, 180 mL, vanilla
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170NS
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Nutra shake, 240 mL
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119NS
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Nutra shake, 240 mL, chocolate
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175NS
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Nutra shake, 240 mL, lemon
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172NS
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Nutra shake, 240 mL, strawberry
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173NS
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Nutra shake, 240 mL, vanilla
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174NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, chocolate
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124NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, orange pineapple
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126NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, orange-citrus
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125NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, peach-citrus
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127NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, powder, 436 g
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123NS
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Nutra shake, 99 percent (99%) lactose free, 120 mL, strawberry
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128NS
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Nutra shake, 99 percent (99%) lactose free, 240 mL, chocolate
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129NS
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Nutra shake, 99 percent (99%) lactose free, 240 mL, strawberry
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130NS
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Nutra shake, 99 percent (99%) lactose free, 240 mL, vanilla
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131NS
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Nutrament, 355 mL
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132NS
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Nutren 1.0 with or without fiber, liquid, 250 mL, each
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5275X
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Nutren Jr., 250 mL, each, vanilla
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5036X
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Nutren Jr., with fiber, 250 mL, each, vanilla
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5848X
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Osmolite HN, 1,000 mL
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135NS
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Osmolite HN, 240 mL
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133NS
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Osmolite HN, 960 mL
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134NS
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Osmolite, liquid, 240 mL, each
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5093X
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Osmolite, ready-to-hang, 1,000 mL, each
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5095X
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Osmolite, ready-to-use, liquid, 960 mL, each
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5094X
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Pediasure with fiber, liquid, 240 mL, each
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5348X
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Pediasure, liquid, 240 mL, each
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5096X
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Portagen, powder, 454 g, each
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5154X
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Profiber, liquid, 250 mL, each
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5350X
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Prosobee, Isomil, Similac, SMA, Enfamil, liquid, 240 mL, each
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5186X
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Prosobee, Isomil, Similac, SMA, Enfamil, liquid, 960 mL, each
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5217X
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Prosobee, Isomil, Similac, SMA, Enfamil, liquid, concentrate, 390 mL, each
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5184X
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Prosobee, Isomil, Similac, SMA, Enfamil, powder, 420 g, each
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5185X
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Resource Just for Kids, liquid, 237 mL, any flavor, each
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5018X
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Resource, liquid, 237 mL, any flavor, each
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5021X
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Sustacal, 8 oz. or 240 mL, each
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5099X
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Sustacal, gel, 150 g, each
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5309X
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Sustacal, powder, 454 g, each
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5331X
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The following products are billed with procedure code B4152:
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Comply, 237 mL
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103NS
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Deliver, 237 mL
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105NS
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Ensure plus HN, 240 mL
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5439X
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Ensure plus, 960 mL
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156NS
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Ensure plus, liquid, 240 mL, any flavor, each
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157NS
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Ensure pudding, powder, 150 g, each
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5083X
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Nutren 1.5, liquid, 250 mL, each
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5276X
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Nutren 2.0, liquid, 250 mL, each
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5277X
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Resource plus, liquid, 237 mL, any flavor, each
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5354X
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Respalor, liquid, 237 mL, each
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5341X
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Scandishake, powder, 85 g
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183NS
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Similac special care with iron, liquid, 120 mL, each
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5345X
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Sustacal plus, liquid, 237 mL, each
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5471X
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Two-cal HN, 237 mL
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145NS
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Two-cal, liquid, 237 mL, each
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5121X
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Ultracal, liquid, 237 mL, each
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5251X
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The following products are billed with procedure code B4153:
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Alimentum with iron, liquid, 240 mL, each
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5349X
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Alimentum with iron, liquid, 960 mL, each
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5149X
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Criticare HN, 237 mL
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104NS
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Isotein HN, powder, 82.2 g
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112NS
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Neocate one plus, liquid, 237 mL
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5028X
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Neocate one plus, powder, 100 g
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5029X
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Neocate, powder, 400 g
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5025X
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Nutramigen, liquid, concentrate, 390 mL, each
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5089X
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Nutramigen, powder, 480 g, each
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5091X
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Nutramigen, ready-to-use, liquid, 960 mL, each
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5090X
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Peptamen Jr., 1,000 mL
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136NS
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Peptamen Jr., liquid, 250 mL, each
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5395X
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Peptamen, 1,000 mL
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176NS
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Propeptide for kids, 250 mL
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181NS
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Propeptide, 250 mL
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180NS
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Reabilian
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182NS
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Tolerex powder, 80 g packet, each
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5244X
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Tolerex 80 mL
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185NS
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Travasorb HN, powder, 83.3 g
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146NS
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Vital high nitrogen, powder, packet, each
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5142X
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Vivonex pediatric, powder, 48.5 g, packets, each
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5023X
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The following products are billed with procedure code B4154:
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Acerflex, powder, 454 g, each
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5467X
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Alitraq, powder, 80 g packets, each
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5340X
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Amin-aid
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100NS
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Calcilo XD, 400 g
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101NS
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Citrotein, powder, 424.8 g
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102NS
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Crucial, liquid, 250 mL, each
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5468X
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Cyclinex-1, with iron, powder, 400 g, each
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5319X
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Cyclinex-2, powder, 400 g, each
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5320X
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Glucerna, 1,000 mL
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109NS
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Glucerna, liquid, 240 mL, each
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5478X
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Glutarex-1, powder, 400 g, each
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5432X
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Glutarex-2, powder, 400 g, each
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5433X
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Hepatic aid II instant drink, powder
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110NS
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Hepatic aid II instant drink, powder, chocolate
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160NS
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Hepatic aid II instant drink, powder, custard
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161NS
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Hepatic aid II instant drink, powder, egg nog
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162NS
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HOM-1, 500 g
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5437X
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HOM-2, powder, 500 g, each
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5425X
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Hominex-1, powder 400 g, each
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5434X
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Hominex-2, powder, 400 g, each
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5435X
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Impact, liquid, 250 mL, each
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5228X
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KetoCal, powder, 300 g, each
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Not applicable
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Ketonex-1 with iron, powder, 400 g, each
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5313X
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Ketonex-2, powder, 400 g, each
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5314X
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Lipisorb, liquid, 240 mL, each
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5241X
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Lipisorb, powder, 454 g, each
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5237X
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Lofenalac, powder, 454 g, each
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5413X
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Magnacal renal, 237 mL
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113NS
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MSUD diet, powder, 480 g, each
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5310X
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MSUD maxamaid, powder, 454 g, each
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5151X
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MSUD-1, powder, 500 g, each
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5311X
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MSUD-2, powder, 500 g, each
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5312X
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Nepro, liquid, 240 mL, each
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5283X
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Neutra-phos, 64 g, bottle, each
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5343X
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Nutrirenal, all sizes
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Not applicable
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Nutrivent 1.5, liquid, 250 mL, each
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5281X
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Peptamen, liquid, 250 mL, each
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5278X
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Periflex, 454 g per can
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5390X
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Phenex-1, powder, 400 g, each
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5422X
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Phenex-2, powder, 400 g, each
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5423X
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Phenylade bar
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137NS
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Phenylade mix, amino acid blend, powder, 454 g, each
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5030X
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Phenylfree, powder, 480 g, each
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5414X
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Phlexy 10, bar
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177NS
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Phlexy 10, capsule 200, not VDP
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178NS
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Phlexy 10, drink mix, powder, 20 g
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179NS
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PKU 2, powder, 500 g, each
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5420X
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PKU 3, powder, 500 g, each
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5421X
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Pregestimil, powder, 454 g
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5122X
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Product 3200 AB/diet, powder, 454 g
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5424X
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Product 3232 A-diet, powder, 454 g, each
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5436X
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Product 80056, powder, 454 g, each
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5240X
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Pro-phree, powder, 400 g, each
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5469X
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Pulmocare, liquid, 240 mL, each
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5120X
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RCF, liquid, 13 oz., each
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5470X
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Reabilan, liquid, 375 mL, each
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5123X
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Replete, liquid, 250 mL, each
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5279X
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Replete with fiber, 250 mL, each
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5280X
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Resource diabetic, 240 mL
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139NS
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Resource diabetic, 1,000 mL
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140NS
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Resource diabetic, 1,500 mL
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141NS
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Resource instant crystals, powder
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142NS
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Scandishake, powder, 540 g, each
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5260X
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Similac PM, 40/60, powder, 480 g, each
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5391X
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Suplena, liquid, 240 mL, each
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5182X
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Traumacal, 237 mL
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144NS
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Travasorb MCT, powder, 89 g
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147NS
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Tyr1/Tyr2, powder, 500 g, each
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5472X
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Tyromex 1, powder, 350 g, each
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5473X
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UCD 1 or UCD 2, 500 g, each
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5372X
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Vitaneed formula, 8 oz., each can
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5231X
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Vivonex 10, powder, 80.4 g packets, each
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5138X
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XP analog, powder, 400 g, each
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5417X
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XP maxamaid, 454 g, flavored or unflavored
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5415X
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XP maxamum, 454 g, flavored or unflavored
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5418X
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The following products are billed with procedure code B4155:
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Casec, powder, 283 g
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154NS
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Duocal, powder, 400 g
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155NS
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Human milk fortifier, per packet
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5373X
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MCT, oil, 960 mL, each
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5183X
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Microlipid, 89 mL, each
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5347X
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Moducal, powder, 368 g
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116NS
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Polycose, liquid, 126 mL, each
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5097X
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Polycose, powder, 350 g, each
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5098X
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Promod, powder, 291 g, each
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5152X
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Propac, powder, 350 mg
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138NS
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Provimin, powder, 150 g each
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5150X
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Vari-flavors
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149NS
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Vivonex, flavor packets, powder, 2.5 g
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150NS
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The following products are billed with procedure code B9998:
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Scandical, 8 oz. can, each
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5476X
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Disposable G tube adapter set, each
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5362X
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Flavonex, powder, 600 g, each
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5326X
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Formula not elsewhere listed
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5181X
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Human milk, per ounce
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5495X
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Neutra-phos (1.25 g packets), 100-unit dose pack
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5282X
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In addition to the products tabled above, the CSHCN Services Program also covers the procedure codes listed in the following table:
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