Medi-Cal Rx List of Covered Enteral Nutrition Products ...

1 Medi-Cal Rx List of Covered Enteral Nutrition Products Effective January 1, 2021 December 18, 2020 Effective for dates of service on or after January 1, 2021, the existing Medi-Cal Fee-For-Service List of Enteral Nutrition Products is updated with certain product additions, deletions, and costs. Medi-Cal Rx claims submitted on or after April 1, 2021, for Enteral Nutrition Products require prior authorization and must be a product on the updated Medi-Cal Rx List of Covered Enteral Nutrition Products . The updated list is attached below, along with the list of deletions effective January 1, 2021. Effective December 18, 2020, the list is also available in Excel format on the Medi-Cal Rx Web Portal in the Forms and Information Section. Note that the list attached in this bulletin is current as of December 18, 2020. Any future changes to the list will be made in the Excel spreadsheet only.

2 The spreadsheet will also be linked in the Medi-Cal Rx provider Manual. 1 Medi-Cal Rx List of Covered Enteral Nutrition Products This spreadsheet contains Enteral Nutrition Products eligible for reimbursement under Medi-Cal Rx when billed by Medi-Cal Fee-For-Service (FFS) pharmacy providers. Refer to the Enteral Nutrition section of the Medi-Cal Rx provider Manual for coverage and established criteria, quantity limits, and additional billing information. This spreadsheet is subject to change with notification in the provider bulletins. "EAC" (Estimated Acquistion Cost) is the maximum product cost reimbursed. The manufacturers have guaranteed, upon request, that Medi-Cal FFS pharmacy providers can purchase the Products at or below the Maximum Acquisition Cost (MAC) for dispensing to eligible Medi-Cal recipients and bill to Medi-Cal Rx. To receive reimbursement, the NDC/UPC on each product package dispensed must be an exact match to a product NDC/UPC in this spreadsheet and the NDC billing code submitted on the claim.

3 In addition to the established criteria, the product-specific criteria in this spreadsheet must be met. Product Category Sub-Category Manufacturer Product Label Name Product-Specific Criteria Caloric density kcal/g or ml) Protein per g or ml) NDC Billing Code UPC Number per Item (For Reference Only) UPC Number per Case (For Reference Only) MAC per gm or ml EAC per gm or ml Effective Date of Change Description of Change Standard Abbott Nutrition ; 1-800-227-5767 JEVITY 1 CAL 1500 ML READY TO HANG For tube-fed only patients 70074062688 070074626888 070074626871 January 1, 2021 No Change Standard Abbott Nutrition ; 1-800-227-5767 JEVITY 1 CAL 1L READY TO HANG For tube-fed only patients 70074062686 070074626864 070074626857 January 1, 2021 No Change Standard Abbott Nutrition ; 1-800-227-5767 JEVITY CAL 8OZ RECLOSEABLE CARTON For patients who are tube-fed only or have altered taste perception 70074064758 070074647586 070074647593 January 1, 2021 No Change Standard Abbott Nutrition ; 1-800-227-5767 JEVITY CAL READY TO HANG For tube-fed only patients 70074062668 070074626680 070074626673 January 1, 2021 Updated MAC and EAC amounts Standard Abbott Nutrition ; 1-800-227-5767 JEVITY CAL 1L READY TO HANG For tube-fed only patients 70074062684 070074626840 070074626833 January 1, 2021 Updated MAC and EAC amounts Standard Abbott Nutrition ; 1-800-227-5767 JEVITY CAL 8OZ RECLOSEABLE CARTON For patients who are tube-fed only or have altered taste perception 70074064624 070074646244 070074646251 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition .

4 1-888-240-2713 Fibersource HN SpikeRight Plus UltraPak 4x1500ml For tube-fed only patients 43900018582 00043900185828 10043900185832 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Fibersource HN SpikeRight Plus UltraPak 6x1000ml For tube-fed only patients 43900018588 00043900185880 10043900185887 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Fibersource HN, unflavored, 24x250ml Tetra Prisma For tube-fed only patients 43900018555 00043900185552 10043900185504 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Nutren Fiber unflavored, 24x250ml Tetra Prisma For tube-fed only patients 98716006056 00798716060561 00798716160568 January 1, 2021 No Change Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Nutren , unflavored, 24x250ml Tetra Prisma For tube-fed only patients 98716006210 00798716062107 00798716162104 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Replete Fiber SpikeRight 4x1500ml For tube-fed only patients 98716016359 00798716163590 10798716263594 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Replete Fiber SpikeRight PLUS UltraPak 6x1000ml For tube-fed only patients 98716016358 000798716163583 10798716263587 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Replete Fiber, unflavored, 24x250ml Tetra Prisma 98716006245 00798716062459 00798716162456 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition .

5 1-888-240-2713 Replete SpikeRight PLUS UltraPak 6 x1000ml For tube-fed only patients 98716016356 00798716163569 10798716263563 January 1, 2021 Updated MAC and EAC amounts Standard Nestl HealthCare Nutrition ; 1-888-240-2713 Replete, unflavored, 24x250ml Tetra Prisma For tube-fed only patients 98716006249 00798716062497 00798716162494 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE 1 CAL READY TO HANG For tube-fed patients requiring less than 2000 calories per day or increased protein requirements 70074062696 070074626963 070074626956 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE 1 CAL 1L READY TO HANG For tube-fed patients requiring less than 2000 calories per day or increased protein requirements 70074062692 070074626925 070074626918 January 1, 2021 Updated MAC and EAC amounts 2 Product Category Sub-Category Manufacturer Product Label Name Product-Specific Criteria Caloric density kcal/g or ml) Protein per g or ml) NDC Billing Code UPC Number per Item (For Reference Only) UPC Number per Case (For Reference Only) MAC per gm or ml EAC per gm or ml Effective Date of Change Description of Change Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition .

6 1-800-227-5767 OSMOLITE 1 CAL 8OZ RECLOSEABLE CARTON For patients requiring less than 2000 calories per day or increased protein requirements 70074064632 070074646329 070074646336 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE CAL READY TO HANG For tube-fed patients requiring less than 2000 calories per day or increased protein requirements 70074062694 070074626949 070074626932 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE CAL 1L READY TO HANG For tube-fed patients requiring less than 2000 calories per day or increased protein requirements 70074062698 070074626987 070074626970 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE CAL 8OZ RECLOSEABLE CARTON For patients requiring less than 2000 calories per day or increased protein requirements 70074064634 070074646343 070074646350 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE CAL 1L READY TO HANG For patients requiring less than 2000 calories per day or increased protein requirements.

7 AND documentation showing patient is not maintained on a lower kcal/g or ml product 70074062700 070074627007 070074626994 January 1, 2021 Updated MAC and EAC amounts Standard Caloric-restriction; high protein tube- feeding formula Abbott Nutrition ; 1-800-227-5767 OSMOLITE CAL 8OZ RECLOSEABLE CARTON For patients requiring less than 2000 calories per day or increased protein requirements; AND documentation showing patient is not maintained on a lower kcal/g or ml product 70074064835 070074648354 070074648378 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition ; 1-800-227-5767 ENSURE PLUS BUTTER PECAN 8OZ RECLOSEABLE CARTON For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074064908 070074649085 070074649092 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition ; 1-800-227-5767 ENSURE PLUS CHOCOLATE 8OZ RECLOSEABLE CARTON For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074064910 070074649108 070074649115 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition .

8 1-800-227-5767 ENSURE PLUS STRAWBERRY 8OZ RECLOSEABLE CARTON For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074064906 070074649061 070074649078 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition ; 1-800-227-5767 ENSURE PLUS VANILLA 8OZ RECLOSEABLE CARTON For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074064904 070074649047 070074649054 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition ; 1-800-227-5767 JEVITY CAL READY TO HANG For tube-fed only patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074062690 070074626901 070074626895 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition ; 1-800-227-5767 JEVITY CAL 1L READY TO HANG For tube-fed only patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 70074062682 070074626826 070074626819 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Abbott Nutrition .

9 1-800-227-5767 JEVITY CAL 8OZ RECLOSEABLE CARTON For tube-fed OR taste-altered patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted 70074064626 070074646268 070074646282 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition ; 1-888-240-2713 Boost Plus Creamy Strawberry 27x237ml Tetra Brik For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 43900093338 00043900933382 10043900933310 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition ; 1-888-240-2713 Boost Plus Rich Chocolate 27x237ml Tetra Brik For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 43900093239 00043900932392 10043900932382 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition ; 1-888-240-2713 Boost Plus, Creamy Strawberry 24x 237ml For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 41679093366 00041679933008 00041679933367 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition .

10 1-888-240-2713 Boost Plus, Rich Chocolate, 24x 237ml For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 41679093266 00041679932001 00041679932360 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition ; 1-888-240-2713 Boost Plus, Very Vanilla 27x237ml Tetra Brik For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 43900093139 00043900931395 10043900931385 January 1, 2021 Updated MAC and EAC amounts Standard Calorie-dense formula Nestl HealthCare Nutrition ; 1-888-240-2713 Boost Plus, Very Vanilla, 24x 237ml For patients with documentation they have tried and failed lower kcal/ g or ml standard Products on this List OR require a calorie-dense, volume restricted diet 41679093166 00041679931004 00041679931363 January 1, 2021 Updated MAC and EA