ccs restricted enteral nutrition products list- march · pdf fileccs restricted...
TRANSCRIPT
MEDI-CAL
"CONTRACTED"
ENTERAL
NUTRITION
PRODUCTS
(Highlighted in
yellow.)
CCS Restricted "Enteral" Nutrition Products List- March 2011 (This listing reflects January 2011 updates from Medi-Cal)
METABOLIC, STANDARD AND DIABETIC ENTERAL NUTRITION PRODUCTS ARE CONTRACTED BY MEDI-CAL: When authorizing metabolic, standard
or diabetic enteral nutrition products, the product must be authorized by the "exact" PRODUCT NUMBER. Contracted products are yellow highlighted below for
easy identifation of product names and corresponding product numbers. If a metabolic, standard or diabetic enteral nutrition product is not listed below, it is NOT
contracted and therefore cannot be authorized. Listed contracted products do not have guaranteed availability. They also may not appear on the manufacturer
website. See This Computes!# 311 for Metabolic Enterals, This Computes! # 280 (Revised) for Standard Enterals, This Computes! #282 (Revised), and This
Computes! #286 for Diabetic Enterals.
Purpose: The following is a list of CCS "restricted" and Medi-Cal "contracted" enteral nutrition products that may be authorized by CCS. This list contains essential product information
needed for authorization of enteral nutrition products. The list displays "contracted" metabolic, standard and diabetic enteral nutrition products in yellow highlights. Each type of
contracted product is identified with either an "M" for metabolic, "S" for standard or "D" for diabetic and a future category of "SI" for specialty infant (not highlighted ) in the 3rd column.
The "non-contracted" enteral nutrition products which include all other types of enterals (NOT metabolic, standard and diabetic enterals) are shown without yellow highlights; these
products CAN BE authorized as usual. All listed product numbers have been verified as active in CMS Net and are Medi-Cal benefits. This list is NOT inclusive of every available
product, but it includes all contracted products and the vast majority of routinely prescribed non-contracted enteral nutrition products. Non-restricted products such as, parenteral nutrition
products are not included here. This list is compatable with the Restricted Drug and Enteral Product Billing Units tool which is used to obtain billing unit information
and is located at: http://www.dhcs.ca.gov/services/ccs/cmsnet/Documents/EnteralTool.pdf
How to Use This List: The columns in this tool contain categories of information that are needed for CCS reference and authorization. The listed products and corresponding product
numbers represent the most current "contracted" enteral products and the manufacturer product number for "non-contracted" products that are available in CMS Net. The pharmacy
vendor is responsible for providing an accurate product name and product number for all enteral nutrition product authorizations. For "contracted" enteral products, vendors can only use
the listed "contracted" product number. For "non-contracted" products, start with the vendor's product name and product number; check CMS Net and search for a product number
match with the name of the requested product. The dispensed product MUST match the product number that is authorized.
Need Help? If the pharmacy vendor provides a product name or product number that is NOT in CMS Net, locate the product on this tool and find the current product number. For
“contracted” products, specific product numbers listed in this document must be used. Other product numbers for "contracted" products will not be paid. For "non-contracted" product
information, multiple product numbers maybe used for authorization; this tool only provides one product number per product. Pharmacy vendors may provide you with UPC case numbers,
as well as product numbers. UPC case numbers are not used for CCS authorization. If pharmacies ask questions about UPC case numbers, refer them to the Medi-Cal Provider Manual:
http://files.medi-cal.ca.gov/pubsdoco/publications/mastersmtp/part2 /enteral_a04p00 .doc. Lastly, more product information can be found at the manufacturer hyperlink in the last column.
The complete URL for enteral nutrition product manufacturers is listed at the end of the tool. If you continue to have trouble finding a product or product number, contact Edan Lum, CMS
Branch Pharmaceutical Consultant at [email protected]
Updates: When you receive a request for a new or expired product (products in a NON-Contracted Category) and find that this list does not include the product or the listing is incorrect,
please email Edan Lum at [email protected] with the omission/change. Updates will occur semi-annually or when Medi-Cal updates "contracted" products.
Page 1 of 59
References: CCS NL: 04-0399
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Acerflex R M P (>1) Metabolic disorder:
MSUD
P 454gm can;
4/case
Pineapple 49735-0100-26/
49735-0188-42
Nutricia
Additions NA I, P, A Inadequate nutrient
intake/Increased
nutritional needs
P 947gm can;
4/case
Unflavored 00065-9270-91 Nestle
Add Ins (Phlexy-10) R M P (>4), A Metabolic disorder:
PKU
EA 18.2gm pkt;
40/case
Unflavored 49735-0126-41 Nutricia
Albumax NA A Inadequate nutrient
intake/Increased
protein needs
P 480gm btl;
4/case
Unflavored 66860-0612-12 Albumax
BCAD 1 R M I Metabolic disorder:
MSUD
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-4060-42 Mead Johnson
BCAD 2 R M P, A Metabolic
disorder:MSUD
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-0083-41 Mead Johnson
Vanilla 41679-0674-17
Chocolate 41679-0675-17
Strawberry 41679-0676-13
L 237ml can;
24/case
NestleBoost (Energy Drink) CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
S
This Computes! 191 Revised CCS NL: 20-0605List of Contracted Enteral Nutrition Products
Page 2 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Vanilla 00212-6743-13/ 41679-
0674-66/ 41679-0674-
17
Chocolate 00212-6753-13/ 41679-
0675-66/ 41679-0675-
17
Strawberry 00212-0676-13/ 41679-
0676-66/ 41679-0676-
17
Butter Pecan 41679-0987-66
Choclate
Mocha
41679-0677-66
Vanilla 00212-3601-62
Chocolate 00212-3602-62
Strawberry 00212-3603-62
Vanilla 41679-0941-07
Chocolate 41679-0040-07
Strawberry 41679-0944-07
Vanilla 00212-9413-13/ 41679-
0941-66/ 41679-0941-
07
Chocolate 41679-0940-66
Strawberry 41679-0944-66
Vanilla 43900-0335-11
Chocolate 43900-0335-20
Nestle
L 237ml btl;
24/case
Boost (Energy Drink)
S L 237ml brik;
27/case
237ml btl;
24/case
S
NestleBoost Kid Essential CD P Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml brik;
27/case
Nestle
Boost High Protein CD A Inadequate calorie
and nutrient
intake/Increased
protein needs
L 237ml can;
24/case
Nestle
A Diabetic feeding
when food is not
tolerated
D
CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
S
Boost Glucose Control
(AKA Boost Diabetic)
R
Page 3 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Strawberry 43900-0335-30
Vanilla 41679-0332-51
Chocolate 41679-0332-61
Strawberry 41679-0332-81
Vanilla 43900-0335-40
Chocolate 43900-0335-88
Strawberry 43900-0335-90
Boost Kid Essentials
(1.5 Cal) with Fiber
CD S P Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237mk brik;
27/case
Vanilla 43900-0335-00 Nestle
Vanilla 41679-0931-11
Chocolate 41679-0932-11
Strawberry 41679-0933-04
Vanilla 00212-9313-13/ 41679-
0931-66
Chocolate 00212-9323-13/ 41679-
0932-66
Strawberry 00212-9333-13/ 41679-
0933-66
Vanilla 41679-0157-21L 237ml can;
24/case
Nestle
Boost Plus (1.52 Cal) CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
S
A Inadequate calorie
and nutrient
intake/Increased
protein needs
Boost with Benefiber CD S
Nestle
S
S
L 237ml brik;
27/case
Nestle
237ml btl;
24/case
L 237ml can;
24/case
Boost Kids Essential
(1.5 Cal)
CD P Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml brik;
27/case
Nestle
Retail:
244ml can;
24/case
Boost Kid Essential CD P Inadequate calorie
and nutrient
intake/Increased
nutritional needs
Page 4 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Chocolate 41679-0158-01
Vanilla 83744-0401-03
Vanilla (with
fiber)
83744-0404-03
Chocolate 83744-0402-03
Strawberry 83744-0403-03
Calcilo XD R M I Hypercalcemia P 375gm can;
6/case
Unflavored 70074-0533-29 Abbott
Chocolate
Splash
00065-9050-71
Strawberry
Burst
00065-9050-72
Vanilla Swirl 00065-9050-70
Chocolate
Splash
00065-9050-74
Strawberry
Burst
00065-9050-75
Vanilla Swirl 00065-9050-73
S
S
LCD P, A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
S 250ml can;
24/case
Nestle
Carnation Instant
Breakfast (CIB),
Lactose Free Plus (1.5
Cal)
CD P, A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 250ml can;
24/case
Nestle
Carnation Instant
Breakfast (CIB),
Lactose Free
L 237ml can;
24/case
Nestle
Bright Beginnings- Soy
Pediatric with and
without fiber
CD P Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml can;
24/case
Bright
Beginnings
A Inadequate calorie
and nutrient
intake/Increased
protein needs
Boost with Benefiber CD S
Page 5 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Carnation Instant
Breakfast (CIB), VHC
Lactose Free (2.25
Cal)
CD S A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 250ml can;
24/case
Vanilla Swirl 00065-9050-76 Nestle
250ml
cans;
24/case
00212-1401-51
1000ml
RTH;
6/case
00212-1414-42
1500ml
RTH;
6/case
00212-1414-44
1000ml
RTH;
6/case
43900-0141-80
1500ml
RTH;
6/case
43900-0141-82
Compleat Pediatric CD S P (1-10) Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 250ml can;
24/case
Unflavored 00212-1424-51 Nestle
Nestle
Compleat SpikeRight CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L
UnflavoredL
Unflavored
Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
S
Compleat (Modified) SCD A
Page 6 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Complete Amino Acid
Mix
E M P (>1), A GI disorders P 200gm can;
2/case
Unflavored 49735-0101-24 Nutricia
Complex MSUD Amino
Acid Blend
R M P (>1), A Metabolic disorder:
MSUD
P 454gm can;
4/case
Unflavored 00847-0590-00 Applied Nutrition
Complex MSUD Drink
Mix
R M P (>1), A Metabolic disorder:
MSUD
P 454gm can;
4/case
Vanilla 00847-0598-22 Applied Nutrition
Complex MSUD
Essential Drink Mix
R M P (>1), A Metabolic disorder:
MSUD
P 454gm can;
4/case
Vanilla 00847-0597-22 Applied Nutrition
250ml can;
24/case
00065-9124-70
1000ml
RTH;
6/case
00065-9128-72
50428-7024-23
50428-7023-65
Unknown 50428-5613-99
Unknown 50428-5609-79
SCVS Nutritional Liquid CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
CD S
Nestle
A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml can;
6/case
L
CVSCVS Liquid Nutrition
L 237ml can;
6/case
Unknown
Crucial E UnflavoredA Inadequate calorie
and nutrient
intake/Increased
nutritional needs
Page 7 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Unknown 50428-5601-28
Chocolate 50428-1428-28
Strawberry 50428-1427-37
Vanilla 50428-1426-95
Chocolate 50428-1425-70
Strawberry 50428-1421-58
Vanilla 50428-1424-30
Chocolate 50428-7161-52
Vanillia 50428-7161-45
Cyclinex-1 R M I Metabolic disorder:
Urea cycle disorders
P 400gm can;
6/case
Unflavored 70074-0511-45 Abbott
Cyclinex-2 R M P, A Metabolic disorder:
Urea cycle disorders
P 400gm can;
6/case
Unflavored 70074-0511-47 Abbott
S
P, ACVS Whey Protein NA
237ml can;
6/case
L 237ml can;
6/case
P 454 gm can
Inadequate calorie
and nutrient
intake/Increased
nutritional needs
S
S
CVS Nutrition Liquid L
CVS Nutrition Plus
Liquid
CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
CD
CVS Nutritional Liquid CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
CVSInadequate protein
intake/increased
nutrient needs
A
CVS
L 237ml can;
6/case
Page 8 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
250ml can;
24/case
00212-3650-51
1000ml
RTH;
6/case
00212-3651-42
1500ml
RTH;
6/case
00212-3652-44
1000ml
RTH;
6/case
43900-0365-08
1500ml
RTH;
6/case
43900-0365-82
Duocal (AKA Super
Soluble Duocal)
NA M P (>1), A Inadequate nutrient
intake/Increased
caloric needs
P 400gm can;
4/case
Unflavored 49735-0102-80/ 49735-
0182-62
Nutricia
Grape 49735-0126-70
Orange-
Pineapple
49735-0110-50
Tropical Fruit 49735-0126-66
D
Nestle
Nutricia237ml brik;
27/case
Unflavored
E028 Splash (AKA
Pediatric E028)
E P (>1 ) GI disorders L
Diabetasource AC
SpikeRight
R A
DDiabetasource AC R A Diabetic feeding
when food is not
tolerated
L
Diabetic feeding
when food is not
tolerated
Unflavored
L
Page 9 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
EleCare E SI I, P GI disorders P 400gm can;
6/case
Unflavored 70074-0546-66/ 70074-
0535-11
Abbott
EleCare Vanilla E P (>1) GI disorders P 400gm can;
6/case
Vanilla 70074-0594-06 Abbott
Enfamil Enfacare Lipil R SI I Prematurity-VLBW P 400gm can;
6/case
Unflavored 00087-0019-44 Mead Johnson
Enfamil Human Milk
Fortifier
NA SI I Prematurity-VLBW EA 0.71gm pkt;
200/case
Unflavored 00087-2014-48 Mead Johnson
Enfamil Premature
Lipil 20 calorie, Low
Iron
R SI I Prematurity-VLBW L 89ml or 3oz
btl; 48/case
Unflavored 00087-2010-44 Mead Johnson
Enfamil Premature
Lipil 20 calorie, With
Iron
R SI I Prematurity-VLBW L 89ml or 3oz
btl; 48/case
Unflavored 00087-1405-42 Mead Johnson
Enfamil Premature
Lipil 24 calorie, Low
Iron
(Specialized Infant
Formula)
R SI I Prematurity-VLBW L 89ml or 3oz
btl; 48/case
Unflavored 00087-0267-44 Mead Johnson
Enfamil Premature
Lipil 24 calorie, With
Iron
R SI I Prematurity-VLBW L 89ml or 3oz
btl; 48/case
Unflavored 00087-1406-42 Mead Johnson
Page 10 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Enfaport Lipil R SI I Metabolic
/Chylothorax
L 8 oz can
RTU
Unflavored 00087-1289-41 Mead Johnson
Apple 70074-0547-77
Mixed Berry 70074-0534-63
Peach 70074-0547-80
70074056641/
70074056643
Ensure/Ensure
Immune Health
Homemade
Vanilla
70074-0504-61
Creamy Milk
Chocolate
70074-0504-63
Strawberries
& Cream
70074-0506-49
Coffee Latte 70074-0517-39
Butter Pecan 70074-0518-93
P 397gm can;
6/case
Vanilla Shake 70074-0607-50
Homemade
Vanilla
70074-0564-71
Abbott237ml can;
24/case
L 237ml can;
24/case
Abbott240ml brik;
27/case
L
LInadequate calorie
and nutrient
intake/Increased
nutritional needs
P (>4), ACDEnsure Enlive! (Clear
Liquid)
CD S P (>4), A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
CDEnure Bone Health P (>4), A Increased nutritional
needs
Abbott
Page 11 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Creamy Milk
Chocolate
70074-0564-74
Homemade
Vanilla
70074-0564-89
Creamy Milk
Chocolate
70074-0564-92
Strawberry
Cream
70074-0564-95
Ensure Fiber (FOS) Homemade
Vanilla
70074-0506-51
Creamy Milk
Chocolate
70074-0553-15
Vanilla 70074-0521-01
Chocolate 70074-0520-99
Wild Berry 70074-0521-05
AbbottL 237ml can;
24/case
237ml can;
24/case
SCD
L 237ml can;
24/case
Ensure High Protein CD P (>4), A Inadequate protein
and caloric
intake/increased
protein
needs/Volume limits
S
AbbottP (>4), A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Normalize gut
function
L
CDEnure Bone Health P (>4), A Increased nutritional
needs
Abbott
Increased nutritional
needs
L 237ml can;
24/case
AbbottEnsure Clinical
Strength
CD P (>4), A
Page 12 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Strawberry
Cream
70074-0564-83
Banana
Cream
70074-0564-86
Vanilla 70074-0504-65
Chocolate 70074-0504-67
Butter Pecan 70074-0518-95
Strawberry 70074-0506-47
Coffee Latte 70074-0517-41
E028 Splash (AKA
Pediatric E028)
E P Elemental,
hypoallergenic
L 237ml brik;
27/case
Grape 497385-0126-70 Nutricia
Essential Amino Acid
Mix
R M P (>1), A Metabolic disorder:
Urea Cycle
P 200gm can;
2/case
Unflavored 49735-0114-90 Nutricia
FAA E P, A GI disorders L 250ml can;
24/case
Unflavored 00065-9092-70 Nestle
Ensure Plus (1.5 Cal) CD P (>4), A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
L 237ml can;
24/case
AbbottS
LIncreased nutritional
needs
237ml
bottle;
16/case
AbbottEnsure Muscle Health CD P (>4), A
Page 13 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Fibersource (1.2 Cal) CD S A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume
limits/Normalize gut
function
L 250ml can;
24/case
Unflavored 00212-1835-51 Nestle
Fibersource HN (1.2
Cal)
CD S A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume
limits/Normalize gut
function
L 250ml can;
24/case
Unflavored 00212-1855-51/ 43900-
0185-56
Nestle
GA R M I, P, A Metabolic
disorder:Glutaric
Acidemia type 1
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0198-41 Mead Johnson
237ml can;
24/case
Vanilla 70074-0502-41
1000ml
RTH;
8/case
70074-0512-07
LR A Diabetic when food
is not tolerated
D Abbott
Unflavored
Glucerna (1.0 Cal)
Page 14 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
70074-0526-03
237ml can;
24/case
Vanilla 70074-0509-05
1000ml
RTH;
8/case
70074-0509-07
1500ml
RTH;
6/case
70074-0509-03
237ml can;
24/case
Vanilla 70074-0535-35
1000ml
RTH;
8/case
Unflavored 70074-0535-37
237ml can;
24/case
Vanilla 70074-0577-02
1000ml
RTH;
8/case
70074-0577-04
D
D Abbott
Glucerna Select R A Diabetic when food
is not tolerated
L Abbott
Unflavored
Diabetic when food
is not
tolerated/increased
caloric needs
Glucerna (1.5 Cal)
LR A Diabetic when food
is not tolerated
D
L
D
Abbott
Unflavored
Glucerna (1.2 Cal) R A Diabetic when food
is not tolerated
L Abbott
Unflavored
Glucerna (1.0 Cal)
R A
Page 15 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
70074-0577-06
Glutarex-1 R M I Metabolic
disorder:Glutaric
Aciduria Type I
P 400gm can;
6/case
Unflavored 70074-0511-41 Abbott
Glutarex-2 R M P, A Metabolic
disorder:Glutaric
Aciduria Type I
P 400gm can;
6/case
Unflavored 70074-0511-43 Abbott
HCY 1 R M I Metabolic disorder:
Homo-cystinuria
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-0095-41 Mead Johnson
HCY 2 R M P, A Metabolic disorder:
Homo-cystinuria
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-0199-41 Mead Johnson
HOM 2 (Milupa) R M P, A Metabolic disorder:
Homo-cystinuria
P 500gm can;
2/case
Unflavored 81361-0935-70 Milupa/Nutricia
Hominex-1 R M I Metabolic disorder:
B6 nonresponsive
homocystinuria
P 400gm can;
6/case
Unflavored 70074-0511-17 Abbott
DGlucerna Select R A Diabetic when food
is not tolerated
L Abbott
Unflavored
Page 16 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Hominex-2 R M P, A Metabolic disorder:
B6 nonresponsive
homocystinuria
P 400gm can;
6/case
Unflavored 70074-0511-19 Abbott
I-Valex-1 R M I Metabolic disorder:
Isovaleric acidemia
P 400gm can;
6/case
Unflavored 70074-0511-37 Abbott
I-Valex-2 R M P, A Metabolic disorder:
Isovaleric acidemia
P 400gm can;
6/case
Unflavored 70074-0511-39 Abbott
250ml can;
24/case
00212-3581-51
1000ml
RTH;
6/case
00212-3581-42
NestleImpact CD L UnflavoredA Inadequate calorie
and nutrient
intake/Support
Immune/Increased
nutritional
needs/Volume limits
Page 17 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Impact 1.5 CD A Inadequate calorie
and nutrient
intake/Support
Immune/Increased
nutritional
needs/Volume limits
L 250ml
cans;
24/case
Unflavored 00212-3589-51 Nestle
Vanilla 00212-1955-62
Chocolate 00212-1956-62
250ml can;
24/case
00212-1621-51
1000ml
RTH;
6/case
00212-1621-42/ 43900-
0162-88
NestleImpact Glutamine CD A Inadequate calorie
and nutrient
intake/Support
Immune/Increased
nutritional
needs/Volume limits
L Unflavored
L 237ml brik;
27/case
NestleImpact Advanced
Recovery
CD A Inadequate calorie
and nutrient
intake/Support
Immune/Increased
nutritional
needs/Volume limits
Page 18 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
250ml can;
24/case
00212-3587-51
1000ml
RTH;
6/case
00212-3587-42
250ml can;
24/case
00212-1825-51
1000ml
RTH;
6/case
00212-1826-42
1500ml
RTH;
6/case
00212-1826-44
250ml can;
24/case
Vanilla 00212-1815-51
1000ml
RTH;
6/case
00212-1816-42
S
S Unflavored Nestle
CD A Increased calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
L Nestle
Unflavored
NestleImpact with Fiber CD L UnflavoredInadequate calorie
and nutrient
intake/Support
Immune/Increased
nutritional
needs/Volume
limits/Normalize gut
function
Isosource (1.2 Cal) LCD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
A
Isosource (1.5 Cal )
Page 19 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
00212-1816-44
1000ml
RTH;
6/case
43900-0181-81
1500ml
RTH;
6/case
43900-0181-82
1000ml
RTH;
6/case
43900-0184-80
1500ml
RTH;
6/case
43900-0184-66
250ml can;
24/case
00212-1845-51
1000ml
RTH;
6/case
00212-1846-42
1500ml
RTH;
6/case
00212-1846-44
S
S
A Inadequate calorie
and nutrient
intake/Increased
protein needs
LS NestleIsosource HN (1.2 Cal)
Isosource (1.5 Cal)
SpikeRight
CD
CD
L UnflavoredA Increased calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
S
Unflavored
Nestle
CD A Inadequate calorie
and nutrient
intake/Increased
protein needs
L Unflavored Nestle
CD A Increased calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
L Nestle
Unflavored
Isosource HN
SpikeRight
Isosource (1.5 Cal )
Page 20 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
237ml can;
24/case
Unflavored 70074-0401-43
1000ml
RTH;
8/case
Unflavored 70074-0806-82
1500ml
RTH;
6/case
Unflavored 70074-0526-05
237ml can;
24/case
Unflavored 70074-0531-19
1000ml
RTH;
8/case
Unflavored 70074-0531-25
1500ml
RTH;
6/case
Unflavored 70074-0531-15
237ml can;
24/case
Unflavored 70074-0573-34
1000ml
RTH;
8/case
Unflavored 70074-0573-30
Abbott
S
Jevity (1.2 Cal) SCD
Jevity (1.5 Cal) CD L Abbott
LInadequate calorie
and nutrient
intake/Increased
nutritional needs
A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
A
Jevity (1 Cal) CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L AbbottS
Page 21 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
Unflavored 70074-0573-32
24 gm pkt;
8/carton
Fruit Punch 59781-0566-23
Orange 59781-0580-12
Fruit Punch 59781-0564-30
Unflavored19
.3 gm pkt
59781-0540-02
Orange 59781-0225-50
Fruit Punch 59781-0564-32
Unflavored19
.3 gm pkt
59781-0540-01
KetoCal 3:1 R M P (>1) Intractible epilepsy P 300gm can;
6/case
Unflavored 49735-0166-72 Nutricia
KetoCal 4:1 R M P (>1) Intractible epilepsy P 300gm can;
6/case
Unflavored 49735-0166-70 Nutricia
SJevity (1.5 Cal) CD
24 gm pkt;
180/case
L
24g pkt;
30/carton
Abbott
AbbottA Inadequate nutrient
intake/Increased
nutritional needs
EA
A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
NAJuven
Page 22 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Ketonex-1 R M I Metabolic disorder:
MSUD, beta-
ketothiolase
deficiency
P 400gm can;
6/case
Unflavored 70074-0511-13 Abbott
Ketonex-2 R M P, A Metabolic disorder:
MSUD, beta-
ketothiolase
deficiency
P 400gm can;
6/case
Unflavored 70074-0511-15 Abbott
Lanaflex R M P, A Metabolic Disorder:
PKU
EA 15.8 gm
packet;
40/carton
Unflavored 49735-0126-43 Nutricia
LMD R M I, P, A Metabolic
disorder:Leucine
metabolism
disorders
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0078-41 Mead Johnson
Orange 49735-0121-67
Berry 49735-0121-69
MCT Oil NA P, A Inadequate nutrient
intake/Increased
nutritional needs,
Fat malabsorption
L 946ml btl;
6/case
Unflavored 41679-0365-13 Nestle
NutriciaLophlex R P (>9), A Metabolic disorder:
PKU
M 14.3gm pkt;
30/case
EA
Page 23 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Methionaid R M P, A Metabolic Disorder:
Hpermethioininemia
454gm can;
4/case
Unflavored 49735-0102-42 Nutricia
Monogen NA M P (>1) Inadequate nutrient
intake/Increased
nutritional needs,
Limit fat intake
P 400gm can;
6/case
Unflavored 49735-0197-08/
49735-0097-08
Nutricia
MSUD 2 (Milupa) R M P, A Metabolic disorder:
MSUD
P 500gm can;
2/case
Unflavored 81361-0935-10
MSUD Aid R M P, A Metabolic disorder:
MSUD
P 200gm can;
4/case
Unflavored 49735-0101-43
49735-0123-60
49735-0177-81
MSUD Maxamum R M P (>8), A Metabolic disorder:
MSUD
P 454gm can;
4/case
Orange 49735-0123-40/ 49735-
0177-89
Neocate Infant
(Specialized Infant
Formula)
E SI I GI disorders P 400gm can;
4/case
Unflavored 49735-0108-04 Nutricia
Nutricia
MSUD Maxamaid R P (1-8) Metabolic disorder:
MSUD
M
MSUD Analog R I Metabolic disorder:
MSUD
M P 400gm can;
4/case
Unflavored
P 454gm can;
4/case
Orange
49735-0118-86/
49735-0183-02
Page 24 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Neocate Infant with
DHA and ARA
(Specialized Infant
Formula)
E SI I GI disorders P 400gm can;
4/case
Unflavored 49735-0125-95 Nutricia
Unflavored 49735-0117-90
Tropical Fruit 49735-0121-24
With
Prebiotics
49735-0129-12
Chocolate 49735-0126-90
Homemade
Vanilla
70074-0536-26
Butter Pecan 70074-0536-29
Mixed Berry 70074-0536-32
Homemade
Vanilla
70074-0596-67
Butter Pecan 70074-0596-61
Mixed Berry 70074-0596-63
1000ml
RTH;
8/case
Vanilla 70074-0596-78
Abbott
237ml
cans;
24/case
Nepro with Carb
Steady
R A Renal failure
P 400gm can;
4/case
Nutricia
L 237 ml
bottle
24/case
Neocate Junior (option
with Prebiotics)
E P (1-10) GI disorders
Page 25 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
250ml
cans;
24/case
Vanilla 00212-1885-51
1000ml
RTH;
6/case
00212-1885-42
1500ml
RTH;
6/case
00212-1885-44
237ml brik;
27/case
Vanilla 00212-3511-62
1000ml
RTH;
6/case
Unflavored 00212-3511-42/ 43900-
0351-80
P 454gm can;
6/case
00087-0338-01
C 384ml, 13fl
oz can;
12/case
00087-0498-01
946ml, 32fl
oz can;
6/case
00087-0499-01
Mead JohnsonRNutramigen LIPIL I
L
A Renal disease
UnflavoredSI
L
GI disorders
Nestle
Novasource Pulmonary R A Pulmonary disease Nestle
Unflavored
Novasource Renal R
L
Page 26 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
177ml, 6fl
oz btl;
24/case
00087-0263-24
Nutramigen LIPIL AA E SI I, P GI disorders P 400gm can;
4/case
Unflavored 00087-1290-49 Mead Johnson
Nutramigen LIPIL with
Enflora (LGG)
R SI I GI disorders P 357 gm
can; 6
can/case
Unflavored 00087-1239-41 Mead Johnson
Unflavored 00065-9030-70
Vanilla 00065-9024-70
1000ml
RTH;
6/case
00065-9150-72
1500ml
RTH;
4/case
00065-9150-73
Unflavored 00065-9031-70
Vanilla 00065-9025-70
1000ml
RTH;
6/case
00065-9152-72
1500ml
RTH;
4/case
00065-9152-73
Nestle
Mead Johnson
L 250ml can;
24/case
R
S
Unflavored
S Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L
Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Normalize gut
function
Nutramigen LIPIL I
Nutren 1.0 Fiber CD A
250ml can;
24/case
L
Nestle
Unflavored
Nutren 1.0 CD A
UnflavoredSI GI disorders
Page 27 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Unflavored 00065-9038-70
Vanilla 00065-9032-70
1000 ml
RTU
8/case
00065-9154-72
Spike
Right/
1000 ml
RTU
98716-0163-54
1500ml
RTH;
4/case
00065-9154-73
250ml can;
24/case
Vanilla 00065-9035-70
1000ml
RTH;
6/case
00065-9035-72
1500ml
RTH;
4/case
00065-9035-73
Nutren 2.0, Ultra
Pack/SpikeRight
250ml can;
24/case
Vanilla 00065-9040-70
S
CD S L
L
NestleInadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
A
Nestle
Unflavored
Nestle
Unflavored
A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume
limites/Normalize
gut function
L 250ml can;
24/case
Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
Nutren 1.5 CD A
Nutren 1.5 Fiber
S
CD
Page 28 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1000ml
RTH;
6/case
00065-9040-72
Spike
Right/
1000 ml
RTU
98716-0331-47
Nutren Glytrol (AKA
Glytrol)
250ml can;
24/case
Vanilla 00065-9085-70
1000ml
RTH;
6/case
Vanilla/
SpikeRight
98716-0163-76
1500ml
RTH;
4/case
Vanilla/
SpikeRight
98716-0163-77
250ml can;
24/case
Vanilla 00065-9141-70
D
Nutren Junior with and
without fiber
CD S
CD
R
S
Unflavored
L
Pulmonary disease
LP (1-10) Nestle
Nutren Pulmonary
(AKA NutriVent or
NutriVent 1.5)
R A
250ml can;
24/case
Inadequate calorie
and nutrient
intake/Increased
nutritional needs
NestleInadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
Vanilla with
fiber
Nestle
A
00065-9045-70
L
L Nestle
Vanilla 00065-9043-70
A Diabetic when food
is not tolerated
Page 29 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1000ml
RTH;
6/case
Unflavored 00065-9141-72
250ml can;
24/case
Vanilla 00065-9022-70
1000ml
RTH;
6/case
00065-9156-72
Spike
Right/
1000 ml
RTU
98716-0163-56
1500ml
RTH;
4/case
00065-9156-73
250ml can;
24/case
Vanilla 00065-9023-70
1000ml
RTH;
6/case
00065-9158-72
Spike
Right/
1000 ml
RTU
98716-0163-58
SNutren Replete with
Fiber, Ultra
Pack/SpikeRight (AKA
Replete with Fiber)
CD A Inadequate calorie
and nutrient
intake/Increased
proteinneeds/Norma
lize gut function
Pulmonary disease
NestleL
Nestle
Unflavored
S
Nutren Pulmonary
(AKA NutriVent or
NutriVent 1.5)
R A
Nutren Replete, Ultra
Pack/
SpikeRight (AKA
Replete)
CD A Inadequate calorie
and nutrient
intake/Increased
protein needs
Unflavored
Nestle
L
L
Page 30 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
4/case
00065-9158-73
Spike
Right/
1500 ml
RTU
98716-0163-59
NutriHep R A Hepatic disease L 250ml can;
24/case
Unflavored 00065-9078-70 Nestle
OA 1 R M I Metabolic disorder:
Propionic Acidemia,
Methylmalonic
Acidemia
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0085-41 Mead Johnson
OA 2 R M P, A Metabolic disorder:
Propionic Acidemia,
Methylmalonic
Acidemia
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0191-41 Mead Johnson
237ml can;
24/case
Vanilla 70074-0546-39
SNutren Replete with
Fiber, Ultra
Pack/SpikeRight (AKA
Replete with Fiber)
CD A Inadequate calorie
and nutrient
intake/Increased
proteinneeds/Norma
lize gut function
Nestle
E A
L
Optimental L
Unflavored
GI disorders Abbott
Page 31 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1000ml
RTH;
8/case
Unflavored 70074-0570-46
OS-2 (Milipa) R M P (>1) Metbolic disorder:
Propionic Acidemia,
Methylmalonic
Acidemia
P 500gm can;
2/case
Unflavored 81361-0934-90 Nutricia
237ml can;
24/case
70074-0407-35
1000ml
RTH;
8/case
70074-0806-68
1500ml
RTH;
6/case
70074-0526-01
237ml can;
24/case
70074-0531-21
1000ml
RTH;
8/case
70074-0531-23
S
E A
Osmolite (1 Cal) S Abbott
Osmolite (1.2 Cal) CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L Unflavored Abbott
Optimental
LCD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
Unflavored
LGI disorders Abbott
Page 32 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
70074-0531-17
237ml can;
24/case
70074-0574-70
1000ml
RTH;
8/case
70074-0574-72
237ml can;
24/case
70074-0543-87
1000ml
RTH;
8/case
70074-0570-44
Vanilla-oral/
enteral
70074-0558-98/
70074-0518-05
Chocolate 70074-0518-83
Strawberry 70074-0518-81
Banana
Cream
70074-0518-85
Orange
Cream
70074-0578-42
S
S
S AbbottPediasure CD
Osmolite (1.5 Cal) CD
Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L UnflavoredA Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml can;
24/case
P (1-13)
Abbott
Oxepa R A Pulmonary disease L Unflavored Abbott
Osmolite (1.2 Cal) CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L Unflavored Abbott
Page 33 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Pediasure with Fiber
(FOS)- oral and
enteral
CD S P (1-13) Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Normalize gut
function
L 237ml can;
24/case
Vanilla-oral/
enteral
70074-0582-21/
70074-0518-07
Abbott
Vanilla 70074-0564-10
Vanilla with
fiber
70074-0564-12
Pediatric Peptinex DT E P (1-10) GI disorders L 250ml can;
24/case
Unflavored 00212-3751-51 Nestle
Pediatric Peptinex DT
with fiber
E P (1-10) GI
disorders/Normalize
gut function
L 250ml can;
24/case
Unflavored 00212-3752-51 Nestle
Unflavored 49735-0117-66
Banana 49735-0117-80
Unflavored 00065-9014-70
Vanilla 00065-9067-70
Unflavored 00065-9088-70
Vanilla 00065-9087-70
1000ml
RTH;
6/case
Unflavored 00065-9089-72
S
NestlePeptamen 1.5 E GI disorders
EA 51gm pkt;
15/case
P (1-10) GI disorders
L 250ml can;
24/case
A
Nutricia
Peptamen E A GI disorders L 250ml can;
24/case
Nestle
Pepdite Junior (AKA
Pepdite One+)
E
PediaSure 1.5 Cal-
with and without fiber
CD P (1-13) Inadequate calorie
and nutrient
intake/Increased
L 237ml can;
24/case
Abbott
Page 34 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
250ml can;
24/case
00065-9092-71
1000ml
RTH;
6/case
00065-9092-72
Unflavored 00065-9069-70
Vanilla 00065-9070-70
Chocolate 00065-9070-71
Strawberry 00065-9070-72
1000ml
RTH;
6/case
Unflavored 00065-9070-90
250ml can;
24/case
98716-0073-63
1000ml
RTH;
6/case
98716-0085-43
Peptamen Junior
Powder
E P (1-10) GI disorders P 400gm can;
12/case
Vanilla 00065-9169-70 Nestle
Peptamen Junior with
Fiber
E P (1-10) GI disorders/
Normalize gut
function
L 250ml can;
24/case
Vanilla 00065-9068-71 Nestle
L 250ml can;
24/case
P (1-10) GI disorders Nestle
Peptamen Junior 1.5 E P (1-10) GI disorders L Unflavored Nestle
Peptamen Junior E
Peptamen AF E A GI disorders/
Increased calorie
needs
L Unflavored Nestle
Page 35 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Peptamen Junior with
Prebio
E P (1-10) GI disorders/
Normalize gut
function
L 250ml can;
24/case
Vanilla 00065-9068-70 Nestle
Peptamen OS E A GI disorders/
Normalize gut
function
L 237ml can;
24/case
Unknown 43900-0337-94 43900-
0371-29
Nestle
Peptamen OS (1.5
Cal)
E A GI disorders/
Increased calorie
needs
L 237ml can;
24/case
Vanilla 43900-0371-22 Nestle
250ml can;
24/case
Vanilla 00065-9076-70
1000ml
RTH;
6/case
00065-9076-72
1500ml
RTH;
4/case
00065-9076-73
Peptinex E A GI disorders L 237ml brik;
27/case
Creamy
Vanilla
00212-3711-62 Nestle
Creamy
Vanilla
43900-0371-40
Rich
Chocolate
43900-0371-20
E A Nestle
Unflavored
Peptinex 1.0 E A GI disorders L 237ml brik;
27/case
Nestle
Peptamen with Prebio GI disorders/
Normalize gut
function
L
Page 36 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Peptinex 1.5 E A GI disorders L 237ml brik;
27/case
Vanilla 43900-0371-30 Nestle
250ml can;
24/case
00212-3701-51
1000ml
RTH;
6/case
00212-3701-42
1500ml
RTH;
6/case
00212-3701-44
Peptinex DT with
Prebiotics (This
product will be
discontinued
soon/limited
availability.)
E A GI disorders L 250ml can;
24/case
Unflavored 00212-3757-51 Nestle
237ml can;
24/case
70074-0506-29
1000ml
RTH;
8/case
70074-0519-49
L UnflavoredA GI disorders Nestle
Perative CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
and wound healing/
Increased protein
needs
L Unflavored Abbott
Peptinex DT- (This
product will be
discontinued
soon/limited
availability.)
E
Page 37 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1500ml
RTH;
6/case
70074-0576-36
Periflex Infant R M I Metabolic disorder:
PKU
P 400gm can;
4/case
Unflavored 49735-0183-26/
49735-0118-80
Nutricia
49735-0114-02
49735-0183-08
49735-0125-31
49735-0183-09
49735-0183-10
49735-0114-01
PFD 1 R M I Metabolic disorder:
Amino acid
metabolism
disorders
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0994-41 Mead Johnson
PFD 2 R M P, A Metabolic disorder:
Amino acid
metabolism
disorders
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0079-41 Mead Johnson
P
Chocolate
Nutricia
Orange
Unflavored
Orange
49735-0183-05/
49735-0126-50
Periflex Junior R P (>1)
49735-0183-07/
49735-0126-52Chocolate 49735-0126-51/
49735-0183-06
454gm can;
4/case
UnflavoredMetabolic disorder:
PKU
M
P 454gm can;
6/case
Metabolic disorder:
PKU
Perative CD A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
and wound healing/
Increased protein
needs
L Unflavored Abbott
Periflex Advance
(PKU)
R M P, A Nutricia
Page 38 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Phenex-1 R M I Metabolic disorder:
PKU
P 400gm can;
6/case
Unflavored 70074-0511-21 Abbott
Unflavored 70074-0511-23
Vanilla 70074-0557-56
Phenyl-Free 1 R M I Metabolic disorder:
PKU
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0074-47 Mead Johnson
Phenyl-Free 2 R M P, A Metabolic disorder:
PKU
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0080-41 Mead Johnson
Phenyl-Free 2 HP R M P, A Metabolic disorder:
PKU
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087–0081-41 Mead Johnson
Unflavored 00847-0954-04
Citrus 00847-0954-14
PhenylAde60 Drink
Mix
R M P, A Metabolic disorder:
PKU
P 454gm can;
4/case
Vanilla 00087-0956-22 Applied Nutrition
P 454gm can;
4/case
Unflavored 00847-0950-00
EA 13gm pkt;
10/case
Unflavored 00847-0950-04
Vanilla 00847-0952-22
Chocolate 00847-0951-12
Applied Nutrition
M
M
Metabolic disorder:
PKU
PhenylAde Drink Mix R P, A Metabolic disorder:
PKU
P 454gm can;
4/case
Applied Nutrition
400gm can;
6/case
Applied Nutrition
P Abbott
EA 25gm pkt;
20/case
R P, A Metabolic disorder:
PKU
M
M
Metabolic disorder:
PKU
PhenylAde Amino Acid
Blend
R P (>1), A
PhenylAde40 Drink
Mix
R P, A
Phenex-2
Page 39 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Strawberry 00847-0954-42
Orange
Crème
00847-0953-32
Chocolate 00847-0950-12
Vanilla 00847-0950-22
Orange
Crème
00847-0950-32
Strawberry 00847-0950-42
Chocolate 00847-0950-14
Vanilla 00847-0950-24
Orange
Crème
00847-0950-34
Strawberry 00847-0950-44
P 454gm can;
4/case
Unflavored 00847-0959-60
EA 13gm pkt;
10/case
Unflavored 00847-0959-64
Black
Current /
Apple
49735-0114-67M EAMetabolic disorder:
PKU
Unflavored 00847-0955-01 Applied Nutrition
Phlexy-10 Drink Mix R P (>1), A 20gm pkt;
30/case
Nutricia
MPhenylAde PheBloc
LNAA (AKA PreKUnil)
NA P, A Metabolic disorder:
PKU
EA 550
tabs/bottle
Phenylade MTE Amino
Acid Blend
NA P (>1), A Metabolic disorder:
PKU
M Applied Nutrition
PhenylAde Essential
Drink Mix
R P, A Metabolic disorder:
PKU
M P
EA
Applied NutritionM
454gm can;
4/case
Applied Nutrition
40gm pkt;
16/case
PhenylAde Drink Mix R P, A Metabolic disorder:
PKU
P 454gm can;
4/case
Page 40 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Tropical
Surprise
49735-0119-10
237ml can/
24/case
70074-0580-14
1000ml
RTH;
8/case
70074-0580-16
45 gm Tomato 81361-9087-01
500gm can;
2/case
Unflavored 81361-0934-60
PKU-3 (Milupa) R M A Metabolic disorder:
PKU
P 500gm can;
2/case
Unflavored 81361-0934-70 Nutricia
Polycal NA P, A Inadequate calorie
intake/Increased
nutritional needs
P 400gm can;
12/case
Unflavored 49735-0011-52 Nutricia
L 124ml btl;
24/case
70074-0804-31
P 350gm can;
6/case
70074-0607-46
M
Nutricia
Unflavored Abbott
M
Polycose NA
PKU-2 (Milupa) R
Pivot 1.5 Cal CD A Increased calorie
and nutrient
intake/Increased
nutritional
needs/Immuno-
suppression
Unflavored Abbott
P (>1)
EA
PMetabolic disorder:
PKU
L
A Inadequate nutrient
intake/Increased
nutritional needs
Metabolic disorder:
PKU
Phlexy-10 Drink Mix R P (>1), A 20gm pkt;
30/case
Nutricia
Page 41 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Portagen E/R M P, A GI disorders P 454gm can;
6/case
Unflavored 00087-0387-01 Mead Johnson
Pregestimil Lipil E SI I GI disorders P 454gm can;
6/case
Unflavored 00087-0367-01 Mead Johnson
250ml can;
24/case
Vanilla 00065-9162-70
1000ml
RTH;
6/case
00065-9166-72
1500ml
RTH;
4/case
00065-9166-73
Procel 100 NA P, A Renal disease P 750 gm
pouch;
6/case
Unflavored 82028-0061-00 Global Health
Products
Product 3232A E M I, P Metabolic
disorder:Disacchard
iase deficiencies,
Carbohydrate
metabolism
disorders
P 454gm can;
6/case
Unflavored 00087-0425-41 Mead Johnson
Nestle
Unflavored
A Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
LProbalance 1.2 (AKA
Nutren Probalance)
CD S
Page 42 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Promod NA I, P, A Inadequate nutrient
intake/Increased
protein needs
L 946ml btl;
6/case
Fruit Punch 70074-0597-22 Abbott
237ml can;
24/case
Vanilla 70074-0507-75
1000ml
RTH;
8/case
70074-0516-17
1500ml
RTH;
6/case
70074-0576-32
237ml can;
24/case
Vanilla 70074-0518-73
1000ml
RTH;
8/case
Unflavored 70074-0518-75
1500ml
RTH;
6/case
Unflavored 70074-0576-34
Pro-Phree NA M I Metabolic disorder P 400gm can;
6/case
Unflavored 70074-0511-49 Abbott
S L Abbott
Unflavored
L Abbott
Inadequate calorie
and nutrient
intake/Increased
nutrient needs
Promote CD A
Promote with Fiber CD A Inadequate calorie
and nutrient
intake/Increased
nutrient
needs/Normalize gut
function
S
Page 43 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Propimex-1 R M I Metabolic disorder:
Propionic Acidemia,
methylmalonic
acidemia
P 400gm can;
6/case
Unflavored 70074-0511-33 Abbott
Propimex-2 R M P, A Metabolic disorder:
Propionic Acidemia,
methylmalonic
acidemia
P 400gm can;
6/case
Unflavored 70074-0511-35 Abbott
Citrus Berry 94688-0015-35
Orange
Cream
94688-0015-45
P 275 gm
can: 6
can/case
Unflavored 94688-0111-62
L 32 ox btl;
4/case
Unflavored 94688-0114-32
Unflavored 94688-0016-51
Citrus Berry 94688-0016-61
NA P, A Inadequate nutrient
intake/Increased
protein needs
MedtritionProsource Plus Protein L
Prosource No Carb
Protein
NA P, A
32 oz btl;
4/case
ProSource Protein NA P, A Increase protein
needs
Increased protein
needs/Renal
L 32 oz btl;
4/case
Medtritian
Page 44 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Orange
Crème 94688-0016-71
Prosource ZAC NA P, A Increased protein
needs/Wound
healing
L 32 oz btl;
4/case
Citrus Berry 94688-0015-55 Medtritian
30 ml btl unknown 26974-0410-52
Grape 26974-0410-50
Natural 26974-0410-40
Wild Cherry 26974-0410-07
Butter Pecan 26974-0410-09
30 ml btl. unknown 26974-0410-53
Natural 26974-0410-41
Wild Cherry 26974-0410-08
Butter Pecan 26974-0410-10
Grape 26974-0410-51
Pro-Stat 150 NA A Inadequate nutrient
intake/Increased
protein needs
L 887ml btl;
6/case
Natural 26974-0410-15 Medical Nutrition
USA
Medical Nutrition
USA
Pro-Stat 101 NA A Inadequate nutrient
intake/Increased
protein needs
887ml btl;
6/case
NA P, A Inadequate nutrient
intake/Increased
protein needs
L
Medtrition
Pro-Stat 64 NA A Inadequate nutrient
intake/Increased
protein needs;
Limited caloric
intake
L Medical Nutrition
USA887ml btl;
6/case
Prosource Plus Protein L 32 oz btl;
4/case
Page 45 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Pro-Stat AWC NA A Inadequate nutrient
intake/Increased
protein needs;
Wound healing
L 887ml btl;
6/case
Wild Cherry 26974-0410-30 Medical Nutrition
USA
Pro-Stat Profile NA A Inadequate nutrient
intake/Increased
protein needs
L 887ml btl;
6/case
Wild Cherry 26974-0410-12 Medical Nutrition
USA
Grape 26974-0410-62
Wild Cherry 26974-0410-60
236ml,
8oz btl
54859-0515-08
472 ml,
16oz btl
54859-0515-16
Black Cherry 54859-0525-08
Lemon-Lime 54859-0535-08
Black Cherry 54859-0525-16
Medical Nutrition
USA
Pro-Stat RC
Unflavored L. Lorens
Pharmaceuticals
Proteinex-18 NA A Inadequate nutrient
intake/Increased
protein needs
L 236ml, 8oz
btl
L. Lorens
Pharmaceuticals
472ml,
16oz btl
NA A Inadequate nutrient
intake/Increased
protein needs; Renal
complications
L
Proteinex NA A Inadequate nutrient
intake/Increased
protein needs
887ml btl;
6/case
L
Page 46 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Lemon-Lime 54859-0535-16
Protifar NA P, A Inadequate nutrient
intake/Increased
protein needs
P 225gm can;
12/case
Unflavored 49735-0111-34 Nutricia
ProViMin R/E M I, P, A Metabolic
disorder/GI disorder
P 150gm can;
6/case
Unflavored 70074-0502-60 Abbott
Vanilla 70074-0406-99
Strawberry 70074-0501-81
1000ml
RTH;
8/case
Vanilla 70074-0512-05
237 ml can unknown 11822-0065-40
237 ml can unknown 11822-3005-50
237 ml can unknown 11822-3005-60
237 ml can unknown 11822-3005-30
237 ml can unknown 11822-3919-20
237 ml can unknown 11822-3919-50
S
S Inadequate calorie
and nutrient
intake/Increased
nutrient needs
LCD ARA Balanced Nutrition
Plus Drink
Abbott
RA Balanced Nutrition
Drink
CD A Inadequate calorie
and nutrient
intake/Increased
nutrient needs
L No product
website
Pulmocare R A Pulmonary disease L 237ml can;
24/case
Proteinex-18 NA A Inadequate nutrient
intake/Increased
protein needs
L L. Lorens
Pharmaceuticals
472ml,
16oz btl
Page 47 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
237 ml can unknown 11822-3952-10
237 ml can unknown 11822-3952-20
237 ml can unknown 11822-3952-30
RCF (Soy) R M I, P, A Intractible epilepsy L 384ml can;
12/case
Unflavored 70074-0401-08 Abbott
Renalcal R A Renal disease L 250ml can;
24/case
Unflavored 00065-9013-70 Nestle
Renastart R A Renal disease EA 100 gm
sachet;
10/box
Unflavored 50600-0551-56 Vitaflo
Vanilla
Cream
00212-1801-62
Butter Pecan 43900-0180-40
Orange 00212-5983-75
Cherry 00212-5984-75
S
237ml brik;
27/case
Inadequate calorie
and nutrient
intake/Increased
nutrient needs
L
L Nestle
Resource Arginaid NA A Inadequate protein
intake/increased
nutrient needs
EA 9.2gm/pkt;
14 pkt/box;
4 box/case
Nestle
S
CD A
Resource 2.0 (AKA
Novasource 2.0)
CD A
RA Balanced Nutrition
Plus Drink
Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
No product
website
Page 48 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Lemon 00212-5985-75
Orange Burst 00212-1966-62
Wildberry 00212-1967-62
Resource Benecalorie NA P, A Inadequate nutrient
intake/Increased
nutritional needs
P 1.5oz
(41.3gm)
cup;
24/case
Unflavored 00212-2825-80 Nestle
EA 7gm pkt;
75/case
00212-2843-71
P 227gm can;
6/case
00212-2841-07
Orange 00212-1862-62
Peach 00212-1864-62
Wildberry 00212-1866-62
Variety 00212-1860-62
Resource Glutasolve NA A GI disorders EA 22.5gm pkt;
56/case
Unflavored 00212-2833-78 Nestle
NA P, A
P, A Inadequate calorie
and nutrient
intake/Increased
nutritional needs
L 237ml brik;
27/case
A
237ml brik;
27/case
Resource Breeze
(Clear Liquid)
CD L Nestle
Resource Arginaid
Extra
NA Inadequate protein
intake/increased
nutrient needs
Nestle
Inadequate nutrient
intake/Increased
protein needs
Unflavored NestleResource Beneprotein
(AKA Resource Instant
Protein Powder)
Resource Arginaid NA A Inadequate protein
intake/increased
nutrient needs
EA 9.2gm/pkt;
14 pkt/box;
4 box/case
Nestle
Page 49 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
French
Vanilla
00212-3311-62
Classic
Chocolate
00212-3312-62
Creamy
Strawberry
00212-3313-62
Resource Just for Kids
1.5 Cal
CD S P Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
L 237ml brik;
27/case
French
Vanilla
00212-3319-62 Nestle
Resource Just for Kids
with Fiber
CD S P (1-10) Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Normalize gut
function
L 237ml brik;
27/case
French
Vanilla
00212-3314-62 Nestle
S L 237ml brik;
27/case
NestleResource Just for Kids CD P (1-10) Inadequate calorie
and nutrient
intake/Increased
nutritional needs
Page 50 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Resource Just for Kids
1.5 Cal with Fiber
CD S P Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
L 237ml brik;
27/case
French
Vanilla
00212-3320-62 Nestle
237ml, 8oz
can; 6/case
70074-0575-09
946ml,
32oz btl;
6/case
70074-0575-13
P 454gm can;
6/case
70074-0576-64
Similac Human Milk
Fortifier
NA SI I Prematurity-VLBW EA .9gm pkt;
150
pkts/case
Unflavored 70074-0545-99 Abbott
P 363gm can;
6/case
70074-0574-31
L 946ml
(32oz) btl;
6/case
70074-0574-56
SI
SI
E I, P GI disorders Unflavored Abbott
Similac (Expert Care)
Neosure with DHA and
ARA
R I Prematurity-VLBW Unflavored Abbott
Similac (Expert Care)
Alimentum Advance
with DHA and ARA
L
Page 51 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Similac Special Care
(30 cal) with Iron RTF
R SI I Prematurity-VLBW L 59 ml (2
oz) btl;
48/case
Unflavored 70074-0562-95 Abbott
Similac PM 60/40 R SI I Renal/Cardiac L 400gm can;
6/case
Unflavored 70074-0608-50 Abbott
Suplena with Carb
Steady
R A Renal disease L 237ml can;
24/case
Homemade
Vanilla
70074-0596-65 Abbott
Tolerex E A GI disorders EA 2.82oz pkt;
60/case
Unflavored 00212-4580-72 Nestle
Vanilla 70074-0407-29
Butter Pecan 70074-0540-65
1000ml
RTH;
8/case
Unflavored 70074-0570-48
Tyr 2 (Milupa) R M P (>1), A Metabolic disorder:
Tyrosinemia type 1
and 2
P 500gm can;
2/case
Unflavored 81361-0935-30 Nutricia
TwoCal HN CD A AbbottLS Inadequate calorie
and nutrient
intake/Increased
nutritional
needs/Volume limits
237ml can;
24/case
Page 52 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Tyrex-1 R M I Metabolic disorder:
Tyrosinemia type 1,
2, 3
P 400gm can;
6/case
Unflavored 70074-0511-29 Abbott
Tyrex-2 R M P,A Metabolic disorder:
Tyrosinemia type 1,
2, 3
P 400gm can;
6/case
Unflavored 70074-0511-27 Abbott
Tyros 1 R M I Metabolic disorder:
Tyrosinemia type 1
and 2
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-0194-41 Mead Johnson
Tyros 2 R M P, A Metabolic disorder:
Tyrosinemia type 1
and 2
P 454gm can;
6/case
Vanilla 00087-0082-41 Mead Johnson
UCD-2 (Milupa) R M P (>1), A Metabolic disorder:
Urea cycle disorders
P 500gm can;
2/case
Unflavored 81361-0936-10 Nutricia
Vital HN E A GI disorders EA 79gm/pkt;
6/carton; 4
cartons/
case
Vanilla 70074-0407-66 Abbott
Strawberry 70074-0563-92
Unflavored 70074-0563-83
Vanilla 70074-0563-90
Vital Jr. E P GI disorders AbbottL 237ml can;
24/case
Page 53 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
237ml can;
24/case
70074-0562-78
1000ml
RTH;
8/case
70074-0562-82
237ml can;
24/case
70074-0565-43
1000ml
RTH;
8/case
70074-0565-45
237ml can;
24/case
70074-0562-80
1000ml
RTH;
8/case
70074-0562-84
Vivonex Pediatric E P, A GI disorders EA 1.7oz pkt;
36/case
Unflavored 00212-7131-76 Nestle
Vivonex Plus E A GI disorders EA 2.8oz pkt;
36/case
Unflavored 00212-7298-18 Nestle
250ml can;
24/case
00212-3625-51Unflavored Nestle
Vital 1.5
Vivonex RTF E A L
LP, A GI disorders
GI disorders
E P, A GI disorders
GI disorders
L
LVital 1.0 E P, A
Abbott
Vanilla
Vanilla
Vital AF 1.2 E
Page 54 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
1000ml
RTH;
6/case
00212-3625-42/ 43900-
0362-80
1500ml
RTH;
6/case
00212-3625-44/ 43900-
036-82
Vivonex T.E.N. E A GI disorders EA 2.84oz pkt;
60/case
Unflavored 00212-7278-73 Nestle
WND 1 R M I Metabolic disorder:
Urea cycle disorders
P 454gm can;
6/case
Unflavored
(vanilla
scent)
00087-0092-41 Mead Johnson
WND 2 R M P, A Metabolic disorder:
Urea cycle disorders
P 454gm can;
6/case
Vanilla 00087-0093-41 Mead Johnson
49735-0118-88
49735-0183-61
49735-0123-64
49735-0177-91
49735-0123-43M P 454gm can;
4/case
Orange
XLeu Maxamaid R P (1-8) Metabolic disorder:
Isovaleric acidemia
NutriciaXLeu Maxamum R P (>8), A Metabolic disorder:
Isovaleric acidemia
P 454gm can;
4/case
Orange Nutricia
M
Unflavored
Metabolic disorder:
Isovaleric acidemia
P
M
Nestle
XLeu Analog R I
Vivonex RTF E A L
400gm can;
4/case
Unflavored
GI disorders
Nutricia
Page 55 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
49735-0177-90
49735-0118-82
49735-0183-28
49735-0123-59
49735-0177-80
49735-0123-44
49735-0177-88
49735-0118-81
49735-0183-27
49735-0123-63
49735-0177-87
49735-0123-41
Nutricia
P 454gm can;
4/case
Orange NutriciaXMet Maxamum R P (>8), A Metabolic disorder:
Homo-cytinuria,
Hypermethioninemia
M
454gm can;
4/case
Orange NutriciaXMet Maxamaid R P (1-8) Metabolic disorder:
Homo-cytinuria,
Hypermethioninemia
M
XMet Analog R I Metabolic disorder:
Homo-cytinuria,
Hypermethioninemia
M
P
OrangeM
P 400gm can;
4/case
Unflavored Nutricia
Nutricia
454gm can;
4/case
Orange
400gm can;
4/case
Unflavored
XLys, XTrp Maxamum R P (>8), A Metabolic disorder:
Glutaric Acidemia
Type I
P 454gm can;
4/case
XLys, XTrp Maxamaid R P (1-8) Metabolic disorder:
Glutaric Acidemia
Type I
M P
M P 454gm can;
4/case
NutriciaXLys, XTrp Analog R I Metabolic disorder:
Glutaric Acidemia
Type I
PM
Orange NutriciaXLeu Maxamum R P (>8), A Metabolic disorder:
Isovaleric acidemia
Page 56 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
49735-0177-95
49735-0118-87
49735-0183-03
49735-0123-61
49735-0177-85
49735-0123-42
49735-0177-79
49735-0123-58
49735-0177-93
49735-0123-57
49735-0177-92
49735-0177-94
49735-0123-71
P 454gm can;
4/case
UnflavoredXPhe Maxamaid R P (1-8) Metabolic disorder:
PKU
M Nutricia
Orange
Strawberry
XMTVI Maxamum R P (>8), A Metabolic disorder:
Propri-onic
Acidemia,
Methylmalonic
Acidemia
M P 454gm can;
4/case
Orange Nutricia
XMTVI Maxamaid R P (1-8) Metabolic disorder:
Propri-onic
Acidemia,
Methylmalonic
Acidemia
M P 454gm can;
4/case
Orange Nutricia
XMTVI Analog R I Metabolic disorder:
Propri-onic
Acidemia,
Methylmalonic
Acidemia
M P 400gm can;
4/case
Unflavored Nutricia
P 454gm can;
4/case
Orange NutriciaXMet Maxamum R P (>8), A Metabolic disorder:
Homo-cytinuria,
Hypermethioninemia
M
Page 57 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
49735-0123-01
49735-0183-23
49735-0183-24
49735-0123-02
Unflavored 49735-0123-11
Orange 49735-0123-12
Orange 49735-0125-51
Forest
Berries
49735-0125-24
49735-0118-85
49735-0183-01
49735-0123-62
49735-0177-86
49735-0188-43
49735-0118-84
M P 400gm can;
4/case
Abbott: http://abbottnutrition.com/products/index.aspx
XPTM Analog R I Metabolic disorder:
Tyrosinemia Type I
(poorly control)
Unflavored Nutricia
XPhe, XTyr Maxamaid R P (1-8) Metabolic disorder:
Tyrosinemia Type I
and 2
M P 454gm can;
4/case
Orange Nutricia
XPhe, XTyr Analog R I Metabolic disorder:
Tyrosinemia Type 1
and 2
M P 400gm can;
4/case
Unflavored Nutricia
Nutricia
Orange
EA 50gm pkt;
30/case
L 250ml brik;
18/case
P 454gm can;
4/case
UnflavoredXPhe Maxamum R P (>8), A Metabolic disorder:
PKU
M
URL for Manufacturers:
Page 58 of 59
Product Name CCS
Classification:
R=Replacement,
E=Elemental,
CD=Calorie Dense,
NA=Nutritional
Additives (NL: 22-
0805)
Medi-Cal
Category:
Metabolic
(M),
Standard (S)
& Diabetic
(D)
(Contract-
ed items in
yellow)
Infant,
Pediatric, or
Adult per
Mnfr.*
(May be used
per
prescriber's
discretion.)
Common
Indications
(If products are
not disease
specific, general
indications are
used.)
Product
Form:
P=Powder,
L=Liquid,
C=Concentr
ate,
EA=Each
Quantity
Per Unit
and Case
(to calc.
monthly
quantity)
Product
Flavors
Product Number:
Contracted or Current
Mnfr. Number in CMS
Net
(Contracted products
are in yellow; use
"exact" product
numbers to auth.)
Manufacturer
(hyperlink)
Nestle: http://www.nestle-nutrition.com/landing.aspx?objectID=2DCF411E-7037-4F88-A58C-669DB4A5C4CCNutricia (Milupa products also available): http://www.shsna.com/pages/products.htm
Vitflo: http://www.vitaflousa.com/
Medtrition: http://www.activehomenutrition.com/
Bright Beginnings/PBM Products: http://www.brightbeginnings.com/products/pediatric-drink.asp
CVS Pharmacy (Generic products): http://www.cvs.com/CVSApp/catalog/shop_category.jsp?filterBy=default&navAction=push&navCount=3&itemId=cat2828
Globel Health Products: http://www.globalhp.com
L. Lorens Pharmaceuticals: http://www.llorenspharm.com/
Mead Johnson Nutritionals: http://www.mjn.com/404error_hcp.html
Medical Nutrition USA: http://www.pro-stat.info/
Applied Nutrition: http://www.medicalfood.com
Albumax: http://www.albumax.net/
Page 59 of 59