Oscar Enteral and Oral Liquid Nutritional Supplements (CG011) Form

Eligibility for Oral Nutritional Supplements

The Plan members who have difficulty ingesting or digesting food or who are at risk for malnutrition may be eligible for oral nutritional supplements. Enteral nutrition products, also known as medical foods, are specially formulated and processed foods intended for the dietary management of specific diseases or medical conditions.

The use of enteral nutrition products has been shown to reduce hospital stays, complications, and mortality rates in patients with various medical conditions, including malnutrition, cancer, gastrointestinal disorders, neurological disorders, and metabolic disorders.

To be considered a medical food, a product must be labeled for the dietary management of a medical disorder, disease, or condition and labeled to be used under medical supervision. These products provide essential nutrients to individuals who have limited or impaired capacity to ingest, digest, absorb, or metabolize regular food or certain nutrients, or who have other medically determined nutrient requirements that cannot be achieved by modifying their normal diet alone.

Enteral nutrition products come in various forms, including nutritionally complete formulas, nutritionally incomplete formulas, formulas for metabolic disorders, and oral rehydration products. They are primarily administered through the gastrointestinal tract, either orally or via a feeding tube or catheter that delivers nutrients beyond the oral cavity or directly to the stomach.

Access to Medical Foods

Medical foods are typically obtained from hospitals, clinics, and other medical facilities, but certain specialized nutritional supplement products may be covered by the Plan's Pharmacy benefit. This includes products necessary for malabsorption disorders, renal dysfunction, tube feeding formulas, and lactose-free infant formulas, as well as other specialized products.

Some medical foods may also be obtained through a prescription from a Pharmacy and covered by the Plan's Pharmacy benefit (i.e., supplied by a pharmacy provider upon the prescription of a physician within the scope of his or her practice).

Clinical Policy for Pharmacy Benefit Coverage

• Nutritional Supplements – Infant Formulas
• Nutritional Supplements – Malabsorption Products
• Nutritional Supplements – Renal Dysfunction Products
• Nutritional Supplements – Tube Feeding Products

NOTE: All oral nutritional supplementation must be prescribed by a licensed provider and eligibility and cost of coverage are based on the member's Schedule of Benefits and Certificate of Coverage.

Definitions

Elemental and Semi-Elemental Products

"Elemental and Semi-Elemental Products" contain partially or fully broken down macronutrients.

Enteral Nutrition

"Enteral Nutrition" refers to nutrition administered through the alimentary (Gastrointestinal) tract, including:

1. Through the oral cavity, as in traditional eating
2. Through a nasogastric or orogastric tube (tube placed through the nose or mouth into the stomach)
3. Through a gastric or gastro-jejunal feeding tube (placed percutaneously directly into the stomach or small intestine, bypassing the oral cavity and esophagus)

Failure to Thrive (FTT)

"Failure to Thrive (FTT)" is applicable to children younger than 2 years old, and defined using WHO growth charts which can identify weight gain issues including:

1. Children weighing less than the 2nd percentile for gestation-corrected age and sex when plotted on the appropriate growth chart on more than one occasion (Note: Special charts for patients with genetic syndromes or prematurity may be applicable); and
2. Decreased growth velocity of weight gain compared to growth in length.

Food Additives

"Food Additives" are products available over-the-counter that are ingested in addition to a regular diet. Examples include calorie supplements, digestive aids, fiber supplements, minerals, protein supplements, thickeners, and vitamins.

Medical Foods

"Medical foods" are a specific category of food products that are formulated to be consumed or administered enterally (through the digestive system) under the supervision of a physician for the dietarymanagement of a specific disease or condition for which distinctive nutritional requirements have been established based on recognized scientific principles.

Medical foods are intended to meet the distinctive nutritional needs of patients with certain medical or metabolic conditions who cannot meet their nutritional requirements through a normal diet alone. They are distinguished from the broader category of foods for special dietary use and from foods that make health claims by the requirement that medical foods are to be used under medical supervision.

Oral Nutritional Supplements

"Oral Nutritional Supplements" must be "medical foods" as defined by the FDA. These include metabolic formula and modified low protein foods that are specially formulated and processed products. They can be obtained in either a pharmacy or over-the-counter. Common trade brands include Ensure, Boost, Glucerna, Nepro, and Suplena.

Parenteral Nutrition

"Parenteral Nutrition" refers to nutrition administered outside of the GI tract, such as intravenous feeding. May be used in cases where traditional enteral feeding is impossible due to obstructions, malabsorption, or congenital conditions. Parenteral nutrition is not discussed in this guideline.

Poor Weight Gain

"Poor Weight Gain" is applicable to children aged 2-18, and defined using the 2022 CDC Growth Charts and BMI-For-Age Charts which can identify weight gain issues including:

1. Abrupt weight loss following a period of normal growth along a well-established pattern of height and weight gain defined as crossing two or more major weight percentiles; or
2. Slow, steady weight gain below the fifth percentile of the NCHS growth curves; or
3. A growth curve proportionate to, but lower than, the child's expected height trajectory; or

Growth milestones that have been met but only with nutritional support consisting of high-calorie foods and/or nutritionally dense foods, where support with nutritional and calorie appropriate food is necessary.

Medical Necessity Criteria for Authorization

The Plan considers Nutritional (Enteral) Products, Supplies, and Equipment medically necessary when ALL the following criteria are met (as applicable) below:

1. Recent documentation (within the last 6 months) of ALL of the following:
   • Medical nutritional product is prescribed by a licensed provider for the therapeutic treatment of a condition requiring specialized nutrients;and
   • Diagnosis or condition, including (as applicable) accurate diagnostic information b. pertaining to the underlying diagnosis or condition that resulted in the requirement for a nutritional product, such as:
     • Growth history and growth charts;and
     • Height and weight;and
     • Member’s overall health status;and
     • Other formulas tried and why they did not meet the member’s needs;and
     • Why the member cannot be maintained on an age-appropriate diet;and
     • Goals and timelines on the medical plan of care;and
     • Specified quantity and duration of the prescription or order;ande.
     • Total caloric intake prescribed by the provider;andf.
     • For members who require tube feeding, documentation indicating that the member has a feeding tube in place;AND
2. Member is characterized by ONE of the following:
   • Member requires tube feedings;or
     • A documented medical diagnosis that requires enteral nutrition products administered through a feeding tube should be provided.
   • Currently undergoing transition from parenteral or enteral diet (with tube feeding) to oral diet;orc.
   • Member has severe swallowing or chewing difficulty due to one of the following:
     • Cancer in the mouth, throat, or esophagus;or
     • Injury, trauma, surgery, or radiation therapy involving the head or neck;or
     • Chronic neurological disorders;or
     • Severe craniofacial anomalies;ord.
   • Adult member 18 years of age and older (≥18) AND ANY of the following:
     • Documented chronic medical disease (e.g. HIV/AIDS, Crohn’s disease, cystic fibrosis, etc) that is being appropriately treated and
       1. inability to meet nutritional needs even with a dietary adjustment of regular or altered consistency (soft/pureed) foods;ori.
     • Medical condition (acute or chronic) such as a metabolic, gastrointestinal, or gastroesophageal disorder that is being appropriately treated AND associated with an inability to meet nutritional needs with a dietary adjustment of regular or altered consistency foods (e.g., soft or pureed) and ONE of the following:
       1. Involuntary weight loss of:
          1. 10 percent or more of usual body weight within six months;orb.
          2. 7.5 percent or more of usual body weight within three months;orc.
          3. 5 percent or more of usual body weight in one month; or
       2. Body mass index less than 18.5 kg/m2;or
       3. Multiple, severe food allergies which if left untreated will cause malnourishment, chronic physical disability, mental retardation or death;ore.
   • Pediatric members under the age of 18 AND ONE of the following:
     • Members with inborn errors in metabolism, including but not limited to:
       1. Glutaric aciduria type I;or
       2. Homocystinuria;or
       3. Isovaleric acidemia;or
       4. Maple syrup urine disease;or
       5. Maternal phenylketonuria;or
       6. Methylmalonic acidemia;or
       7. Other disorders of leucine metabolism;or
       8. Phenylketonuria;or
       9. Propionic acidemia;or
       10. Tyrosinemia types I and II;or
       11. Urea cycle disorders;or
     • Member has malnutrition or risk of malnutrition, as demonstrated by any ONE of the following:
       1. Allergic or eosinophilic enteritis (colitis/proctitis, esophagitis, gastroenteritis);or
       2. Allergy or hypersensitivity to cow or soy milk diagnosed through a formal food challenge;or
       3. Allergy to specific foods including food-induced anaphylaxis; or
       4. Cystic fibrosis with malabsorption;or
       5. Malabsorption unresponsive to standard age appropriate interventions when associated with failure to gain weight or meet established growth expectations;or
       6. Poor oral intake related to anatomic or motility related disorders of the GI tract;or
       7. Symptoms of malabsorption related to inflammatory disorders of the GI tract;or
     • Members aged 2-18 with poor weight gain, as defined above in “Definitions”, that is unresponsive to standard age appropriate interventions;or
     • Members aged <2 years old with failure to thrive, as defined above in “Definitions”, that is unresponsive to standard age appropriate interventions;oriv.
     • Pediatric members residing in Texas with nutritional deficiencies related to documented autism spectrum disorder;or
     • Pregnant Women with Hyperemesis Gravidarum who meet ALL of the following criteria:
       • Condition is refractory to pharmacologic and nonpharmacologic intervention;i.
       • Member cannot maintain weight despite appropriate interventions;andiii.
       • The treatment plan includes assessment and consultation with a nutritionist or nutrition service;AND
   • If the requested product is for ONE of the following:
     • Carbohydrate modular products administered orally or through a feeding tube, there must be documented evidence that the member is unable to meet caloric nutritional needs with the current use of an enteral nutrition product;orb.
     • Diabetic products, the member must have documented evidence of BOTH of the following:
       • Diagnosis of hyperglycemia or diabetes;andi.
       • HbA1c (A1c) value measured within six months of the authorization request;ii.
     • Elemental or semi-elemental nutrition products, members must have documented evidence of ALL of the following:
       • Chronic intestinal malabsorption disease (lactose intolerance is excluded);i.
       • Be unable to absorb nutrients or tolerate intact protein in a way that cannot otherwise be medically managed or managed with alternative dietary options;ii.
       • History of use of disease-specific or specialized nutrition products that have not been successful (unless medically contraindicated);orc.

6. Hepatic products, the member must have documented results of liver function test measured within six months of the request;ord.
7. Lipid (fat) modular products administered orally or through a feeding tube, the member must have documented evidence of ONE of the following diagnosis:
   • Inability to digest/absorb conventional fats;or
   • ii. Uncontrolled seizure disorder that cannot be otherwise managed (in cases of ketogenic diet);ore.
8. Medical Foods Dispensed by Prescription under Pharmacy Benefit, in the absence of product-specific clinical guideline or coverage criteria, documentation of ALL of the following:
   • i. The product is prescribed for the specific dietary management of a disease or condition with distinctive nutritional requirements;and
   • ii. The member has limited or impaired capacity to ingest, digest, absorb or metabolize normal foodstuffs or certain nutrients, or has medically determined special nutrient requirements;and
   • Normal diet alone cannot meet the distinctive nutritional needs;and
   • iv. The safety and effectiveness of the product has been established for the member's age and disease or condition;and
   • v. The product is being used adjunctively with standard of care treatment options for the member's disease or condition, including drug therapy, non-drug, and supportive care.
9. f. Protein modular products administered orally or through a feeding tube, there must be documented evidence that the member is unable to meet protein requirements with current use of a high protein enteral nutrition product;org.
10. g. Related supplies and equipment for nutritional products, provided that ALL of the following are met:
    • i. The criteria for nutritional products are met, as outlined in the Plan's clinical policy;and
    • Medical necessity is documented for each requested item;and
    • iii. For additional feeding tubes, submitted documentation supports medical necessity, such as infection at gastrostomy site, leakage, or occlusion;and
    • iv.For enteral feeding pumps (with or without alarms), the member meets ANY of the following criteria:
      1. Gravity or syringe feedings are not medically indicated;or
      2. The member requires an administration rate of less than 100 ml/hr;or
      3. The member requires night-time feedings;or
      4. The member has a medical condition necessitating the use of an enteral feeding pump, such as blood glucose fluctuations, circulatory overload, dumping syndrome, reflux or aspiration, or severe diarrhea;and
    • v. For a backpack or carrying case for a portable enteral feeding pump, documented evidence of BOTH of the following:
      1. The member requires enteral feedings lasting more than eight hours continuously, or the feeding intervals exceed the time the member must be away from home due to attending school or work, frequent medical appointments, or extensive physician-ordered outpatient therapies;and
      2. The member is ambulatory or uses a wheelchair that cannot support the use of a portable pump through other means, such as an IV pole;or
11. h. Renal products, the member must have documented evidence of ONE of the following indicators measured within six months of the request:
    • Blood serum potassium (elevated);or i.
    • BUN levels (>20mg/dl);or ii.
    • iii. GFR < 60.

If the applicable criteria for prior authorization above are met, the requested Nutritional (Enteral) Products, Supplies, or Equipment will be authorized for the requested duration or a maximum of thirty (30) days, whichever is lesser.

Continued Care

Authorization Period and Extension Requests:

1. Initially, authorization is provided for up to a maximum of thirty (30) days.
2. B. For extensions of services beyond the initial authorization period, re-authorization is required.
3. C. The prior authorization may be recertified with appropriate documentation that supports the ongoing medical necessity for the requested nutritional products.

If approved, the requested nutritional products, supplies, or equipment will be authorized for the duration requested or a maximum of thirty (30) days, whichever is less.

Experimental or Investigational / Not Medically Necessary

• Over-the-counter products may not be covered, even if prescribed by a healthcare provider (refer to member's benefit plan for confirmation);or
• Medically necessary products must have a specific medical indication, not solely based on food preference or patient convenience;or
• Not medically necessary products may include, but are not limited to:
  • Baby food or standard infant formula;or
  • Breast milk;or
  • Enteral nutrition products used orally as a convenient alternative to preparing and/or consuming regular, solid, or pureed foods;or
  • Food thickeners;or
  • Gluten-free foods;or
  • High-protein powders or nutritional drinks;or
  • Items not categorized as medical foods;or
  • Low carbohydrate diet supplements;or
  • Non-prescription weight loss or weight gain products;or
  • Nutritional products for members who could be sustained on an age-appropriate diet;or
  • Products for assistance with weight loss;or
  • Regular food, including solid, semi-solid, and pureed foods;or
  • Relizorb (enzyme cartridge), considered experimental or investigational;or
  • Shakes, cereals, thickened products, puddings, bars, gels, and other non-liquid products. ;or

Table 1: Enteral Nutrition Formulas

Source:American Society for Parenteral and Enteral Nutrition (ASPEN)

Disclaimer

The following is a guide to help healthcare providers choose the most appropriate enteral formula for their patients. The list provided below is not exhaustive and is meant to highlight commonly used products. The Plan does not endorse any specific brand of product, and these listings should not be taken as a substitute for medical advice. Choosing the right formula for a member can be a complex process that takes into account factors such as age, fluid status, gastrointestinal function, food allergies, and diet preferences. While most members can tolerate a standard formula, specialty formulas typically require medical justification for coverage by the Plan, as outlined in the Medical Necessity Criteria provided in this policy. Formulas are grouped by reimbursement codes, called HCPCS codes, when applicable.

Claims such as gluten-free, lactose-free, non-GMO, and organic should be reviewed with each company before use. This table is reviewed regularly, at least annually, for updates, but new products are constantly entering the market, and therefore this table's listing may not be comprehensive. Ultimately, each member's nutritional needs should be considered individually. Please refer to the manufacturer's website for the most up-to-date product information.

The products listed below are provided for informational purposes only. Inclusion or exclusion of a product does not imply or guarantee coverage or reimbursement by the Plan. The actual coverage or non-coverage of services for an individual member will be determined by the terms and conditions of their policy at the time of service, as well as applicable state and federal law.

Please refer to the member's policy documents (such as the Certificate/Evidence of Coverage, Schedule of Benefits, or Plan Formulary) or contact the Plan to confirm coverage. The coverage of services is subject to the terms, conditions, and limitations of a member's policy.

Table 1.1 - Adult Formulas

Adult Formula - Polymeric; Standard Volume

• Diabetisource AC®, Nestlé Health Science - carbohydrate: Kosher, Gluten-Free, Lactose-free
• Fibersource HN®, Nestlé Health Science - High protein: Kosher, Gluten-Free, suitable for lactose intolerance
• Glucerna 1.0 Cal®, Abbott - carbohydrate: Kosher, Halal, Gluten-Free, suitable for lactose intolerance
• Glucerna 1.2 Cal®, Abbott - carbohydrate: Kosher, Halal, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Glytrol®, Nestlé Health Science - Carbohydrate/High protein with Con: Kosher, Gluten-Free, suitable for lactose intolerance
• Impact®, Nestlé Health Science - inflammation/High Con: Kosher, Gluten-Free, Lactose-free. Contains Immune Nutrients: Yes
• Isosource HN®, Nestlé Health Science - High protein: Kosher, Gluten-Free, suitable for lactose intolerance
• Nutren 1.0®, Nestlé Health Science - Standard without fiber: Contains Soy. Kosher, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Nutren 1.0 Fiber®, Nestlé Health Science - Standard with fiber: Contains Soy. Kosher, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Osmolite 1.0 Cal®, Abbott - Standard without fiber: Kosher, Halal, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Osmolite 1.2 Cal®, Abbott - Standard without fiber: Kosher, Halal, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Promote®, Abbott - High protein without fiber: Kosher, Halal, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Promote with Fiber®, Abbott - High protein with fiber: Contains Soy. Kosher, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Replete®, Nestlé Health Science - High Protein without fiber: Kosher, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No
• Replete® Fiber, Nestlé Health Science - High Protein with fiber: Contains Soy. Kosher, Gluten-Free, suitable for lactose intolerance. Contains Immune Nutrients: No

Adult Formula - Polymeric; Concentrated Volume

• Glucerna® 1.5 Cal, Abbott - Low carbohydrate/Concentrated: Kosher, Halal, Gluten-Free
• Isosource® 1.5 Cal, Nestlé Health Science - With fiber: Contains Soy
• Jevity® 1.5 Cal, Abbott - Concentrated with fiber: Contains Soy

Pea Protein

Standard 1.4 (vanilla), Kate Farms - Standard plant-based: Lactose-free, Vegan, plant-based, gluten-free, no soy, no corn, no peanuts, no tree nuts, Organic, Non-GMO, Kosher

Adult Formula - Hydrolyzed; Standard Volume

• Peptamen®, Nestlé Health Science - MCT:LCT=70:30, No added fiber: Gluten-Free, suitable for lactose intolerance, kosher
• Peptamen AF®, Nestlé Health Science - Modulating inflammation/MCT:LCT=50:50 with EPA and DHA, High Protein with soluble fiber: Gluten-Free, suitable for lactose intolerance, kosher
• Peptamen® Intense VHP, Nestlé Health Science - Modulating inflammation/Very High Protein, low carbohydrate with soluble fiber, MCT:LCT=50:50 with EPA and DHA: Gluten-Free, suitable for lactose intolerance, kosher
• Perative®, Abbott - High Protein/Contains Arginine: Contains Soy, Kosher, Halal, Gluten-Free, suitable for lactose intolerance
• Vital® 1.0 Cal, Abbott - Gluten-Free, suitable for lactose intolerance
• Vital® HP, Abbott - Modulating Inflammation/High Protein: Gluten-Free, suitable for lactose intolerance

Adult Formula - Hydrolyzed; Concentrated Volume

• Impact® Peptide 1.5, Nestlé Health Science - Modulating Inflammation/High Protein: Contains Soy, Gluten-Free, suitable for lactose intolerance, Contains Immune Nutrients: Yes

Whey Protein

• Peptamen® 1.5 with Prebio™, Nestlé Health Science - MCT:LCT=70:30, and with soluble fiber. Contains Soy. Gluten-Free, suitable for lactose intolerance, kosher.

Pea Protein

• Peptide 1.5® (plain), Kate Farms - Plant based. Lactose-free, Vegan, Plant-based, gluten-free, no corn, no nuts, no soy, Organic, Non-GMO, Kosher.

Milk Protein

• Pivot® 1.5, Abbott - Modulating inflammation/High Protein. Contains Soy. Halal, Gluten-Free, suitable for lactose intolerance.
• Very low protein without fiber/Low phosphorus, potassium and magnesium. Kosher, Gluten-Free, suitable for lactose intolerance.
• Vital® 1.5 Cal, Abbott - Gluten-Free, suitable for lactose intolerance.

Adult Formula - Elemental; Standard Volume

• Vivonex®, Nestlé Health Science - Very low fat/low powder with no fiber. Kosher, Gluten-Free, Lactose-Free.
• Vivonex® Plus, Nestlé Health Science - Very low fat/moderate protein powder, with added glutamine, arginine and branched-chain amino acids. Kosher, Gluten-Free, Lactose-Free.
• Vivonex® RTF, Nestlé Health Science - Low fat, moderate liquid with no added protein fiber. Kosher, Gluten-Free, Lactose-Free.

Adult Formula - Blenderized

• Compleat Organic Blends®, Nestlé Health Science - Standard. Gluten-Free, Lactose-Free, Organic, Non-GMO, no dairy, no soy, no corn.
• Compleat Organic Blends®, Nestlé Health Science - Standard- Plant Based. Gluten-Free, Lactose-Free, Organic, Non-GMO, no dairy, no soy, no corn, plant-based.
• Garden Blends® with Chicken, Real Food Blends® - Blenderized whole foods.
• Garden Blends® with Vegetables, Real Food Blends® - Blenderized whole foods.
• Garden Blends® with Wild Salmon, Real Food Blends® - Blenderized whole foods.
• Functional Formularies - Blenderized whole foods. Organic, Gluten-Free, dairy-free, no soy, no corn, Non-GMO, plant-based, suitable for lactose intolerance.
• Real Food Blends® Eggs, Apples, and Oats - Blenderized whole foods. Gluten-Free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients.
• Real Food Blends® Turkey, Sweet Potatoes, and Peaches - Blenderized whole foods. Gluten-Free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients.

Table 1.2 - Pediatric Formulas

Pediatric Formula - Polymeric; Standard Volume

• Boost® Kid Essentials, Nestlé Health Science - Milk Based. Contains soy. Gluten-Free, kosher, suitable for lactose intolerance.
• Boost® Kid Essentials 1.0, Nestlé Health Science - Milk Based. Gluten-Free, kosher, suitable for lactose intolerance.
• PediaSure® Enteral Formula 1.0 Cal, Abbott - Milk Based. Gluten-Free, halal, kosher, suitable for lactose intolerance.
• PediaSure® Enteral Formula 1.0 Cal with Fiber, Abbott - Milk Based. Gluten-Free, halal, kosher, suitable for lactose intolerance.
• Nutren Junior®, Nestlé Health Science - Milk and Soy protein. Contains soy. Gluten-Free, suitable for lactose intolerance, Kosher.
• Nutren Junior® Fiber, Nestlé Health Science - Milk and Soy protein. Contains soy. Gluten-Free, suitable for lactose intolerance, Kosher.
• PediaSure® SideKicks® Shake, Abbott - Milk and Soy protein. Gluten-Free, halal, kosher, suitable for lactose tolerance.
• PediaSure® SideKicks® with Fiber Shake, Abbott - Milk and Soy protein.

Pediatric Formula - Polymeric; Standard Volume

• Milk and Soy Protein | Pediasure Sidekicks® 0.63 cal Shake, Abbott - Gluten-free, halal, kosher, suitable for lactose intolerance
• Organic Pea Protein | Kate Farms Pediatric Standard 1.2, Kate Farms® - Vegan, no milk, no soy, no gluten, no nuts, no corn | Gluten-free, lactose-free
• Soy Protein | Pea Pediatric Drink®, Bright Beginnings - Vegetarian, milk free, may be suitable for cow milk allergy, contains soy | Gluten-free, kosher, lactose-free

Food Ingredients

• Compleat® Pediatric, Nestlé Health Science - No Soy, NO corn | Gluten-free, suitable for lactose intolerance
• Compleat® Pediatric Reduced Calorie, Nestlé Health Science - No soy, no corn | Gluten-free, suitable for lactose intolerance

Formula Composition

• Milk Based | Boost® Kid EssentialsTM 1.5, Nestlé Health Science - Contains soy | Gluten-free, kosher, suitable for lactose intolerance
• Milk Based | Boost® Kid EssentialsTM 1.5 with Fiber, Nestlé Health Science - Contains soy | Gluten-free, kosher, suitable for lactose intolerance
• Milk Protein | Pediasure® 1.5 Cal, Abbott - Contains soy | Gluten-free, halal, kosher, suitable for lactose intolerance
• Milk and Soy Protein | PediaSure® 1.5 Cal with Fiber, Abbott - Contains soy | Gluten-free, halal, kosher, suitable for lactose intolerance

Pediatric Formula - Hydrolyzed; Standard Volume

• Whey Protein | Peptamen Junior®, Nestlé Health Science - Contains milk and soy ingredients | Gluten-free, kosher, suitable for lactose intolerance
• Whey Protein | Peptamen Junior® HP, Nestlé Health Science - Contains milk and soy ingredients | Gluten-free, kosher, suitable for lactose intolerance
• Whey Protein | Peptamen Junior® Fiber, Nestlé Health Science - Contains milk and soy ingredients | Gluten-free, kosher, suitable for lactose intolerance
• Whey Protein | Peptamen Junior® with Prebio1TM, Nestlé Health Science - Contains milk and soy ingredients | Gluten-free, kosher, suitable for lactose intolerance
• Whey Protein/Casein | Pediasure® Peptide 1.0 Cal, Abbott | Gluten-free, halal, kosher, suitable for lactose intolerance
• Pea Protein | Kate Farms Pediatric Peptide 1.0, Kate Farms - Vegan, no milk, no soy, no gluten, no nuts, no corn | Gluten-free, suitable for lactose intolerance

Hydrolyzed; Concentrated Volume

• Whey Protein | Peptamen Junior® 1.5, Nestlé Health Science - Contains milk and soy ingredients | Gluten-free, kosher, suitable for lactose tolerance
• Whey Protein/Casein | PediaSure® Peptide 1.5 Cal, Abbott | Gluten-free, halal, kosher, suitable for lactose tolerance
• Organic Pea Protein | Kate Farms Pediatric Peptide 1.5®, Kate Farms - Vegan, no milk, no soy, no gluten, no nuts, no corn | Gluten-free, suitable for lactose intolerance

Pediatric Formula - Elemental; Standard Volume

• Free Amino Acid | EleCare® Jr, Abbott - No milk, no soy, no fructose, no galactose | Gluten-free, halal, suitable for lactose intolerance
• Free Amino Acid | Alfamino® Infant, Nestlé Health Science - No milk ingredients | Gluten-free, lactose-free
• Free Amino Acid | Alfamino® Junior, Nestlé Health Science - No milk ingredients | Gluten-free, lactose-free
• Free Amino Acid | Vivonex® Pediatric, Nestlé Health Science - No milk ingredients | Gluten-free, kosher, lactose-free
• Free Amino Acid | Neocate® Junior: Unflavored, Nutricia - No dairy, no soy oil | Kosher
• Free Amino Acid | Neocate® Junior, Nutricia - No dairy, no soy oil | Kosher
• Free Amino Acid | Neocate® Junior with Probiotics: Unflavored, Nutricia - No dairy, no soy oil | Kosher
• Free Amino Acid | Neocate® Junior with Probiotics: Vanilla, Nutricia - No dairy, no soy oil | Kosher
• Free Amino Acid | Neocate® Junior with Probiotics: Strawberry, Nutricia - No dairy, no soy oil | Kosher
• Free Amino Acid | Neocate® Splash, Nutricia - No dairy, no soy oil, no casein | Kosher

Composition

• Compleat® Pediatric Organic Blends (chicken or garden blend), Nestlé Health Science - Non-GMO, no dairy, no soy, no corn | Gluten-free, lactose-free
• Nourish, Functional Formularies

Table 1.3 - Infant Formulas

Infant Formula - Term Infants; Polymeric

• Milk based/Whey protein
  • Advantage Infant Formula®, Up and Up (Target) - DHA, Lutein, Vitamin E; 20 cal/oz
  • Enfamil® Enspire™, Mead Johnson - DHA, lactoferrin, 20 cal/oz, non-GMO
  • Enfamil NeuroPro Infant®, Mead Johnson - DHA, 20 cal/oz, non-GMO, whey/casein 60/40. Contains soy
  • Enfamil Premium Newborn®, Mead Johnson - DHA, 20 cal/oz, non-GMO, whey/casein 80/20
  • Enfamil® Infant, Mead Johnson - DHA, 20 cal/oz, whey/casein 60/40. Contains soy
• Natural Stage 1 Organic Infant Formula®, Gerber - DHA, 20 cal/oz, prebiotics, non-GMO
• Natural Stage 2 Organic Infant Formula®, Gerber - DHA, 20 cal/oz, prebiotics, non-GMO
• Organic Dairy Infant Formula®, Earth's Best - DHA, lutein, prebiotics, non-GMO. Contains soy
• Organic Dairy Infant Formula with Iron, The Honest Company - DHA, 20 cal/oz, FOS, non-GMO. Contains soy
• Organic Premium Infant Formula with Iron, Plum® Organics - DHA, 20 cal/oz, non-GMO. Contains soy
• Organic Sensitivity® Infant Formula, Earth's Best - DHA, lutein, 20 cal/oz, reduced lactose. Contains soy
• Pure Bliss by Similac®, Abbott - Protein, DHA and Vitamin E, 19 cal/oz, Non-GMO. Contains soy
• Similac Advance®, Abbott - Lutein, DHA and Vitamin E, Nucleotides; 19 cal/oz. Contains soy
• Similac Advanced 20®, Abbott - Lutein, DHA and Vitamin E, Human milk oligosaccharides; 20 cal/oz. Contains soy
• Similac Organic®, Abbott - Vitamin E, Milk oligosaccharides. Contains soy
• Similac Advance for Neuro Support®, Abbott - Protein, DHA and Vitamin E, Nucleotides; 19 cal/oz
• Similac® with Iron 24, Abbott - DHA; 24 cal/oz. Contains soy
• Milk based/whey and casein
  • Added Rice Starch Infant Formula with Iron, Up and Up (Target) - 20 cal/oz, prebiotics, DHA, added rice starch.
  • Holle Stage 1 Organic (Bio) Infant Milk Formula, Organic Start - 20 cal/oz, non-GMO
  • Holle Stage Pre Organic (Bio) Infant Milk Formula, Organic Start - 20 cal oz, no maltodextrin, reduced vegetable oil, whole milk fat, non-GMO
• Similac® PM 60/40, Abbott - Whey/casein 60/40; 20 cal/oz; low mineral content
• Milk based/milk protein isolate
  • Enfamil NeuroPro™ Sensitive - DHA, 20 cal/oz, non-GMO
  • Sensitivity® Infant Formula, Up and Up (Target) - DHA, lutein, prebiotics, non-GMO, reduced lactose
  • Similac Pro Sensitive®, Abbott - Lutein, DHA and Vitamin E, Human milk oligosaccharides; 19 cal/oz

Infant Formula - Term Infants; Polymeric

• Milk based/milk protein isolate
  • Similac Sensitive®, Abbott - Lutein, DHA and Vitamin E, 19 cal/oz, Non-GMO
• Milk based/milk protein isolate with rice starch
  • Enfamil A.R.®, Mead Johnson - DHA, 20 cal/oz, whey/casein 20:80
  • Lutein, DHA and Vitamin E, 19 cal/oz, Non-GMO
• Soy protein
  • Enfamil® ProSobee®, Mead Johnson - DHA, 20 cal/oz
  • Non-GMO Plant Based Formula® - DHA, 20 cal/oz
  • Similac® Soy Isomil, Abbott - Nucleotides and Vitamin E, Contains soy
  • Similac® Soy Isomil 20, Abbott - Human DHA and Vitamin E, 20 cal/oz
  • Similac® for Diarrhea, Abbott - Soy fiber; 20 cal/oz

Infant Formula - Preterm Infants; Hydrolyzed

• Milk based/whey protein hydrolysate
  • Good Start® Gentle, Gerber - DHA, prebiotic, 20 cal/oz, non-GMO
  • Good Start® Soothe (HMO)®, Gerber - DHA, prebiotic, 20 cal/oz, non-GMO, reduced lactose
• Casein hydrolysate
  • Enfamil® Gentlease®, Mead Johnson - DHA, 20 cal/oz, non-GMO, Contains soy
  • Enfamil® Reguline®, Mead Johnson - DHA, 20 cal/oz, Contains soy
  • Similac Pro Total Comfort®, Abbott - Lutein, DHA and Vitamin E, human milk oligosaccharides, 19 cal/oz; non-GMO, Contains soy
  • Similac Total Comfort®, Abbott - Human DHA and Vitamin E, 19 cal/oz
• Free amino acids
  • Elecare®, Abbott - DHA, 20 cal/oz, MCT, Free of soy
  • Nutramigen®, Mead Johnson - Contains soy
  • Nutramigen® with Enflora LGG®, Mead Johnson - DHA, 20 cal/oz, LGG probiotic, Contains soy
  • Similac® Alimentum®, Abbott - DHA and ARA, MCT, Vitamin E, 20 cal/oz

Infant Formula - Term Infants; Polymeric

• Goat Milk
• Similac Sensitive for Neuro Support®, Abbott - Lutein, DHA and Vitamin E, 19 cal/oz, Non-GMO

Infant Formula - Preterm Infants; Polymeric

• Whey protein
  • Similac® Special Care® 24, Abbott - Lutein, Vitamin E; 24 cal/oz, Contains soy

Infant Formula - Preterm Infants; Partially Hydrolyzed

Whey protein isolate hydrolysate: Enfamil® Acidified

Infant Formula - Preterm Infants; Hydrolyzed

• Casein hydrolysate: Similac® Human Milk Fortifier Hydrolyzed Protein Concentrated Liquid, Abbott
• Casein hydrolysate: Liquid Protein Fortifier, Abbott

Table 1.4 - Modular Products

Modular Products - Powder

Beneprotein®, Nestlé Health Science: 6 g protein/svg
Active® Protein powder, Medline: 6 g protein/svg
ProCel® Protein powder, Whey, unflavored, Global Health: 5 g protein/svg
RenaMent®, Meditrition: 10 g protein/svg; low sodium, potassium and phosphorous
Vital Cuisine® ProPass®, Hormel: protein/svg lactose and soy
ProSource® Protein Powder, Medtrition: protein/svg Contains land ins milk
Protein/amino acids, Meditrition: Contains a prebiotic, arginine, glutamine, zinc copper and vitamin C; 10 g protein/svg
Protein/arginine, Argitein®, Medtrition: 5 g protein/svg; 4.5 g L-arginine/svg
Prebiotic and probiotic, Diff-Stat®, Nutricia: Fructo-oligosaccharides; saccharomyces boulardii, bacillus coagulans Contains milk and sucralose
Banatrol® Plus with Prebiotic, Medline: Banana flakes; 2 g/svg; prebiotics
Fiber, FiberCel® Fiber Powder, Global Health: 5 g fiber/svg Lactose-free, gluten-free
Nutrisource® Fiber, Nestlé Health Science: Partially hydrolyzed guar gum, 3 g/svg Lactose-free, gluten-free, suitable for a low FODMAP diet, kosher
Soluble fiber, Vital Cuisine® Fiber Basics®, Hormel: 3 g fiber/svg

Banatrol Plus®, Medtrition: Banana flakes; 2 g fiber/svg; transalacto-oligosaccharide Contains milk

Modular Products - Vitamins/Minerals

Phlexy-Vits®, Nutricia: Multi vitamin and mineral supplement
VitaMent®, Medtrition: Multi vitamin and mineral supplement
UtyMax®, Medtrition: Cranberry concentrate Contains sucralose
Energy and protein, RenaMent®, Medtrition: Whey protein 10 g and 230 kcals/svg

Modular Products - Powder

Modular Products - Liquid

17 g protein/svg; contains arginine, citrulline and cysteine

Medium chain triglycerides Liquigen®, Nutricia Medium chain triglyceride oil; 15 g/oz Soluble fiber FiberHeal®, DermaRite 15 g fiber/svg; contains fructo-oligosaccharides

Table 2: Medical Foods Dispensed by Prescription under the Pharmacy Benefit (not under the Plan medical benefit)

Disclaimer: The list provided below is not exhaustive and is meant to highlight commonly used products.

The products listed below are provided for informational purposes only. Inclusion or exclusion of a product does not imply or guarantee coverage or reimbursement by the Plan. The actual coverage or non-coverage of services for an individual member will be determined by the terms and conditions of their policy at the time of service, as well as applicable state and federal law. Please refer to the member's policy documents (such as the Certificate/Evidence of Coverage, Schedule of Benefits, or Plan Formulary) or contact the Plan to confirm coverage. The coverage of services is subject to the terms, conditions, and limitations of a member's policy.