The following specialized infant formulas will transition to the Pharmacy Program and should be billed using their National Drug Code (NDC) numbers on a pharmacy claim form:
Product name | Manufacturer | Form | Size and packaging size | NDC |
|---|---|---|---|---|
Alfamino Infant | Nestle | PWD | 14.1 oz | 13034078821 |
Alfamino Junior - Unflavored | Nestle | PWD | 14.1 oz | 13034078795 |
Alfamino Junior - Vanilla | Nestle | PWD | 14.1 oz | 13287010606 |
Boost Kid Essentials – Chocolate | Nestlé | RTU | 8 fl oz | 43900033520 |
Boost Kid Essentials – Strawberry | Nestlé | RTU | 8 fl oz | 43900033530 |
Boost Kid Essentials – Vanilla | Nestlé | RTU | 8 fl oz | 43900033511 |
Boost Kid Essentials 1.5 - Chocolate | Nestlé | RTU | 8 fl oz | 43900033588 |
Boost Kid Essentials 1.5 - Strawberry | Nestlé | RTU | 8 fl oz | 43900033590 |
Boost Kid Essentials 1.5 - Vanilla | Nestlé | RTU | 8 fl oz | 43900033540 |
Boost Kid Essentials 1.5 with Fiber – Vanilla | Nestlé | RTU | 8 fl oz | 43900033500 |
Calcilo XD | Abbott | PWD | 12.4 oz | 70074053329 |
Compleat Pediatric Reduced Calorie | Nestlé | RTU | 8.45 fl oz | 43900038074 |
Compleat Pediatric | Nestlé | RTU | 8.45 fl oz | 43900014240 |
EleCare For Infants DHA/ARA - Unflavored | Abbott | PWD | 14.1 oz | 70074053511 |
EleCare Jr. – Unflavored | Abbott | PWD | 14.1 oz | 70074068628 |
EleCare Jr. – Vanilla | Abbott | PWD | 14.1 oz | 70074068631 |
EnfaCare NeuroPro | MJN | PWD | 13.6 oz | 00087512208 |
Enfamil Premature with Iron (24 Cal) | MJN | RTF | 2 fl oz (6 pack) | 00087511568 |
Enfaport | MJN | RTU | 6 fl oz (6 pack) | 00087510525 |
Extensive HA | Nestle | PWD | 14.1 oz | 50000059852 |
Isosource 1.5 Cal with Fiber | Nestlé | RTU | 8.45 fl oz | 43900018150 |
KetoCal 3:1 | Nutricia | PWD | 11 oz | 49735016672 |
KetoCal 4:1 | Nutricia | PWD | 11 oz | 49735016670 |
Monogen (with DHA) | Nutricia | PWD | 14.1 oz (400 g) | 49735017097 |
Neocate Infant DHA/ARA | Nutricia | PWD | 14.1 oz (400 g) | 49735012595 |
Neocate Junior with Prebiotics - Chocolate | Nutricia | PWD | 14.1 oz (400 g) | 49735012690 |
Neocate Junior with Prebiotics – Strawberry | Nutricia | PWD | 14.1 oz (400 g) | 49735016456 |
Neocate Junior with Prebiotics – Vanilla | Nutricia | PWD | 14.1 oz (400 g) | 49735010627 |
Neocate Junior without Prebiotics | Nutricia | PWD | 14.1 oz (400 g) | 49735011790 |
Neocate Splash - Grape | Nutricia | RTU | 8 fl oz | 49735012435 |
Neocate Splash - Orange-Pineapple | Nutricia | RTU | 8 fl oz | 49735012436 |
Neocate Splash - Tropical Fruit | Nutricia | RTU | 8 fl oz | 49735012437 |
Neocate Splash - Unflavored | Nutricia | RTU | 8 fl oz | 49735014451 |
Neocate Splash - Vanilla | Nutricia | RTU | 8 fl oz | 49735010059 |
Nutramigen | MJN | CONC | 13 fl oz | 00087049801 |
Nutramigen | MJN | RTU (Bottle) | 1 qt (32 fl oz) | 00087511564 |
Nutramigen with Probiotic LGG | MJN | PWD | 12.6 oz | 00087123941 |
Nutren Junior - Vanilla | Nestlé | RTU | 8.45 fl oz | 98716006062 |
Nutren Junior Fiber – Vanilla | Nestlé | RTU | 8.45 fl oz | 98716006063 |
PediaSure 1.5 Cal – Vanilla | Abbott | RTU | 8 fl oz | 70074067386 |
PediaSure 1.5 Cal with Fiber-Vanilla | Abbott | RTU | 8 fl oz | 70074067375 |
PediaSure Enteral Formula 1.0 Cal with Fiber | Abbott | RTU | 8 fl oz | 70074067404 |
PediaSure Enteral Formula 1.0 Cal | Abbott | RTU | 8 fl oz | 70074067402 |
PediaSure Grow and Gain - Chocolate | Abbott | RTU | 8 fl oz | 70074-0580-59 |
PediaSure Grow and Gain - Vanilla | Abbott | RTU | 8 fl oz | 70074-0580-50 |
PediaSure Peptide 1.0 Cal - Strawberry | Abbott | RTU | 8 fl oz | 70074067412 |
PediaSure Peptide 1.0 Cal - Unflavored | Abbott | RTU | 8 fl oz | 70074067414 |
PediaSure Peptide 1.0 Cal - Vanilla | Abbott | RTU | 8 fl oz | 70074067410 |
PediaSure Peptide 1.5 Cal - Vanilla | Abbott | RTU | 8 fl oz | 70074067418 |
Peptamen Junior - Unflavored | Nestlé | RTU | 8.45 fl oz | 98716006253 |
Peptamen Junior - Vanilla | Nestlé | RTU | 8.45 fl oz | 98716006252 |
Peptamen Junior 1.5 - Unflavored | Nestlé | RTU | 8.45 fl oz | 98716007363 |
Peptamen Junior 1.5 - Vanilla | Nestlé | RTU | 8.45 fl oz | 98716070482 |
Peptamen Junior Fiber - Vanilla | Nestlé | RTU | 8.45 fl oz | 98716060200 |
Portagen | MJN | PWD | 14.46 oz | 00087511728 |
Pregestimil | MJN | PWD | 16 oz | 00087036701 |
Pregestimil (20 Cal) | MJN | RTU | 2 fl oz (6 pack) | 00087143341 |
Pregestimil (24 Cal) | MJN | RTU | 2 fl oz (6 pack) | 00087143441 |
PurAmino | MJN | PWD | 14.1 oz | 00087510480 |
RCF (Ross Carbohydrate Free) | Abbott | CONC | 13 fl oz | 70074040108 |
Similac PM 60/40 | Abbott | PWD | 14.1 oz | 70074060850 |
Similac Special Care 24 with Iron | Abbott | RTF | 2 fl oz (4 pack) | 70074056270 |
Similac Alimentum | Abbott | PWD | 12.1 oz | 70074064712 |
Similac Alimentum | Abbott | RTU | 1 qt (32 fl oz) | 70074057513 |
Similac NeoSure | Abbott | PWD | 13.1 oz | 70074057431 |
Similac NeoSure | Abbott | RTF | 1 qt (32 fl oz) | 70074057456 |
Super Soluble Duocal | Nutricia | PWD | 14.1 oz (400 g) | 49735018262 |
Suplena with Carb Steady – Vanilla | Abbott | RTU | 8 fl oz | 70074062089 |
Tolerex | Nestlé | PWD | 2.82 oz (6 packets /carton) | 43900045806 |
Vivonex T.E.N. – Unflavored | Nestlé | PWD | 2.84 oz (10 packets /carton) | 43900071274 |