Nestlé HealthCare Nutrition Enteral Products
Number of 100 kCal Units Per Case
Product
ALFAMINO™ INFANT, Unflavored Powder, 400 g canisters
ALFAMINO™ JUNIOR, Unflavored Powder, 400 g canisters
ARGINAID®, Orange, 0.32 oz pkts
ARGINAID®, Cherry, 0.32 oz pkts
ARGINAID EXTRA®, Orange Burst, 8 fl oz
ARGINAID EXTRA®, Wild Berry, 8 fl oz
BENECALORIE®, 1.5 fl oz cups
BENEPROTEIN®, 7 g pkts
BENEPROTEIN®, 8 oz canister
BOOST®, Very Vanilla, 8 fl oz
BOOST®, Rich Chocolate, 8 fl oz
BOOST®, Creamy Strawberry, 8 fl oz
BOOST BREEZE®, Orange, 8 fl oz
BOOST BREEZE®, Peach, 8 fl oz
BOOST BREEZE®, Wild Berry, 8 fl oz
BOOST BREEZE®, Variety Case, 8 fl oz
BOOST® COMPACT, Very Vanilla, 4 fl oz
BOOST® COMPACT, Rich Chocolate, 4 fl oz
BOOST GLUCOSE CONTROL®, Vanilla, 8 fl oz
BOOST GLUCOSE CONTROL®, Chocolate, 8 fl oz
BOOST GLUCOSE CONTROL®, Strawberry, 8 fl oz
BOOST® HIGH PROTEIN, Very Vanilla, 8 fl oz
BOOST® KID ESSENTIALS, Vanilla, 8 fl oz
BOOST® KID ESSENTIALS, Chocolate, 8 fl oz
BOOST® KID ESSENTIALS, Strawberry, 8 fl oz
BOOST® KID ESSENTIALS 1.5, Vanilla, 8 fl oz
BOOST® KID ESSENTIALS 1.5, Chocolate, 8 fl oz
BOOST® KID ESSENTIALS 1.5, Strawberry, 8 fl oz
BOOST® KID ESSENTIALS 1.5 with FIBER, Vanilla, 8 fl oz
BOOST PLUS®, Very Vanilla, 8 fl oz
BOOST PLUS®, Rich Chocolate, 8 fl oz
BOOST PLUS®, Creamy Strawberry, 8 fl oz
BOOST® VHC, Vanilla, 8 fl oz
CARNATION BREAKFAST ESSENTIALS® (Ready-To-Drink), Vanilla, 8 fl oz
CARNATION BREAKFAST ESSENTIALS® (Ready-To-Drink), Chocolate, 8 fl oz
CARNATION BREAKFAST ESSENTIALS® (Ready-To-Drink), Strawberry, 8fl oz
COMPLEAT®, 250 mL
COMPLEAT®, SpikeRight® PLUS UltraPak®, 1000 mL
COMPLEAT®, SpikeRight® PLUS UltraPak®, 1500 mL
COMPLEAT® PEDIATRIC, 250 mL
COMPLEAT® PEDIATRIC REDUCED CALORIE, Unflavored, 250 mL
DIABETISHIELD®, Orange Twist, 8 fl oz
DIABETISHIELD®, Mixed Berry, 8 fl oz
DIABETISOURCE® AC, 250 mL
DIABETISOURCE® AC, SpikeRight®, 1000 mL
DIABETISOURCE® AC, SpikeRight®, 1500 mL
FIBERSOURCE® HN, 250 mL
FIBERSOURCE® HN, SpikeRight® PLUS UltraPak® , 1000 mL
FIBERSOURCE® HN, SpikeRight® PLUS UltraPak® , 1500 mL
GLUTASOLVE®, 22.5 g pkts
Product
Code
NDC Formatted
Number
HCPCS Code
kcal/mL*
Container Size
(mL or g)
kcal /
Container†
Pack
Factor/Cs
kcal/Cs
100 kcal
Units/Case
1303478822
1303478796
35983000
35984000
19660000
19670000
28250000
28430000
28410000
4390067438
4390067538
4390067639
18620000
18640000
18660000
18600000
4390010004
4390010003
36010000
36020000
36030000
4390094139
33510000
33520000
33530000
33540000
33580000
33590000
33500000
4390093138
4390093238
4390093331
4390018216
5000041570
5000041518
5000041580
14010000
14180100
4390014183
14240000
4390038074
34910000
34930000
36500000
36508100
4390036583
18550000
18580100
4390018583
28330000
13034078821
13034078795
43900035980
43900035988
43900019660
43900019670
43900028250
43900028430
43900028410
43900067439
43900067539
43900067638
43900018629
43900018649
43900018666
43900018600
41679051663
41679051571
43900036011
43900036021
43900036031
43900094139
43900033511
43900033520
43900033530
43900033540
43900033588
43900033590
43900033500
43900093139
43900093239
43900093338
43900018215
50000041568
50000041516
50000041578
43900014010
43900014180
43900014182
43900014240
43900038074
43900034910
43900034930
43900036500
43900036508
43900036582
43900018555
43900018588
43900018582
43900028300
B4161
B4161
B4155
B4155
B4102
B4102
B4155
B4155
B4155
B4150
B4150
B4150
B4102 & B4103
B4102 & B4103
B4102 & B4103
B4102 & B4103
B4152
B4152
B4154
B4154
B4154
B4150
B4160
B4160
B4160
B4160
B4160
B4160
B4160
B4152
B4152
B4152
B4152
B4150 & B4160
B4150 & B4160
B4150 & B4160
B4149
B4149
B4149
B4149
B4149
B4102
B4102
B4154
B4154
B4154
B4150
B4150
B4150
B4155
—
—
0.11
0.11
1.06
1.06
7.5
—
—
1
1
1
1.06
1.06
1.06
1.06
1.9
1.9
1.06
1.06
1.06
1
1
1
1
1.5
1.5
1.5
1.5
1.5
1.5
1.5
2.25
1
1
1
1.06
1.06
1.06
1
0.6
0.63
0.63
1.2
1.2
1.2
1.2
1.2
1.2
0.65
400 g
400 g
9.2 g
9.2 g
237 mL
237 mL
44.4 g
7g
227 g
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
125 mL
125 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
237 mL
250 mL
1000 mL
1500 mL
250 mL
250 mL
237 mL
237 mL
250 mL
1000 mL
1500 mL
250 mL
1000 mL
1500 mL
22.5 g
1976
1840
25
25
250
250
330
25
811
240
240
240
250
250
250
250
240
240
250
250
250
240
240
240
240
360
360
360
360
360
360
360
530
240
240
240
265
1060
1590
250
150
150
150
300
1200
1800
300
1200
1800
90
6
6
56
56
27
27
24
75
6
27
27
27
27
27
27
27
24
24
27
27
27
27
27
27
27
27
27
27
27
27
27
27
27
24
24
24
24
6
4
24
24
27
27
24
6
4
24
6
4
56
11856
11040
1400
1400
6750
6750
7920
1875
4866
6480
6480
6480
6750
6750
6750
6750
5760
5760
6750
6750
6750
6480
6480
6480
6480
9720
9720
9720
9720
9720
9720
9720
14310
5760
5760
5760
6360
6360
6360
6000
3600
4050
4050
7200
7200
7200
7200
7200
7200
5040
118.56
110.4
14
14
67.5
67.5
79.2
18.75
48.66
64.8
64.8
64.8
67.5
67.5
67.5
67.5
57.6
57.6
67.5
67.5
67.5
64.8
64.8
64.8
64.8
97.2
97.2
97.2
97.2
97.2
97.2
97.2
143.1
57.6
57.6
57.6
63.6
63.6
63.6
60
36
40.5
40.5
72
72
72
72
72
72
50.4
Product
GLYTROL®, Vanilla, 250 mL
GLYTROL®, SpikeRight® PLUS UltraPak®, 1000 mL
GLYTROL®, SpikeRight® PLUS UltraPak®, 1500 mL
IMPACT®, 250 mL
IMPACT®, SpikeRight® PLUS UltraPak®, 1000 mL
IMPACT ADVANCED RECOVERY®, Vanilla, 8 fl oz
IMPACT ADVANCED RECOVERY®, Chocolate, 8 fl oz
IMPACT® PEPTIDE 1.5, 250 mL
IMPACT® PEPTIDE 1.5, SpikeRight® PLUS UltraPak® , 1000 mL
ISOSOURCE® 1.5 CAL, 250 mL
ISOSOURCE® 1.5 CAL, SpikeRight® PLUS UltraPak® , 1000 mL
ISOSOURCE® 1.5 CAL, SpikeRight® PLUS UltraPak® , 1500 mL
ISOSOURCE® HN, 250 mL
ISOSOURCE® HN, SpikeRight® PLUS UltraPak® , 1000 mL
ISOSOURCE® HN, SpikeRight® PLUS UltraPak® , 1500 mL
MCT Oil®, 1 qt
MICROLIPID®, 3 fl oz
NOVASOURCE® RENAL, 8 fl oz
NOVASOURCE® RENAL, SpikeRight®, 1000 mL
NUTREN® 1.0, Unflavored, 250 mL
NUTREN® 1.0 FIBER, Unflavored, 250 mL
NUTREN® 1.5, Unflavored, 250 mL
NUTREN® 1.5, SpikeRight® PLUS UltraPak® , 1000 mL
NUTREN® 2.0, Unflavored, 250 mL
NUTREN® 2.0, SpikeRight® PLUS UltraPak® , 1000 mL
NUTREN JUNIOR®, Vanilla, 250 mL
NUTREN JUNIOR®, SpikeRight® PLUS UltraPak® , 1000 mL
NUTREN JUNIOR® FIBER, Vanilla, 250 mL
NUTREN JUNIOR® FIBER, SpikeRight® PLUS UltraPak®, 1000 mL
NUTREN® PULMONARY, Vanilla, 250 mL
NUTREN® PULMONARY, SpikeRight® PLUS UltraPak® , 1000 mL
NUTRIHEP®, Unflavored, 250 mL
NUTRISOURCE® FIBER Powder, 7.2 oz canister‡
NUTRISOURCE® FIBER Powder, 4 g pkts‡
OPTISOURCE® HIGH PROTEIN DRINK, Caramel, 237 mL
OPTISOURCE® HIGH PROTEIN DRINK, Strawberry, 237 mL
PEPTAMEN®, Unflavored, 250 mL
PEPTAMEN®, Vanilla, 250 mL
PEPTAMEN® 1.5, Unflavored, 250 mL
PEPTAMEN® 1.5, Vanilla, 250 mL
PEPTAMEN® 1.5, SpikeRight® PLUS UltraPak®, 1000 mL
PEPTAMEN® 1.5 with PREBIO1TM, Vanilla, 250 mL
PEPTAMEN® 1.5 with PREBIO1TM, SpikeRight® PLUS UltraPak®, 1000 mL
PEPTAMEN AF®, Unflavored, 250 mL
PEPTAMEN AF®, SpikeRight® PLUS UltraPak® , 1000 mL
PEPTAMEN® INTENSE VHP, Unflavored, 250 mL
PEPTAMEN® INTENSE VHP, SpikeRight® PLUS UltraPak® , 1000 mL
PEPTAMEN® with PREBIO1TM, Vanilla, 250 mL
PEPTAMEN® with PREBIO1TM, SpikeRight® PLUS UltraPak®, 1000 mL
PEPTAMEN® with PREBIO1TM SpikeRight® PLUS UltraPak®, 1500 mL
PEPTAMEN JUNIOR®, Unflavored, 250 mL
PEPTAMEN JUNIOR®, Vanilla, 250 mL
PEPTAMEN JUNIOR®, Strawberry, 250 mL
PEPTAMEN JUNIOR®, SpikeRight® PLUS UltraPak® , 1000 mL
Product
Code
NDC Formatted
Number
HCPCS Code
kcal/mL*
Container Size
(mL or g)
kcal /
Container†
Pack
Factor/Cs
kcal/Cs
100 kcal
Units/Case
9871616275
9871622390
9871632391
35810000
35810800
19571000
19581000
4390097400
4390097371
18150000
18180100
4390028182
18450000
18480100
4390028466
03651300
00870200
35110000
35180100
9871616210
9871616056
9871616220
9871626354
9871616230
9871644146
9871616062
9871677380
9871616063
9871677400
9871616480
9871622392
9871616479
4390097551
4390097648
17471000
17481000
9871616269
9871616260
9871618192
9871618190
9871628194
4390034958
4390034957
9871666370
9871676390
4390097235
4390097267
9871618185
9871622804
9871622805
9871616253
9871616252
9871660130
9871677360
98716006275
98716016376
98716016377
43900035810
43900035818
43900019550
43900019560
43900097399
43900097370
43900018150
43900018181
43900018182
43900018457
43900018480
43900018466
41679036513
41679008702
43900035111
43900035180
98716006210
98716006056
98716006220
98716016354
98716006230
98716033147
9871616062
98716067370
9871616063
9871677400
98716006480
98716016362
98716006479
43900097550
43900097647
43900017472
43900017482
98716006269
98716006260
98716008192
98716008190
98716018194
43900034958
43900034957
98716066360
98716066380
43900097234
43900097266
98716018185
98716012804
98716012805
98716006253
98716006252
98716060140
98716067350
B4154
B4154
B4154
B4154
B4154
B4154
B4154
B4153
B4153
B4152
B4152
B4152
B4150
B4150
B4150
B4155
B4155
B4154
B4154
B4150
B4150
B4152
B4152
B4152
B4152
B4160
B4160
B4160
B4160
B4154
B4154
B4154
B4104
B4104
B4150
B4150
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4153
B4161
B4161
B4161
B4161
1
1
1
1
1
1.4
1.4
1.5
1.5
1.5
1.5
1.5
1.2
1.2
1.2
7.7
4.5
2
2
1
1
1.5
1.5
2
2
1
1
1
1
1.5
1.5
1.5
—
—
0.85
0.85
1
1
1.5
1.5
1.5
1.5
1.5
1.2
1.2
1
1
1
1
1
1
1
1
1
250 mL
1000 mL
1500 mL
250 mL
1000 mL
237 mL
237 mL
250 mL
1000 mL
250 mL
1000 mL
1500 mL
250 mL
1000 mL
1500 mL
946 mL
88.7mL
237 mL
1000 mL
250 mL
250 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
205 g
4g
237 mL
237 mL
250 mL
250 mL
250 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
250 mL
1000 mL
1500 mL
250 mL
250 mL
250 mL
1000 mL
250
1000
1500
250
1000
340
340
375
1500
375
1500
2250
300
1200
1800
7253
399
475
2000
250
250
375
1500
500
2000
250
1000
250
1000
375
1500
375
769
15
200
200
250
250
375
375
1500
375
1500
300
1200
250
1000
250
1000
1500
250
250
250
1000
24
6
4
24
6
15
15
24
6
24
6
4
24
6
4
6
48
27
6
24
24
24
6
24
6
24
6
24
6
24
6
24
4
75
27
27
24
24
24
24
6
24
6
24
6
24
6
24
6
4
24
24
24
6
6000
6000
6000
6000
6000
5100
5100
9000
9000
9000
9000
9000
7200
7200
7200
43518
19152
12825
12000
6000
6000
9000
9000
12000
12000
6000
6000
6000
6000
9000
9000
9000
3076
1125
5400
5400
6000
6000
9000
9000
9000
9000
9000
7200
7200
6000
6000
6000
6000
6000
6000
6000
6000
6000
60
60
60
60
60
51
51
90
90
90
90
90
72
72
72
435.18
191.52
128.25
120
60
60
90
90
120
120
60
60
60
60
90
90
90
30.76
11.25
54
54
60
60
90
90
90
90
90
72
72
60
60
60
60
60
60
60
60
60
Product
PEPTAMEN JUNIOR® FIBER, Vanilla, 250 mL
PEPTAMEN JUNIOR® 1.5, Unflavored, 250 mL
PEPTAMEN JUNIOR® 1.5, SpikeRight® PLUS UltraPak®, 1000 mL
PEPTAMEN JUNIOR® with PREBIO1TM, Vanilla, 250 mL
PEPTAMEN JUNIOR® with PREBIO1TM, Chocolate, 250 mL
RENALCAL®, Unflavored, 250 mL
REPLETE®, Unflavored, 250 mL
REPLETE®, SpikeRight® PLUS UltraPak®, 1000 mL
REPLETE® FIBER, Unflavored, 250 mL
REPLETE® FIBER, SpikeRight® PLUS UltraPak® , 1000 mL
REPLETE® FIBER, SpikeRight® PLUS UltraPak® , 1500 mL
RESOURCE® 2.0, Vanilla Crème, 32 fl oz
RESOURCE® 2.0, Vanilla Crème, 8 fl oz
TOLEREX®, 2.82 oz pkts
VIVONEX® PEDIATRIC, 1.7 oz pkts
VIVONEX® PLUS, 2.8 oz pkts
VIVONEX® RTF, 250 mL
VIVONEX® RTF, SpikeRight® PLUS UltraPak®, 1000 mL
VIVONEX® RTF, SpikeRight® PLUS UltraPak®, 1500 mL
VIVONEX® T.E.N., 2.84 oz pkts
Product
Code
NDC Formatted
Number
HCPCS Code
kcal/mL*
Container Size
(mL or g)
kcal /
Container†
Pack
Factor/Cs
kcal/Cs
100 kcal
Units/Case
9871660210
9871617363
9871618543
9871616261
9871636416
9871616064
9871616249
9871626356
9871616245
9871626358
9871626359
27600000
18010000
04580500
07131000
07129800
36250000
36280100
4390036283
07127400
98716060200
98716007363
98716008543
98716016261
98716036415
98716006064
98716006249
98716016356
98716006245
98716016358
98716016359
43900027600
43900018010
43900045806
43900071319
43900071299
43900036250
43900036280
43900036282
43900071274
B4161
B4161
B4161
B4161
B4161
B4154
B4150
B4150
B4150
B4150
B4150
B4152
B4152
B4153
B4161
B4153
B4153
B4153
B4153
B4153
1
1.5
1.5
1
1
2
1
1
1
1
1
2
2
1
0.8
1
1
1
1
1
250 mL
250 mL
1000 mL
250 mL
250 mL
250 mL
250 mL
1000 mL
250 mL
1000 mL
1500 mL
946 mL
237 mL
300 mL
250 mL
300 mL
250 mL
1000 mL
1500 mL
300 mL
250
375
1500
250
250
500
250
1000
250
1000
1500
1920
480
300
200
300
250
1000
1500
300
24
24
6
24
24
24
24
6
24
6
4
12
27
60
36
36
24
6
4
60
6000
9000
9000
6000
6000
12000
6000
6000
6000
6000
6000
23040
12960
18000
7200
10800
6000
6000
6000
18000
60
90
90
60
60
120
60
60
60
60
60
230.4
129.6
180
72
108
60
60
60
180
* kcal/mL is a rounded number and should not be used for the purpose of calculating number of calories/case. Rely on the label declaration for calculating calories/container.
† kcal/container is based on the label declaration for the product. This is the value that should be used as the basis for calculations.
‡ This product is intended for use under medical supervision.
The reimbursement information contained in this publication is gathered from third party sources and is presented for illustrative purposes only. This information should not be interpreted as a guarantee of reimbursement or as
endorsed by Medicare, Medicaid, or an Insurance Carrier. Billing entities should contact their third-party payers for specific information on their coding, coverage and payment policies. While this publication provides examples
of clinical information that may be pertinent in seeking enteral coverage for a beneficiary, it does not constitute a recommendation related to a medical necessity determination or the documentation that should be provided
in connection with a given patient or claim. All medical necessity determinations must be made by the responsible clinician(s). In addition, the actual documentation used to support a given claim must be true in all respects
and accurately represent the individual beneficiary’s condition and circumstances. The person or entity submitting claims for reimbursement is solely responsible for ensuring the appropriate filing and accurate content of any
particular claim. Persons who submit false or fraudulent claims for reimbursement are subject to significant civil and criminal penalties.
Please be advised that certain Nestlé HealthCare Nutrition products have been assigned NDC Formatted Numbers. NDC Formatted Numbers are not actual National Drug Codes (NDC). NDC Formatted Numbers are product
codes adjusted according to standard industry practice to meet the format requirements of certain suppliers and payers. Nestlé HealthCare Nutrition submits product information including various product codes to the compendia
including First Data Bank, RedBook and Medispan but cannot confirm that the NDC Formatted Numbers submitted have been published by the compendia.
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