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Friday, November 15, 2013 Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Adult Nutritional 56500 Ensure Clear Ready-to-Drink Blueberry Pomegranate Retail / 10-fl-oz Bottle / Case of 12 None No Medicare rate 70074-0565-02 70074-0565-01 (4 bottles) Adult Nutritional 56604 Ensure Clear Ready-to-Drink Peach Retail / 10-fl-oz Bottle / Case of 12 None No Medicare rate 70074-0566-06 70074-0566-05 (4 bottles) Adult Nutritional 56640 Ensure Clear Ready-to-Drink Apple Institutional / 6.7-fl-oz (198 mL) Brik Pak / Case of 32 B4102 No Medicare rate 70074-0566-41 70074-0566-40 (32 tetras) Adult Nutritional 56642 Ensure Clear Ready-to-Drink Mixed Berry Institutional / 6.7-fl- B4102 oz (198 mL) Brik Pak / Case of 32 No Medicare rate 70074-0566-43 70074-0566-42 (32 tetras) Adult Nutritional 50464 Ensure Plus Ready-to-Drink Vanilla Institutional / 8-fl-oz (237- B4152 mL) Can / Case of 24 $0.55 70074-0504-65 Adult Nutritional 50466 Ensure Plus Ready-to-Drink Milk Chocolate Institutional / 8-fl- B4152 oz (237-mL) Can / Case of 24 $0.55 70074-0504-67 Adult Nutritional 50646 Ensure Plus Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4152 $0.55 70074-0506-47 Adult Nutritional 51894 Ensure Plus Ready-to-Drink Butter Pecan Institutional / 8-fl-oz B4152 (237-mL) Can / Case of 24 $0.55 70074-0518-95 Adult Nutritional 53809 Ensure Plus Ready-to-Drink Dark Chocolate Retail / 8-fl-oz Bottle / Case of 24 B4152 $0.55 70074-0538-11 Adult Nutritional 57263 Ensure Plus Ready-to-Drink Vanilla Retail / 8-fl-oz Bottle / Case of 24 B4152 $0.55 70074-0407-07 (6 bottles) Adult Nutritional 57266 Ensure Plus Ready-to-Drink Milk Chocolate Retail / 8-fl-oz Bottle / Case of 24 B4152 $0.55 70074-0407-02 (6 bottles) Adult Nutritional 57269 Ensure Plus Ready-to-Drink Strawberry Retail / 8-fl-oz Bottle / B4152 Case of 24 $0.55 70074-0407-18 (6 bottles) Adult Nutritional 57272 Ensure Plus Ready-to-Drink Butter Pecan Retail / 8-fl-oz Bottle B4152 / Case of 24 $0.55 70074-0517-87 (6 bottles) Adult Nutritional 58251 Ensure Plus Ready-to-Drink Vanilla Institutional / 32-fl-oz (946- B4152 mL) Bottle / Case of 6 $0.55 70074-0582-52 Adult Nutritional 58299 Ensure Plus Ready-to-Drink Milk Chocolate Institutional / 8-fl- B4152 oz (237-mL) Bottle / Case of 24 $0.55 70074-0583-00 Adult Nutritional 58301 Ensure Plus Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4152 $0.55 70074-0583-02 Adult Nutritional 58303 Ensure Plus Ready-to-Drink Vanilla Institutional / 8-fl-oz (237- B4152 mL) Bottle / Case of 24 $0.55 70074-0583-04 Adult Nutritional 53806 Ensure Ready-to-Drink Dark Chocolate Retail / 8-fl-oz Bottle / B4150 Case of 24 $0.68 70074-0538-08 Adult Nutritional 57231 Ensure Ready-to-Drink Milk Chocolate Retail / 8-fl-oz Bottle / Case of 24 B4150 $0.68 70074-0407-01 (6 bottles) Adult Nutritional 57234 Ensure Ready-to-Drink Strawberry Retail / 8-fl-oz Bottle / Case of 24 B4150 $0.68 70074-0407-05 (6 bottles) Adult Nutritional 57240 Ensure Ready-to-Drink Butter Pecan Retail / 8-fl-oz Bottle / Case of 24 B4150 $0.68 70074-0517-85 (6 bottles) Adult Nutritional 57243 Ensure Ready-to-Drink Vanilla Retail / 8-fl-oz Bottle / Case of 24 B4150 $0.68 70074-0407-11 (6 bottles) Adult Nutritional 53432 Ensure Ready-to-Drink Vanilla Retail CLUB / 8-fl-oz Bottle / Case of 16 B4150 $0.68 70074-0534-32 (16 bottles) Adult Nutritional 53623 Ensure Ready-to-Drink Milk Chocolate CLUB / 8-fl-oz Bottle / Case of 16 B4150 $0.68 70074-0536-23 (16 bottles) Adult Nutritional 56564 Ensure Complete Ready-to-Frink Vanilla Institutional/ 8 fl-oz Bottle/ Case of 24 B4152 $0.55 70074-0565-65 70074-0565-64 (24 Bottles) Adult Nutritional 56562 Ensure Complete Ready-to-Frink Chocolate Institutional/ 8 floz Bottle/ Case of 24 B4152 $0.55 70074-0565-63 70074-0565-62 (24 Bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description Adult Nutritional 62010 Adult Nutritional HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single Ensure Complete Ready-to-Frink Strawberry Institutional/ 8 fl- B4152 oz Bottle/ Case of 24 $0.55 70074-0620-11 70074-0620-10 (24 Bottles) 62761 Ensure Complete Ready-to-Frink Vanilla Retaill/ 8 fl-oz Bottle/ B4152 Case of 24 $0.55 70074-0627-63 70074-0627-62 (4 70074-0627-61 bottles) (24 Bottles) Adult Nutritional 62758 Ensure Complete Ready-to-Frink Chocolate Retaill/ 8 fl-oz Bottle/ Case of 24 B4152 $0.55 70074-0627-60 70074-0627-59 (4 70074-0627-58 bottles) (24 Bottles) Adult Nutritional 56488 Ensure Clinical Strength Ready-to-Drink Homemade Vanilla Retail / 8-fl-oz Bottle/ Case of 16 B4152 $0.55 70074-0564-89 (4 bottles) Adult Nutritional 56491 Ensure Clinical Strength Ready-to-Drink Creamy Milk Chocolate Retail / 8-fl-oz Bottle / Case of 16 B4152 $0.55 70074-0564-92 (4 bottles) Adult Nutritional 56494 Ensure Clinical Strength Ready-to-Drink Strawberries & Cream B4152 Retail / 8-fl-oz Bottle / Case of 16 $0.55 70074-0564-95 (4 bottles) Adult Nutritional 56562 Ensure Clinical Strength Ready-to-Drink Creamy Milk Chocolate Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4152 $0.55 70074-0565-63 Adult Nutritional 56564 Ensure Clinical Strength Ready-to-Drink Homemade Vanilla Institutional/ 8-fl-oz (237-mL) Bottle / Case of 24 B4152 $0.55 70074-0565-65 Adult Nutritional 62010 Ensure Clinical Strength Ready-to-Drink Strawberries & Cream B4152 Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 $0.55 70074-0620-11 Adult Nutritional 52098 Ensure High Protein Ready-to-Drink Milk Chocolate Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0520-99 Adult Nutritional 52100 Ensure High Protein Ready-to-Drink Vanilla Institutional / 8-fl- B4150 oz (237-mL) Can / Case of 24 $0.68 70074-0521-01 Adult Nutritional 50459 Ensure High Protein SHAKE Ready-to-Drink Homemade Vanilla None Retail / 14-fl-oz (414-mL) Bottle / Case of 12 No Medicare rate 70074-0504-57 70074-0504-58 (4 bottles) Adult Nutritional 50515 Ensure High Protein SHAKE Ready-to-Drink Creamy Milk Chocolate Retail / 14-fl-oz (414-mL) Bottle / Case of 12 No Medicare rate 70074-0504-69 70074-0505-14 (4 bottles) Adult Nutritional 50460 Ensure Immune Health Ready-to-Drink Vanilla Institutional / 8- B4150 fl-oz (237-mL) Can / Case of 24 $0.68 70074-0504-61 Adult Nutritional 50462 Ensure Immune Health Ready-to-Drink Milk Chocolate Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0504-63 Adult Nutritional 50648 Ensure Immune Health Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0506-49 Adult Nutritional 51892 Ensure Immune Health Ready-to-Drink Butter Pecan Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0518-93 Adult Nutritional 56458 Ensure Immune Health Ready-to-Drink Creamy Milk Chocolate B4150 Retail / 8-fl-oz Bottle / Case of 16 $0.68 70074-0564-59 (4 bottles) Adult Nutritional 56461 Ensure Immune Health Ready-to-Drink Strawberries & Cream B4150 Retail / 8-fl-oz Bottle / Case of 16 $0.68 70074-0564-62 (4 bottles) Adult Nutritional 56467 Ensure Immune Health Ready-to-Drink Homemade Vanilla Retail / 8-fl-oz Bottle / Case of 16 B4150 $0.68 70074-0564-68 (4 bottles) Adult Nutritional 58293 Ensure Immune Health Ready-to-Drink Milk Chocolate Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4150 $0.68 70074-0582-94 Adult Nutritional 58295 Ensure Immune Health Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4150 $0.68 70074-0582-96 Adult Nutritional 58297 Ensure Immune Health Ready-to-Drink Vanilla Institutional / 8- B4150 fl-oz (237-mL) Bottle / Case of 24 $0.68 70074-0582-98 Adult Nutritional 56476 Ensure Muscle Health Ready-to-Drink Vanilla Retail / 8-fl-oz Bottle / Case of 16 B4150 $0.68 70074-0564-77 (4 bottles) Adult Nutritional 56479 Ensure Muscle Health Ready-to-Drink Milk Chocolate Retail / 8- B4150 fl-oz Bottle / Case of 16 $0.68 70074-0564-80 (4 bottles) Adult Nutritional 56482 Ensure Muscle Health Ready-to-Drink Strawberry Retail / 8-fl- B4150 oz Bottle / Case of 16 $0.68 70074-0564-83 (4 bottles) Adult Nutritional 56485 Ensure Muscle Health Ready-to-Drink Banana Cream Retail / 8- B4150 fl-oz Bottle / Case of 16 $0.68 70074-0564-86 (4 bottles) Adult Nutritional 56558 Ensure Muscle Health Vanilla Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 $0.68 None B4150 NDC-Format NDC-Format Code for Carton Code for Case 70074-0565-59 NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Adult Nutritional 56560 Ensure Muscle Health Milk Chocolate Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4150 $0.68 70074-0565-61 Adult Nutritional 62012 Ensure Muscle Health Strawberry Institutional / 8-fl-oz (237mL) Bottle / Case of 24 B4150 $0.68 70074-0620-13 Adult Nutritional 00750 Ensure Powder Homemade Vanilla / 14-oz (397-g) Can / Case B4150 of 6 $0.68 70074-0607-50 Adult Nutritional 54844 Ensure Pudding Homemade Vanilla / 4-oz (113-g) Plastic Cups None / Case of 48 No Medicare rate 70074-0548-45 (4 cups) Adult Nutritional 54846 Ensure Pudding Creamy Milk Chocolate / 4-oz (113-g) Plastic Cups / Case of 48 None No Medicare rate 70074-0548-47 (4 cups) Adult Nutritional 54848 Ensure Pudding Butterscotch Delight / 4-oz (113-g) Plastic Cups / Case of 48 None No Medicare rate 70074-0548-49 (4 cups) Adult Nutritional 50240 Glucerna 1.0 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0502-41 Adult Nutritional 62671 Glucerna 1.0 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0626-72 Adult Nutritional 51206 Glucerna 1.0 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0512-07 Adult Nutritional 62673 Glucerna 1.0 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4154 mL) Bottle / Case of 6 $1.22 70074-0626-74 Adult Nutritional 52602 Glucerna 1.0 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4154 mL) Bottle / Case of 6 $1.22 70074-0526-03 Adult Nutritional 62675 Glucerna 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4154 mL) Bottle / Case of 6 $1.22 70074-0626-76 Adult Nutritional 50902 Glucerna 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4154 mL) Bottle / Case of 6 $1.22 70074-0509-03 Adult Nutritional 50904 Glucerna 1.2 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0509-05 Adult Nutritional 62677 Glucerna 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0626-78 Adult Nutritional 50906 Glucerna 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0509-07 Adult Nutritional 53534 Glucerna 1.5 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0535-35 Adult Nutritional 62679 Glucerna 1.5 Cal Ready-to-Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4154 $1.22 70074-0626-80 Adult Nutritional 53536 Glucerna 1.5 Cal Ready-to-Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4154 $1.22 70074-0535-37 Adult Nutritional 62059 Glucerna Hunger Smart Shake Ready-to-Drink Vanilla Retail / 11.5-fl-oz (340-mL) Bottle / Case of 12 B4154 $1.22 70074-0620-60 70074-0620-61 (4 bottles) Adult Nutritional 62062 Glucerna Hunger Smart Shake Ready-to-Drink Chocolate Retail / 11.5-fl-oz (340-mL) Bottle / Case of 12 B4154 $1.22 70074-0620-63 70074-0620-64 (4 bottles) Adult Nutritional 62074 Glucerna Nutrition Bars Crispy Delight / Chocolate Chip / 1.41- None oz (40-g) Bar / Case of 24 No Medicare rate 70074-0620-75 70074-0620-76 (4 70074062074 bars) (24 bars) Adult Nutritional 62077 Glucerna Nutrition Bars Crispy Delight / Peanut Chocolate Chip None / 1.41-oz (40-g) Bar / Case of 24 No Medicare rate 70074-0620-78 70074-0620-79 (4 70074062077 bars) (24 bars) Adult Nutritional 53742 Glucerna Mini-Snack Bar Cinnamon Bun / 0.70-oz (20-g) Bar / None Case of 48 No Medicare rate 70074-0537-43 (8 bars) Adult Nutritional 59704 Glucerna Mini-Snack Bar Oatmeal Raisin / 0.70-oz (20-g) Bar / None Case of 48 No Medicare rate 70074-0597-05 (8 bars) Adult Nutritional 59708 Glucerna Mini-Snack Bar Chocolate Peanut / 0.70-oz (20-g) Bar / Case of 48 None No Medicare rate 70074-0597-09 (8 bars) Adult Nutritional 54326 Glucerna Shake Ready-to-Drink Classic Butter Pecan Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0543-27 Adult Nutritional 54328 Glucerna Shake Ready-to-Drink Homemade Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0543-29 70074-0626-71 (8 bottles) 70074-0626-73 (6 bottles) 70074-0626-75 (6 bottles) 70074-0626-77 (8 bottles) 70074-0626-79 (8 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Adult Nutritional 54544 Glucerna Shake Ready-to-Drink Rich Chocolate Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0545-45 Adult Nutritional 56052 Glucerna Shake Ready-to-Drink Creamy Strawberry Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0560-53 Adult Nutritional 57801 Glucerna Shake Ready-to-Drink Homemade Vanilla Retail/ 8-fl- B4154 oz Bottle / Case of 24 $1.22 70074-0578-03 Adult Nutritional 57804 Glucerna Shake Ready-to-Drink Rich Chocolate Retail / 8-fl-oz B4154 Bottle / Case of 24 $1.22 70074-0578-06 Adult Nutritional 57807 Glucerna Shake Ready-to-Drink Creamy Strawberry Retail / 8- B4154 fl-oz Bottle / Case of 24 $1.22 70074-0578-09 Adult Nutritional 57810 Glucerna Shake Ready-to-Drink Classic Butter Pecan Retail / 8- B4154 fl-oz Bottle / Case of 24 $1.22 70074-0578-12 Adult Nutritional 53736 Glucerna Snack Bar Blueberry / 1.41-oz (40-g) Bar / Case of 24 None No Medicare rate Adult Nutritional 56957 Glucerna Snack Bar Chocolate Caramel / 1.41-oz (40-g) Bar / Case of 24 None No Medicare rate 70074-0569-58 (4 bars) Adult Nutritional 56681 Glucerna Snack Bar Double Chocolate Crisp / 1.41-oz (40-g) Bar / Case of 24 None No Medicare rate 70074-0566-82 (4 bars) Adult Nutritional 57609 Glucerna Snack Bar Caramel Nut / 1.41-oz (40-g) Bar / Case of 24 None No Medicare rate 70074-0576-10 (4 bars) Adult Nutritional 59856 Glucerna Snack Shake Ready-to-Drink Homemade Vanilla Retail / 8-fl-oz Can / Case of 16 None No Medicare rate 70074-0598-58 Adult Nutritional 59859 Glucerna Snack Shake Ready-to-Drink Creamy Chocolate Delight Retail / 8-fl-oz Can / Case of 16 None No Medicare rate 70074-0598-61 Adult Nutritional 62999 Glucerna Advance/ Chocolate/ 237 mL bottle / Case of 16 B4154 $1.22 70074-0630-00 (4 bottles) 70074-0629-99 (16 bottles) Adult Nutritional 63001 Glucerna Advance/ Vanilla/ 237 mL bottle / Case of 16 B4154 $1.22 70074-0630-02 (4 bottles) 70074-0630-17 (16 bottles) Adult Nutritional 63024 Glucerna Nutrition Bars Mini Snacks Oatmeal Raisin / 20g / case 36 (carton of 6) None No Medicare rate 70074-0630-25 70074-0630-26 (6 bars) 70074-0630-24 (36 bars) Adult Nutritional 63027 Glucerna Nutrition Bars Mini Snacks Chocolate Caramel/ 20g / None case 36 (carton of 6) No Medicare rate 70074-0630-28 70074-0630-29 (6 bars) 70074-0630-27 (36 bars) Adult Nutritional 63030 Glucerna Nutrition Bars Mini Snacks Chocolate Peanut / 20g / None case 36 (carton of 6) No Medicare rate 70074-0630-31 70074-0630-32 (6 bars) 70074-0630-30 (36 bars) Adult Nutritional 58253 Hi-Cal Ready-To-Hang Vanilla Institutional / 1 Liter (1000-mL) B4152 Bottle / Case of 8 $0.55 70074-0582-54 Adult Nutritional 00143 Jevity 1 Cal Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0401-43 Adult Nutritional 62685 Jevity 1 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0626-86 Adult Nutritional 00682 Jevity 1 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0806-82 Adult Nutritional 62687 Jevity 1 Cal Ready-To-Hang Institutional / 1.5 Liter (1500-mL) B4150 Bottle / Case of 6 $0.68 70074-0626-88 Adult Nutritional 52604 Jevity 1 Cal Ready-To-Hang Institutional / 1.5 Liter (1500-mL) B4150 Bottle / Case of 6 $0.68 70074-0526-05 Adult Nutritional 62667 Jevity 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4150 $0.68 70074-0626-68 Adult Nutritional 53114 Jevity 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4150 $0.68 70074-0531-15 Adult Nutritional 53118 Jevity 1.2 Cal Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4150 $0.68 70074-0531-19 Adult Nutritional 62683 Jevity 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) B4150 Bottle / Case of 8 $0.68 70074-0626-84 Adult Nutritional 53124 Jevity 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) B4150 Bottle / Case of 8 $0.68 70074-0531-25 70074-0537-36 (24 bars) 70074-0626-85 (8 bottles) 70074-0626-87 (6 bottles) 70074-0626-67 (6 bottles) 70074-0626-83 (8 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single Adult Nutritional 62681 Jevity 1.5 Cal Ready-To- Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4152 $0.55 70074-0626-82 Adult Nutritional 57329 Jevity 1.5 Cal Ready-To- Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4152 $0.55 70074-0573-30 Adult Nutritional 62689 Jevity 1.5 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4152 $0.55 70074-0626-90 Adult Nutritional 57331 Jevity 1.5 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4152 $0.55 70074-0573-32 Adult Nutritional 57333 Jevity 1.5 Cal Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4152 $0.55 70074-0573-34 Adult Nutritional 56094 Juven Powder Unflavored Institutional / 0.68 oz (19.3-g) Packet / 30 Packets (Outer Carton) B4155 $0.95 Adult Nutritional 54000 Juven Powder Unflavored Institutional / 0.68-oz (19.3-g) Packet / Case of 180 B4155 $0.95 Adult Nutritional 56622 Juven Powder Fruit Punch / 0.85-oz (24-g) Packet / 8 Packets B4155 per Box $0.95 Adult Nutritional 56433 Juven Powder Fruit Punch Institutional / 0.85-oz (24-g) Packet B4155 / Carton of 30 (Outer Carton) $0.95 Adult Nutritional 56431 Juven Powder Fruit Punch Institutional / 0.85-oz (24-g) Packet B4155 / Case of 180 $0.95 Adult Nutritional 56625 Juven Powder Orange Institutional / 0.85-oz (24-g) Packet / 8 B4155 Packets per Box $0.95 Adult Nutritional 58012 Juven Powder Orange Institutional / 0.85-oz (24-g) Packet / Carton of 30 (Outer Carton) B4155 $0.95 Adult Nutritional 57935 Juven Powder Orange Institutional / 0.85-oz (24-g) Packet / Case of 180 B4155 $0.95 59781-0225-50 Adult Nutritional 53624 Nepro with Carb Steady Ready-to-Drink Homemade Vanilla Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4154 $1.22 70074-0536-26 Adult Nutritional 53627 Nepro with Carb Steady Ready-to-Drink Butter Pecan Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4154 $1.22 70074-0536-29 Adult Nutritional 53633 Nepro with Carb Steady Ready-to-Drink Homemade Vanilla / 8-fl-oz (237-mL) Bottle / Case of 24 B4154 $1.22 70074-0536-34 Adult Nutritional 53630 Nepro with Carb Steady Ready-to-Drink Mixed Berry Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4154 $1.22 70074-0536-32 Adult Nutritional 62669 Nepro with Carb Steady Ready-to-Hang Vanilla Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4154 $1.22 70074-0626-70 Adult Nutritional 59677 Nepro with Carb Steady Ready-to-Hang Vanilla Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4154 $1.22 70074-0596-78 Adult Nutritional 62090 Nepro with Carb Steady Ready-to-Drink Butter Pecan Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0620-91 Adult Nutritional 62092 Nepro with Carb Steady Ready-to-Drink Mixed Berry Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0620-93 Adult Nutritional 62094 Nepro with Carb Steady Ready-to-Drink Homemade Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0620-95 Adult Nutritional 62691 Osmolite 1 Cal Ready-To-Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4150 $0.68 70074-0626-92 Adult Nutritional 00668 Osmolite 1 Cal Ready-To-Hang Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4150 $0.68 70074-0806-68 Adult Nutritional 00735 Osmolite 1 Cal Ready-to-Drink Institutional / 8-fl-oz (237-mL) B4150 Can / Case of 24 $0.68 70074-0407-35 Adult Nutritional 62695 Osmolite 1 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4150 $0.68 70074-0626-96 Adult Nutritional 52600 Osmolite 1 Cal Ready-To-Hang Institutional / 1.5 Liter (1500mL) Bottle / Case of 6 B4150 $0.68 70074-0526-01 Adult Nutritional 62693 Osmolite 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4150 mL) Bottle / Case of 6 $0.68 70074-0626-94 NDC-Format NDC-Format Code for Carton Code for Case 70074-0626-81 (8 bottles) 70074-0626-89 (6 bottles) 59781-0560-94 (30 packets) 59781-0540-02 59781-0540-01 (30 packets) 59781-0540-00 (180 packets) 59781-0566-23 (8 packets) 59781-0564-33 (30 packets) 59781-0564-30 59781-0564-32 (30 packets) 59781-0564-31 (180 packets) 59781-0566-26 (8 packets) 59781-0580-12 (30 packets) 59781-0225-51 (30 packets) 59781-0579-35 (180 packets) 70074-0626-69 (8 bottles) 70074-0626-91 (8 bottles) 70074-0626-95 (6 bottles) 70074-0626-93 (6 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description Adult Nutritional 53116 Adult Nutritional HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single Osmolite 1.2 Cal Ready-To-Hang Institutional / 1.5 Liter (1500- B4150 mL) Bottle / Case of 6 $0.68 70074-0531-17 53120 Osmolite 1.2 Cal Ready-to-Drink Institutional / 8-fl-oz (237mL) Can / Case of 24 B4150 $0.68 70074-0531-21 Adult Nutritional 62697 Osmolite 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4150 mL) Bottle / Case of 8 $0.68 70074-0626-98 Adult Nutritional 53122 Osmolite 1.2 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4150 mL) Bottle / Case of 8 $0.68 70074-0531-23 Adult Nutritional 57469 Osmolite 1.5 Cal Ready-to-Drink Institutional / 8-fl-oz (237mL) Bottle / Case of 24 B4152 $0.55 70074-0574-70 Adult Nutritional 62699 Osmolite 1.5 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4152 mL) Bottle / Case of 8 $0.55 70074-0627-00 Adult Nutritional 57471 Osmolite 1.5 Cal Ready-To-Hang Institutional / 1 Liter (1000- B4152 mL) Bottle / Case of 8 $0.55 70074-0574-72 Adult Nutritional 54386 Oxepa Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0543-87 Adult Nutritional 62717 Oxepa Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle B4154 / Case of 8 $1.22 70074-0627-18 Adult Nutritional 57043 Oxepa Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle B4154 / Case of 8 $1.22 70074-0570-44 Adult Nutritional 50628 Perative Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4153 $1.91 70074-0506-29 Adult Nutritional 62723 Perative Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4153 $1.91 70074-0627-24 Adult Nutritional 51948 Perative Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4153 $1.91 70074-0519-49 Adult Nutritional 62671 Perative Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4153 $1.91 70074-0627-22 Adult Nutritional 57635 Perative Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4153 $1.91 70074-0576-36 Adult Nutritional 58013 Pivot 1.5 Cal Ready-to-Drink Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4153 $1.91 70074-0580-14 Adult Nutritional 62719 Pivot 1.5 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) B4153 Bottle / Case of 8 $1.91 70074-0627-20 Adult Nutritional 58015 Pivot 1.5 Cal Ready-To-Hang Institutional / 1 Liter (1000-mL) B4153 Bottle / Case of 8 $1.91 70074-0580-16 Adult Nutritional 00746 Polycose Powder Institutional / 12.3-oz (349-g) Can / Case of B4155 6 $0.95 70074-0607-46 Adult Nutritional 59721 ProMod Liquid Protein Ready-to-Drink Fruit Punch Institutional B4155 / 32-fl-oz (946-mL) Bottle / Case of 6 $0.95 70074-0597-22 Adult Nutritional 50774 Promote Ready-to-Drink Vanilla Institutional / 8-fl-oz (237mL) Can / Case of 24 B4150 $0.68 70074-0507-75 Adult Nutritional 62701 Promote Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0627-02 Adult Nutritional 51616 Promote Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0516-17 Adult Nutritional 62705 Promote Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4150 $0.68 70074-0627-06 Adult Nutritional 57631 Promote Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4150 $0.68 70074-0576-32 Adult Nutritional 51872 Promote With Fiber Ready-to-Drink Vanilla Institutional / 8-fl- B4150 oz (237-fl-oz) Can / Case of 24 $0.68 70074-0518-73 Adult Nutritional 62703 Promote With Fiber Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0627-04 Adult Nutritional 51874 Promote With Fiber Ready-To-Hang Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4150 $0.68 70074-0518-75 NDC-Format NDC-Format Code for Carton Code for Case 70074-0626-97 (8 bottles) 70074-0626-99 (8 bottles) 70074-0627-17 (8 bottles) 70074-0627-23 (8 bottles) 70074-0627-21 (6 bottles) 70074-0627-19 (8 bottles) 70074-0627-01 (8 bottles) 70074-0627-05 (6 bottles) 70074-0627-03 (8 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Adult Nutritional 62707 Promote With Fiber Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4150 $0.68 70074-0627-08 Adult Nutritional 57633 Promote With Fiber Ready-To-Hang Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4150 $0.68 70074-0576-34 Adult Nutritional 00699 Pulmocare Ready-to-Drink Vanilla Institutional / 8-fl-oz (237mL) Can / Case of 24 B4154 $1.22 70074-0406-99 Adult Nutritional 62725 Pulmocare Ready-To-Hang Vanilla Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0627-26 Adult Nutritional 51204 Pulmocare Ready-To-Hang Vanilla Institutional / 1 Liter (1000- B4154 mL) Bottle / Case of 8 $1.22 70074-0512-05 Adult Nutritional 53636 Suplena with Carb Steady Ready-to-Drink Homemade Vanilla Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4154 $1.22 70074-0536-38 Adult Nutritional 62088 Suplena w Carb Steady Ready-to-Drink Homemade Vanilla Institutional / 8 fl-oz (237-mL) Can / Case of 24 B4154 $1.22 70074-0620-89 Adult Nutritional 00729 TwoCal HN Ready-to-Drink Vanilla Institutional / 8-fl-oz (237- B4152 mL) Can / Case of 24 $0.55 70074-0407-29 Adult Nutritional 54064 TwoCal HN Ready-to-Drink Butter Pecan Institutional / 8-fl-oz B4152 (237-mL) Can / Case of 24 $0.55 70074-0540-65 Adult Nutritional 62709 TwoCal HN Ready-To-Hang Vanilla Institutional / 1 Liter (1000- B4152 mL) Bottle / Case of 8 $0.55 70074-0627-10 Adult Nutritional 57047 TwoCal HN Ready-To-Hang Vanilla Institutional / 1 Liter (1000- B4152 mL) Bottle / Case of 8 $0.55 70074-0570-48 Adult Nutritional 56542 Vital AF 1.2 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4153 $1.91 70074-0627-15 Adult Nutritional 56542 Vital AF 1.2 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4153 $1.91 70074-0565-43 Adult Nutritional 62069 Vital AF 1.2 Cal Ready-to-Hang Vanilla Institutional / 1.5 Liter B4153 (1500-mL) Bottle/ Case of 6 $1.91 70074-0565-43 Adult Nutritional 62715 Vital AF 1.2 Cal Ready-to-Hang Vanilla Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4153 $1.91 70074-0627-16 Adult Nutritional 56544 Vital AF 1.2 Cal Ready-to-Hang Vanilla Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4153 $1.91 70074-0565-45 Adult Nutritional 56277 Vital 1.0 Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) B4153 Can / Case of 24 $1.91 70074-0562-78 Adult Nutritional 62067 Vital 1.0 Cal Ready-to-Hang Vanilla Institutional / 1.5 Liter (1500-mL) Bottle / Case of 6 B4153 $1.91 70074-0620-68 70074-0620-67 (6 bottles) Adult Nutritional 62711 Vital 1.0 Ready-to-Hang Vanilla Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4153 $1.91 70074-0627-12 70074-0627-11 (8 bottles) Adult Nutritional 56281 Vital 1.0 Ready-to-Hang Vanilla Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4153 $1.91 70074-0562-82 Adult Nutritional 56279 Vital 1.5 Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) B4153 Can / Case of 24 $1.91 70074-0562-80 Adult Nutritional 62713 Vital 1.5 Ready-To-Hang Vanilla Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4153 $1.91 70074-0627-14 Adult Nutritional 56283 Vital 1.5 Ready-To-Hang Vanilla Institutional / 1 Liter (1000mL) Bottle / Case of 8 B4153 $1.91 70074-0562-84 Adult Nutritional 62071 Vital 1.5 Ready-To-Hang Vanilla Institutional / 1.5 Liter (1500- B4153 mL) Bottle / Case of 6 $1.91 70074-0620-72 Adult Nutritional 00766 Vital HN Powder Vanilla Institutional / 2.79-oz (79-g) Packet / B4153 Case of 24 $1.91 Metabolic 53328 Calcilo XD Powder Institutional / 13.2-oz (375-g) Can / Case of 6 B4162 No Medicare rate 70074-0533-29 Metabolic 51144 Cyclinex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 No Medicare rate 70074-0511-45 Metabolic 51146 Cyclinex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 (Ped) No Medicare rate 70074-0511-47 70074-0627-07 (6 bottles) 70074-0627-25 (8 bottles) 70074-0627-09 (8 bottles) 70074-0627-16 (8 bottles) 70074-0627-15 (8 bottles) 70074-0627-13 (8 bottles) 70074-0620-71 (6 bottles) 70074-0407-66 (6 packets) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single Metabolic 51146 Cyclinex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4157 (Adult) No Medicare rate 70074-0511-47 Metabolic 51140 Glutarex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 No Medicare rate 70074-0511-41 Metabolic 51142 Glutarex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 (Ped) No Medicare rate 70074-0511-43 Metabolic 51142 Glutarex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4157 (Adult) No Medicare rate 70074-0511-43 Metabolic 51116 Hominex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 No Medicare rate 70074-0511-17 Metabolic 51118 Hominex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 (Ped) No Medicare rate 70074-0511-19 Metabolic 51118 Hominex-2 Powder Institutional / 14.1-oz (400-g) Can / Case B4157 (Adult) of 6 No Medicare rate 70074-0511-19 Metabolic 51136 I-Valex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of B4162 6 No Medicare rate 70074-0511-37 Metabolic 51138 I-Valex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of B4162 (Ped) 6 No Medicare rate 70074-0511-39 Metabolic 51138 I-Valex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of B4157 (Adult) 6 No Medicare rate 70074-0511-39 Metabolic 51112 Ketonex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 No Medicare rate 70074-0511-13 Metabolic 51114 Ketonex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 (Ped) No Medicare rate 70074-0511-15 Metabolic 51114 Ketonex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4157 (Adult) No Medicare rate 70074-0511-15 Metabolic 51120 Phenex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of B4162 6 No Medicare rate 70074-0511-21 Metabolic 51122 Phenex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of B4162 (Ped) 6 No Medicare rate 70074-0511-23 Metabolic 51122 Phenex-2 Powder Institutional / 14.1-oz (400-g) Can / Case of B4157 (Adult) 6 No Medicare rate 70074-0511-23 Metabolic 55755 Phenex-2 Powder Vanilla Institutional / 14.1-oz (400-g) Can / B4157 (Adult) Case of 6 No Medicare rate 70074-0557-56 Metabolic 55755 Phenex-2 Powder Vanilla Institutional / 14.1-oz (400-g) Can / B4162 (Ped) Case of 6 No Medicare rate 70074-0557-56 Metabolic 51148 Pro-Phree Powder Institutional / 14.1-oz (400-g) Can / Case of 6 $0.95 70074-0511-49 Metabolic 51132 Propimex-1 Powder Institutional / 14.1-oz (400-g) Can / Case B4162 of 6 No Medicare rate 70074-0511-33 Metabolic 51134 Propimex-2 Powder Institutional / 14.1-oz (400-g) Can / Case B4162 (Ped) of 6 No Medicare rate 70074-0511-35 Metabolic 51134 Propimex-2 Powder Institutional / 14.1-oz (400-g) Can / Case B4157 (Adult) of 6 No Medicare rate 70074-0511-35 Metabolic 50260 ProViMin Powder Institutional / 5.3-oz (150-g) Can / Case of 6 B4155 $0.95 Metabolic 00108 RCF Concentrated Liquid Institutional / 13-fl-oz (384-mL) Can B4155 / Case of 12 $0.95 70074-0401-08 Metabolic 51128 Tyrex-1 Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4162 No Medicare rate 70074-0511-29 Metabolic 51126 Tyrex-2 Institutional Powder / 14.1-oz (400-g) Can / Case of 6 B4162 (Ped) No Medicare rate 70074-0511-27 Metabolic 51126 Tyrex-2 Institutional Powder / 14.1-oz (400-g) Can / Case of 6 B4157 (Adult) No Medicare rate 70074-0511-27 Pediatric Nutritional 53510 EleCare with DHA and ARA Powder Institutional / 14.1-oz (400-g) Can / Case of 6 No Medicare rate 70074-0535-11 B4155 B4161 NDC-Format NDC-Format Code for Carton Code for Case 70074-0502-60 (6 cans) 70074-0535-10 (6 cans) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description Pediatric Nutritional 54665 Pediatric Nutritional HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single EleCare Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4161 No Medicare rate 70074-0546-66 70074-0546-65 (6 cans) 59405 EleCare Vanilla Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4161 No Medicare rate 70074-0594-06 70074-0594-05 (6 cans) Pediatric Nutritional 56585 EleCare Jr Vanilla Powder Institutional / 14.1-oz (400-g) Can / B4161 Case of 6 No Medicare rate 70074-0565-86 Pediatric Nutritional 55253 EleCare Jr Unflavored Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4161 No Medicare rate 70074-0552-54 Pediatric Nutritional 55251 EleCare for Infants (DHA/ARA) Powder Institutional / 14.1-oz (400-g) Can / Case of 6 B4161 No Medicare rate 70074-0535-11 Pediatric Nutritional 00240 Pedialyte Ready-to-Drink Grape Retail / 33.8 fl-oz (1-Liter) Bottle / Case of 8 B4103 No Medicare rate 70074-0802-40 Pediatric Nutritional 00336 Pedialyte Ready-to-Drink Unflavored Retail/ 33.8 fl-oz (1-Liter) B4103 Bottle / Case of 8 No Medicare rate 70074-0803-36 Pediatric Nutritional 00365 Pedialyte Ready-to-Drink Fruit Retail / 33.8 fl-oz (1-Liter) Bottle / Case of 8 B4103 No Medicare rate 70074-0803-65 Pediatric Nutritional 51752 Pedialyte Ready-to-Drink Bubble Gum Retail / 33.8 fl-oz (1Liter) Bottle / Case of 8 B4103 No Medicare rate 70074-0517-53 Pediatric Nutritional 53983 Pedialyte Ready-to-Drink Strawberry Retail/ 33.8 fl-oz (1-Liter) B4103 Bottle / Case of 8 No Medicare rate 70074-0539-84 Pediatric Nutritional 00245 Pedialyte Freezer Pops Variety Retail / 2.1-oz (62.5-mL) Sleeve / Case of 128 B4103 No Medicare rate 70074-0002-46 (16 sleeves) Pediatric Nutritional 56078 Pedialyte Powder Pack Apple Retail / 0.3-oz (8.5-g) Packet / Case of 40 B4103 No Medicare rate 70074-0560-79 (4 packets) Pediatric Nutritional 56081 Pedialyte Powder Pack Fruit Punch Retail / 0.3-oz (8.5-g) Packet / Case of 40 B4103 No Medicare rate 70074-0560-82 (4 packets) Pediatric Nutritional 56090 Pedialyte Powder Pack Variety Retail (2 each - Fruit Punch, Grape, Apple, Strawberry) / 0.3-oz Packet / Case of 64 B4103 No Medicare rate 70074-0560-91 (8 packets) Pediatric Nutritional 56435 Pedialyte Singles Ready-to-Drink Fruit Retail / 6.8-fl-oz (200mL) Carton / Case of 16 B4103 No Medicare rate 70074-0564-37 70074-0564-36 (4 tetras) Pediatric Nutritional 56438 Pedialyte Singles Ready-to-Drink Apple Retail / 6.8-fl-oz (200- B4103 mL) Carton / Case of 16 No Medicare rate 70074-0564-40 70074-0564-39 (4 tetras) Pediatric Nutritional 56441 Pedialyte Singles Ready- to-Drink Cherry Retail / 6.8-fl-oz (200- B4103 mL) Carton / Case of 16 No Medicare rate 70074-0564-43 70074-0564-42 (4 tetras) Pediatric Nutritional 56416 PediaSure Sidekicks Ready-to-Drink Vanilla Retail / 8-fl-oz (237-mL) Bottle / Case of 16 None No Medicare rate Pediatric Nutritional 56523 PediaSure Sidekicks 0.63 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4158 No Medicare Rate 70074-0565-24 Pediatric Nutritional 62311 PediaSure Sidekicks Clear Ready-to-Drink Wild Berry Institutional / 6.8-fl-oz (200-mL) Tetra / Case of 32 B4155 $0.95 70074-0623-12 Pediatric Nutritional 62309 PediaSure Sidekicks Clear Ready-to-Drink Tropical Fruit Institutional / 6.8-fl-oz (200-mL) Tetra / Case of 32 B4155 $0.95 70074-0623-10 Pediatric Nutritional 62486 PediaSure Sidekicks Ready-to-Drink Vanilla Retail / 8-fl-oz (237-mL) Bottle / Case of 24 None No Medicare rate 70074-0624-87 (6 bottles) Pediatric Nutritional 56419 PediaSure Sidekicks Ready-to-Drink Chocolate Retail / 8-fl-oz (237-mL) Bottle / Case of 16 None No Medicare rate 70074-0564-20 (4 bottles) Pediatric Nutritional 62484 PediaSure Sidekicks Ready-to-Drink Chocolate Retail / 8-fl-oz (237-mL) Bottle / Case of 24 None No Medicare rate 70074-0624-85 (6 bottles) Pediatric Nutritional 56422 PediaSure Sidekicks Ready-to-Drink Strawberry Retail / 8-fl-oz None (237-mL) Bottle / Case of 16 No Medicare rate 70074-0564-23 (4 bottles) Pediatric Nutritional 62482 PediaSure Sidekicks Ready-to-Drink Strawberry Retail / 8-fl-oz None (237-mL) Bottle / Case of 24 No Medicare rate 70074-0624-83 (6 bottles) Pediatric Nutritional 57464 PediaSure Sidekicks Ready-to-Drink Chocolate Club Pack / 8-fl- None oz (237-mL) Bottle / Case of 16 No Medicare rate Pediatric Nutritional 62130 PediaSure Sidekicks Clear Ready-to-Drink Wild Berry Retail / 6.8-fl-oz (200-mL) Tetra / Case of 32 $0.95 B4155 NDC-Format NDC-Format Code for Carton Code for Case 70074-0564-17 (4 bottles) 70074-0574-64 (16 bottles) 70074-0621-31 70074-0621-32 (8 70074-0621-30 tetras) (32 tetras) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Pediatric Nutritional 62125 PediaSure Sidekicks Clear Ready-to-Drink Tropical Fruit Retail / 6.8-fl-oz (200-mL) Tetra / Case of 32 B4155 $0.95 70074-0621-26 70074-0621-27 (8 70074-0621-25 tetras) (32 tetras) Pediatric Nutritional 51880 PediaSure Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4160 No Medicare rate 70074-0518-81 Pediatric Nutritional 51882 PediaSure Ready-to-Drink Chocolate Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4160 No Medicare rate 70074-0518-83 Pediatric Nutritional 51884 PediaSure Ready-to-Drink Banana Institutional / 8-fl-oz (237mL) Can / Case of 24 B4160 No Medicare rate 70074-0518-85 Pediatric Nutritional 53581 PediaSure Ready-to-Drink Vanilla Institutional / 8-fl-oz (237mL) Bottle / Case of 24 B4160 No Medicare rate 70074-0535-82 Pediatric Nutritional 53587 PediaSure Ready-to-Drink Chocolate Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4160 No Medicare rate 70074-0535-88 Pediatric Nutritional 53589 PediaSure Ready-to-Drink Strawberry Institutional / 8-fl-oz (237-mL) Bottle / Case of 24 B4160 No Medicare rate 70074-0535-90 Pediatric Nutritional 53818 PediaSure Ready-to-Drink Berry Retail / 8-fl-oz Bottle / Case of 24 B4160 No Medicare rate Pediatric Nutritional 55897 PediaSure Ready-to-Drink Vanilla Institutional / 8-fl-oz (237mL) Can / Case of 24 B4160 No Medicare rate Pediatric Nutritional 58049 PediaSure Ready-to-Drink Vanilla Retail / 8-fl-oz Bottle / Case B4160 of 24 No Medicare rate 70074-0580-50 (6 bottles) Pediatric Nutritional 58052 PediaSure Ready-to-Drink Banana Retail / 8-fl-oz Bottle / Case B4160 of 24 No Medicare rate 70074-0580-53 (6 bottles) Pediatric Nutritional 58055 PediaSure Ready-to-Drink Strawberry Retail / 8-fl-oz Bottle / Case of 24 B4160 No Medicare rate 70074-0580-56 (6 bottles) Pediatric Nutritional 58058 PediaSure Ready-to-Drink Chocolate Retail / 8-fl-oz Bottle / Case of 24 B4160 No Medicare rate 70074-0580-59 (6 bottles) Pediatric Nutritional 56409 PediaSure 1.5 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz B4160 (237-mL) Can / Case of 24 No Medicare rate 70074-0564-10 Pediatric Nutritional 56411 PediaSure 1.5 Cal with Fiber Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4160 No Medicare rate 70074-0564-12 Pediatric Nutritional 62749 PediaSure 1.5 Cal with Fiber Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL ) Bottle / Case of 8 B4160 No Medicare rate 70074-0627-50 70074-0627-49 (8 bottles) Pediatric Nutritional 62022 PediaSure 1.5 Cal with Fiber Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL ) Bottle / Case of 8 B4160 No Medicare rate 70074-0620-23 70074-0620-22 (8 bottles) Pediatric Nutritional 51804 PediaSure Enteral Formula 1.0 Cal Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4160 No Medicare rate 70074-0518-05 Pediatric Nutritional 62727 PediaSure Enteral Formula 1.0 Cal with Fiber Ready-to-Hang B4160 Unflavored Institutional / 1 Liter (1000-mL ) Bottle / Case of 8 No Medicare rate 70074-0627-28 70074-0627-27 (8 bottles) Pediatric Nutritional 62020 PediaSure Enteral Formula 1.0 Cal with Fiber Ready-to-Hang B4160 Unflavored Institutional / 1 Liter (1000-mL ) Bottle / Case of 8 No Medicare rate 70074-0620-21 70074-0620-20 (8 bottles) Pediatric Nutritional 51806 PediaSure Enteral Formula 1.0 Cal with Fiber Ready-to-Drink Vanilla Institutional / 8-fl-oz (237-mL) Can / Case of 24 B4160 No Medicare rate 70074-0518-07 Pediatric Nutritional 62119 PediaSure Peptide 1.0 Cal Ready-to-Drink Vanilla Institutional B4161 / 8-fl-oz (237-mL) Bottle / Case of 24 No Medicare rate 70074-0621-20 Pediatric Nutritional 62121 PediaSure Peptide 1.0 Cal Ready-to-Drink Strawberry Institutional / 8-fl-oz (237 mL) Bottle / Case of 24 B4161 No Medicare rate 70074-0621-22 Pediatric Nutritional 62123 PediaSure Peptide 1.0 Cal Ready-to-Drink Unflavored Institutional / 8-fl-oz (237 mL) Bottle / Case of 24 B4161 No Medicare rate 70074-0621-24 Pediatric Nutritional 62729 PediaSure Peptide 1.0 Cal Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4161 No Medicare rate 70074-0627-30 70074-0627-29 (8 bottles) Pediatric Nutritional 62051 PediaSure Peptide 1.0 Cal Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4161 No Medicare rate 70074-0620-52 70074-0620-51 (8 bottles) Pediatric Nutritional 56655 PediaSure Peptide 1.5 Cal Ready-to-Drink Vanilla Institutional B4161 / 8-fl-oz (237-mL) Bottle / Case of 24 No Medicare rate 70074-0566-56 Pediatric Nutritional 62731 PediaSure Peptide 1.5 Cal Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL) Bottle / Case of 8 No Medicare rate 70074-0627-32 B4161 70074-0538-19 (6 bottles) 70074-0558-98 70074-0627-31 (8 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Pediatric Nutritional 62014 PediaSure Peptide 1.5 Cal Ready-to-Hang Unflavored Institutional / 1 Liter (1000-mL) Bottle / Case of 8 B4161 No Medicare rate 70074-0620-15 Pediatric Nutritional 53585 PediaSure with Fiber Ready-to-Drink Vanilla Institutional / 8-fl- B4160 oz (237-mL) Bottle / Case of 24 No Medicare rate 70074-0535-86 Pediatric Nutritional 58061 PediaSure with Fiber Ready-to-Drink Vanilla Retail / 8-fl-oz Bottle / Case of 24 B4160 No Medicare rate 70074-0580-62 (6 bottles) Pediatric Nutritional 56368 PediaSure with Fiber Ready-to-Drink Strawberry Retail / 8-floz Bottle / Case of 24 B4160 No Medicare rate 70074-0563-69 (6 bottles) Pediatric Nutritional 58220 PediaSure with Fiber Ready-to-Drink Vanilla Institutional / 8-fl- B4160 oz (237-mL) Can / Case of 24 No Medicare rate 70074-0582-21 Pediatric Nutritional 00108 RCF Concentrated Liquid Institutional / 13-fl-oz (384-mL) Can B4155 / Case of 12 $0.95 70074-0401-08 Pediatric Nutritional 62427 Similac Prenatal Dietary Supplement / 4 x 3 30-ct each multivit/min tablets and DHA/lutein softgels None No Medicare rate Pediatric Nutritional 57508 Similac Expert Care Alimentum Ready-to-Feed / 8-fl-oz (237mL) Can / Case of 24 B4161 No Medicare rate 70074-0575-09 Pediatric Nutritional 57512 Similac Expert Care Alimentum Ready-to-Feed / 1 Quart (946- B4161 mL) Bottle / Case of 6 No Medicare rate 70074-0575-13 Pediatric Nutritional 57663 Similac Expert Care Alimentum Powder / 1-lb (454-g) Can / Case of 6 B4161 No Medicare rate 70074-0576-64 Pediatric Nutritional 51276 Similac Expert Care Diarrhea Ready-to-Feed / 8-fl-oz (237-mL) B4159 Can / Case of 24 No Medicare rate 70074-0512-77 Pediatric Nutritional 57768 Similac Expert Care Diarrhea Ready-to-Feed / 1-Quart (946mL) Bottle / Case of 6 B4159 No Medicare rate 70074-0577-69 Pediatric Nutritional 57430 Similac Expert Care NeoSure Powder / 13.1-oz (371-g) Can / Case of 6 B4160 No Medicare rate 70074-0574-31 Pediatric Nutritional 57455 Similac Expert Care NeoSure Ready-to-Feed / 1-Quart (946mL) Bottle/ Case of 6 B4160 No Medicare rate 70074-0574-56 Pediatric Nutritional 59645 Similac Expert Care NeoSure Ready-to-Feed Retail/ 2-fl-oz (59- B4160 mL) Bottle/ Case of 48 No Medicare rate Pediatric Nutritional 50827 Similac Go & Grow Milk-Based Formula Powder / 1.37-lb (623- B4158 g) SimplePac / Case of 6 No Medicare rate 70074-0508-28 Pediatric Nutritional 50837 Similac Go & Grow Soy-Based Powder / 1.37-lb (623-g) SimplePac / Case of 6 B4159 No Medicare rate 70074-0508-38 Pediatric Nutritional 50959 Similac For Spit-Up Powder / 12.3-oz (349-g) Can / Case of 6 B4158 No Medicare rate 70074-0509-60 70074-0509-59 (6 cans) Pediatric Nutritional 53729 Similac For Spit-Up Powder / 1.41-lb (638-g) SimplePac / Case B4158 of 6 No Medicare rate 70074-0537-30 70074-0537-29 (6 cans) Pediatric Nutritional 56728 Similac For Spit-Up Ready-to-Feed / 1-Quart (946-mL) Bottle / B4158 Case of 6 No Medicare rate 70074-0567-31 70074-0567-28 (6 bottles) Pediatric Nutritional 50817 Similac Sensitive Powder / 1.41-lb (638-g) SimplePac / Case of 6 B4158 No Medicare rate 70074-0508-18 Pediatric Nutritional 53445 Similac Sensitive Club Powder / 2.12-lb (963-g) SimplePac / Case of 6 B4158 No Medicare rate 70074-0534-46 Pediatric Nutritional 56258 Similac Sensitive Concentrated Liquid / 1-Quart (946-mL) Bottle / Case of 6 B4158 No Medicare rate 70074-0562-59 Pediatric Nutritional 57533 Similac Sensitive Ready-to-Feed / 1-Quart (946-mL) Bottle / Case of 6 B4158 No Medicare rate 70074-0575-34 Pediatric Nutritional 57535 Similac Sensitive Concentrated Liquid / 13-fl-oz (384-mL) Can B4158 / Case of 12 No Medicare rate 70074-0575-36 Pediatric Nutritional 57539 Similac Sensitive Powder / 12.6-oz (357-g) Can / Case of 6 B4158 No Medicare rate 70074-0575-41 Pediatric Nutritional 53676 Similac Sensitive On-the-Go Ready-to-Feed / 8-fl-oz (237-mL) B4158 Bottle / Case of 24 No Medicare rate 70074-0560-92 Pediatric Nutritional 53359 Similac Advance Powder / 1.45-lb (657-g) SimplePac / Case of B4158 6 No Medicare rate 70074-0533-60 70074-0620-14 (8 bottles) 70074-0624-28 (1 70074-0624-27 Box) (12 Boxes) 70074-0578-86 (6 cans) 70074-0596-46 (8 bottles) 70074-0562-58 (6 bottles) 70074-0536-77 (6 bottles) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Pediatric Nutritional 53363 Similac Advance Ready-to-Feed / 1-Quart (946-mL) Bottle / Case of 6 B4158 No Medicare rate 70074-0533-64 Pediatric Nutritional 53496 Similac Advance Club Powder / 2.12-lb (963-g) SimplePac / Case of 6 B4158 No Medicare rate 70074-0534-97 Pediatric Nutritional 53526 Similac Advance On-the-Go Ready-to-Feed / 8-fl-oz (237-mL) Bottle / Case of 12 B4158 No Medicare rate Pediatric Nutritional 55957 Similac Advance Powder / 12.4-oz (352-g) Can / Case of 6 B4158 No Medicare rate 70074-0559-58 Pediatric Nutritional 56250 Similac Advance Concentrated Liquid / 1-Quart (946-mL) Bottle / Case of 6 B4158 No Medicare rate 70074-0562-51 Pediatric Nutritional 56973 Similac Advance Concentrated Liquid / 13-fl-oz (384-mL) Can / Case of 12 B4158 No Medicare rate 70074-0569-74 Pediatric Nutritional 57600 Similac Advance Newborn Bottles Ready-to-Feed Retail / 2-floz (59 mL) Bottle / Case of 48 B4158 No Medicare rate 70074-0576-01 (8 bottles) Pediatric Nutritional 57938 Similac Advance On-the-Go Powder Singles / 0.61-oz (17.4-g) B4158 Packets / Case of 96 No Medicare rate 70074-0579-39 (16 packets) Pediatric Nutritional 58605 Similac Advance On-the-Go Ready-to-Feed / 8-fl-oz (237-mL) Bottle / Case of 24 B4158 No Medicare rate 70074-0586-14 Pediatric Nutritional 54598 Similac Human Milk Fortifier Powder Institutional / 0.9-g Packet / Case of 150 None No Medicare rate 70074-0545-99 (50 packets) Pediatric Nutritional 50821 Similac Organic Powder / 1.45-lb (657-g) SimplePac / Case of B4158 6 No Medicare rate 70074-0508-22 Pediatric Nutritional 59883 Similac Organic Ready-to-Feed / 1-Quart (946-mL) Bottle / Case of 6 B4158 No Medicare rate 70074-0598-84 Pediatric Nutritional 00850 Similac PM 60/40 Powder / 14.1-oz (400-g) Can / Case of 6 B4154 $1.22 70074-0608-50 Pediatric Nutritional 50819 Similac Soy Isomil Powder / 1.45-lb (657-g) SimplePac / Case B4159 of 6 No Medicare rate 70074-0508-20 Pediatric Nutritional 55963 Similac Soy Isomil Powder / 12.4-oz (352-g) Can / Case of 6 B4159 No Medicare rate 70074-0559-64 Pediatric Nutritional 55967 Similac Soy Isomil Ready-to-Feed / 1-Quart (946-mL) Bottle / B4159 Case of 6 No Medicare rate 70074-0559-68 Pediatric Nutritional 56975 Similac Soy Isomil Concentrated Liquid / 13-fl-oz (384-mL) Can / Case of 12 B4159 No Medicare rate 70074-0569-76 Pediatric Nutritional 56982 Similac Soy Isomil On-the-Go Powder Singles / 0.62-oz (17.6- B4159 g) Packets / Case of 96 No Medicare rate Pediatric Nutritional 58601 Similac Soy Isomil On-the-Go Ready-to-Feed / 8-fl-oz (237mL) Bottle / Case of 24 B4159 No Medicare rate 70074-0586-04 Pediatric Nutritional 50825 Similac Soy Isomil CLUB Powder / 2.13-lb (964-gm) SimplePac B4159 / Case of 6 No Medicare rate 70074-0508-26 Pediatric Nutritional 59582 Similac Special Care 24 with Iron Ready-to-Feed Retail / 2-floz (59-mL) Bottle / Case of 48 B4160 No Medicare rate Pediatric Nutritional 56294 Similac Special Care 30 With Iron Ready-to-Feed Retail / 2-floz (59-mL) Bottle / Case of 48 B4160 No Medicare rate Pediatric Nutritional 62082 PediaSure Vanilla 16ct B4160 No Medicare rate 70041-0624-95 70074-0620-82 Pediatric Nutritional 63013 Similac For Supplementation / 1.45-lb (658-gm) Powder / Case of 6 B4158 No Medicare rate 70074-0629-50 70074-0630-13 (4 units) Pediatric Nutritional 62990 Similac For Supplementation / 2-fl-oz (59-mL) Bottle / Case of B4158 48 No Medicare rate Pediatric Nutritional 63057 Pedialyte AdvancedCare Cherry Punch / 1 Liter (1000-mL) / Liquid/ Case 8 B4103 No Medicare rate 70074-0630-58 70074-0630-57 (8 bottles) Pediatric Nutritional 63059 Pedialyte AdvancedCare Blue Raspberry / 1 Liter (1000-mL / Liquid/ Case 9 B4103 No Medicare rate 70074-0630-60 70074-0630-59 (8 bottles) Pediatric Nutritional 56649 Similac Human Milk Fortifier Concentrated Liquid Institutional / 5-mL Packet / Case of 144 B4155 $0.95 70074-0566-50 70074-0586-03 (6 bottles) 70074-0508-25 (6 cans) 70074-0562-95 (8 bottles) 70074-0629-91 (8 70074-0629-90 bottles) (48 bottles) 70074-0566-49 (144 packets) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses. Category Item # SKU Description Pediatric Nutritional 62595 Pediatric Nutritional Pediatric Nutritional HCPCS Code Med B Allow Rate (per 100 Cal) NDC-Format Code for Single NDC-Format NDC-Format Code for Carton Code for Case Similac Total Comfort Ready-to-Feed Institutional / 2-fl-oz (59- B4158 mL) Bottle / Case of 48 No Medicare rate 70074-0625-96 70074-0625-95 (48 bottles) 62597 Similac Total Comfort Powder / 1.41-lb (638-g) SimplePac / Case of 4 B4158 No Medicare rate 70074-0625-98 70074-0625-97 (4 SimplePacs) 62599 Similac Total Comfort Powder / 12.6 oz Can / Case of 6 B4158 No Medicare rate 70074-0626-00 70074-0625-99 (6 cans) NDC-format codes have been submitted by Abbott Nutrition to data warehouses. While Abbott Nutrition cannot confirm that NDC-format codes have been published, the codes listed are based on the formatting established by NDC data warehouses.