Nestlé HealthCare Nutrition Enteral Products
Nestlé HealthCare Nutrition Enteral Products
Nestlé HealthCare Nutrition Enteral Products
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<strong>Nestlé</strong> <strong>HealthCare</strong> <strong>Nutrition</strong> <strong>Enteral</strong> <strong>Products</strong><br />
Number of 100 kcal Units Per Case<br />
Product<br />
ARGINAID ® , Orange, 0.32 oz pkts - New Name,<br />
Replaces RESOURCE ® ARGINAID ®<br />
Product Code<br />
NDC Formatted<br />
Number<br />
HCPCS<br />
Code<br />
kCal/<br />
mL*<br />
Container<br />
Size (mL or g)<br />
kCal/<br />
Container †<br />
Pack<br />
Factor/ Cs kCal/Cs<br />
100 kCal<br />
Units/Case<br />
35983000 00212598375 B4155 0.11 9.2 g 25 56 1400 14.00<br />
ARGINAID ® , Cherry, 0.32 oz pkts - New Name,<br />
Replaces RESOURCE ® ARGINAID ® 35984000 00212598475 B4155 0.11 9.2 g 25 56 1400 14.00<br />
ARGINAID ® , Lemon, 0.32 oz pkts 35985000 00212598575 B4155 0.11 9.2 g 25 56 1400 14.00<br />
BENECALORIE ® , 1.5 fl oz cups - New Name,<br />
Replaces RESOURCE ® BENECALORIE ® 28250000 00212282580 B4155 7.5 44.4 g 330 24 7920 79.20<br />
BENEPROTEIN ® , 7 g pkts - New Name,<br />
Replaces RESOURCE ® BENEPROTEIN ® 28430000 00212284371 B4155 — 7 g 25 75 1875 18.75<br />
BENEPROTEIN ® , 8 oz canister - New Name,<br />
Replaces RESOURCE ® BENEPROTEIN ®<br />
28410000 00212284107 B4155 — 227 g 811 6 4866 48.66<br />
BOOST ® , Very Vanilla, 8 fl oz 4390067438 00212674313 B4150 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® , Rich Chocolate, 8 fl oz 4390067538 00212675313 B4150 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® , Creamy Strawberry, 8 fl oz 4390067639 00212067613 B4150 1.0 237 mL 240 27 6480 64.80<br />
BOOST GLUCOSE CONTROL ® , Vanilla, 8 fl oz 36010000 00212360162 B4154 1.06 237 mL 250 27 6750 67.50<br />
BOOST GLUCOSE CONTROL ® , Chocolate, 8 fl oz 36020000 00212360262 B4154 1.06 237 mL 250 27 6750 67.50<br />
BOOST GLUCOSE CONTROL ® , Strawberry, 8 fl oz 36030000 00212360362 B4154 1.06 237 mL 250 27 6750 67.50<br />
BOOST ® HIGH PROTEIN, Very Vanilla, 8 fl oz 4390094139 00212941313 B4150 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® KID ESSENTIALS, Vanilla, 8 fl oz 33510000 00212335113 B4160 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® KID ESSENTIALS, Chocolate, 8 fl oz 33520000 00212335213 B4160 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® KID ESSENTIALS, Strawberry, 8 fl oz 33530000 00212335313 B4160 1.0 237 mL 240 27 6480 64.80<br />
BOOST ® KID ESSENTIALS 1.5, Vanilla, 8 fl oz 33540000 00212335413 B4160 1.5 237 mL 360 27 9720 97.20<br />
BOOST ® KID ESSENTIALS 1.5, Chocolate, 8 fl oz 33580000 00212335813 B4160 1.5 237 mL 360 27 9720 97.20<br />
BOOST ® KID ESSENTIALS 1.5, Strawberry, 8 fl oz 33590000 00212335913 B4160 1.5 237 mL 360 27 9720 97.20<br />
BOOST ® KID ESSENTIALS 1.5 with FIBER, Vanilla, 8 fl oz 33500000 00212335013 B4160 1.5 237 mL 360 27 9720 97.20<br />
BOOST PLUS ® , Very Vanilla, 8 fl oz 4390093138 00212931313 B4152 1.5 237 mL 360 27 9720 97.20<br />
BOOST PLUS ® , Rich Chocolate, 8 fl oz 4390093238 00212932313 B4152 1.5 237 mL 360 27 9720 97.20<br />
BOOST PLUS ® , Creamy Strawberry, 8 fl oz 4390093331 00212933313 B4152 1.5 237 mL 360 27 9720 97.20<br />
BOOST ® VHC, Vanilla, 8 fl oz - New Name,<br />
Replaces CARNATION ® INSTANT BREAKFAST ®<br />
LACTOSE FREE VHC<br />
CARNATION ® INSTANT BREAKFAST ® LACTOSE FREE,<br />
Vanilla Swirl, 250 mL<br />
CARNATION ® INSTANT BREAKFAST ® LACTOSE FREE,<br />
Chocolate Splash, 250 mL<br />
CARNATION ® INSTANT BREAKFAST ® LACTOSE FREE<br />
PLUS, Vanilla Swirl, 250 mL<br />
CARNATION ® INSTANT BREAKFAST ® LACTOSE FREE<br />
PLUS, Chocolate Splash, 250 mL<br />
CARNATION ® INSTANT BREAKFAST ® LACTOSE FREE<br />
VHC, Vanilla, 250 mL - Replaced by BOOST ® VHC<br />
4390018216 43900018215 B4152 2.25 237 mL 530 27 14310 143.10<br />
9871633888 0065905070 B4150 1.0 250 mL 250 24 6000 60.00<br />
9871633890 0065905071 B4150 1.0 250 mL 250 24 6000 60.00<br />
9871638940 0065905073 B4152 1.5 250 mL 375 24 9000 90.00<br />
9871633896 0065905074 B4152 1.5 250 mL 375 24 9000 90.00<br />
9871633900 0065905076 B4152 2.25 250 mL 560 24 13440 134.40
Product<br />
Product Code<br />
NDC Formatted<br />
Number<br />
HCPCS<br />
Code<br />
kCal/<br />
mL*<br />
Container<br />
Size (mL or g)<br />
kCal/<br />
Container †<br />
Pack<br />
Factor/ Cs kCal/Cs<br />
100 kCal<br />
Units/Case<br />
COMPLEAT ® , 250 mL 14010000 00212140151 B4149 1.06 250 mL 265 24 6360 63.60<br />
COMPLEAT ® , SpikeRight ® PLUS UltraPak ® , 1000 mL 14180100 00212141814 B4149 1.06 1000 mL 1060 6 6360 63.60<br />
COMPLEAT ® , SpikeRight ® PLUS UltraPak ® , 1500 mL 4390014183 00212182414 B4149 1.06 1500 mL 1590 4 6360 63.60<br />
COMPLEAT ® PEDIATRIC, 250 mL 14240000 00212142451 B4149 1.0 250 mL 250 24 6000 60.00<br />
COMPLEAT ® PEDIATRIC Reduced Calorie, Unflavored,<br />
250 mL<br />
4390038074 43900038074 B4149 0.6 250 mL 150 24 3600 36.00<br />
CRUCIAL ® , 250 mL 9871616280 0065912470 B4153 1.5 250 mL 375 24 9000 90.00<br />
CRUCIAL ® , SpikeRight ® , 1000 mL 9871626284 00212628461 B4153 1.5 1000 mL 1500 6 9000 90.00<br />
DIABETISOURCE ® AC, 250 mL 36500000 00212365051 B4154 1.2 250 mL 300 24 7200 72.00<br />
DIABETISOURCE ® AC, SpikeRight ® , 1000 mL 36508100 00212365014 B4154 1.2 1000 mL 1200 6 7200 72.00<br />
DIABETISOURCE ® AC, SpikeRight ® , 1500 mL 36582000 00212365814 B4154 1.2 1500 mL 1800 6 10800 108.00<br />
FIBERSOURCE ® HN, 250 mL 18550000 00212185551 B4150 1.2 250 mL 300 24 7200 72.00<br />
FIBERSOURCE ® HN, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
FIBERSOURCE ® HN, SpikeRight ® PLUS UltraPak ® ,<br />
1500 mL<br />
GLUTASOLVE ® , 22.5 g pkts - New Name,<br />
Replaces RESOURCE ® GLUTASOLVE ®<br />
18580100 00212185814 B4150 1.2 1000 mL 1200 6 7200 72.00<br />
4390018583 00212185214 B4150 1.2 1500 mL 1800 4 7200 72.00<br />
28330000 00212283378 B4155 0.65 22.5 g 90 56 5040 50.40<br />
IMPACT ® , 250 mL 35810000 00212358151 B4154 1.0 250 mL 250 24 6000 60.00<br />
IMPACT ® , SpikeRight ® , 1000 mL 35810800 00212358114 B4154 1.0 1000 mL 1000 6 6000 60.00<br />
IMPACT ® 1.5, 250 mL 35890000 00212358951 B4154 1.5 250 mL 375 24 9000 90.00<br />
IMPACT ADVANCED RECOVERY ® , Vanilla, 8 fl oz 19571000 00212195562 B4154 1.4 237 mL 340 15 5100 51.00<br />
IMPACT ADVANCED RECOVERY ® , Chocolate, 8 fl oz 19581000 00212195662 B4154 1.4 237 mL 340 15 5100 51.00<br />
IMPACT ® with FIBER, 250 mL 35870000 00212358751 B4154 1.0 250 mL 250 24 6000 60.00<br />
IMPACT ® with FIBER, SpikeRight ® , 1000 mL 35880100 00212358814 B4154 1.0 1000 mL 1000 6 6000 60.00<br />
IMPACT ® GLUTAMINE, 250 mL 16210000 00212162151 B4153 1.3 250 mL 325 24 7800 78.00<br />
IMPACT ® GLUTAMINE, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
16280100 00212162814 B4153 1.3 1000 mL 1300 6 7800 78.00<br />
IMPACT ® PEPTIDE 1.5, 250 mL 4390097400 43900097399 B4153 1.5 250 mL 375 24 9000 90.00<br />
IMPACT ® PEPTIDE 1.5, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
4390097371 43900097370 B4153 1.5 1000 mL 1500 6 9000 90.00<br />
ISOSOURCE ® 1.5 CAL, 250 mL 18150000 00212181551 B4152 1.5 250 mL 375 24 9000 90.00<br />
ISOSOURCE ® 1.5 CAL, SpikeRight ® , 1000 mL 18180100 00212181814 B4152 1.5 1000 mL 1500 6 9000 90.00<br />
ISOSOURCE ® 1.5 CAL, SpikeRight ® , 1500 mL 18182000 00212182014 B4152 1.5 1500 mL 2250 6 13500 135.00<br />
ISOSOURCE ® HN, 250 mL 18450000 00212184551 B4150 1.2 250 mL 300 24 7200 72.00<br />
ISOSOURCE ® HN, SpikeRight ® , 1000 mL 18480100 00212184814 B4150 1.2 1000 mL 1200 6 7200 72.00<br />
ISOSOURCE ® HN, SpikeRight ® , 1500 mL 18462800 00212846214 B4150 1.2 1500 mL 1800 6 10800 108.00<br />
MCT Oil ® , 1 qt 03651300 41679036513 B4155 7.7 946 mL 7253 6 43518 435.18<br />
MICROLIPID ® , 3 fl oz 00870200 41679008702 B4155 4.5 88.7mL 399 48 19152 191.52<br />
NOVASOURCE ® RENAL, 8 fl oz 35110000 00212351162 B4154 2.0 237 mL 475 27 12825 128.25<br />
NOVASOURCE ® RENAL, SpikeRight ® , 1000 mL 35180100 00212351814 B4154 2.0 1000 mL 2000 6 12000 120.00
Product<br />
Product Code<br />
NDC Formatted<br />
Number<br />
HCPCS<br />
Code<br />
kCal/<br />
mL*<br />
Container<br />
Size (mL or g)<br />
kCal/<br />
Container †<br />
Pack<br />
Factor/ Cs kCal/Cs<br />
100 kCal<br />
Units/Case<br />
NUTREN ® 1.0, Vanilla, 250 mL 9871616210 0065902470 B4150 1.0 250 mL 250 24 6000 60.00<br />
NUTREN ® 1.0 FIBER, Vanilla, 250 mL 9871616056 0065902570 B4150 1.0 250 mL 250 24 6000 60.00<br />
NUTREN ® 1.5, Vanilla, 250 mL 9871616220 0065903270 B4152 1.5 250 mL 375 24 9000 90.00<br />
NUTREN ® 1.5, SpikeRight ® PLUS UltraPak ® , 1000 mL 9871626354 00212120414 B4152 1.5 1000 mL 1500 6 9000 90.00<br />
NUTREN ® 2.0, Vanilla, 250 mL 9871616230 0065904070 B4152 2.0 250 mL 500 24 12000 120.00<br />
NUTREN ® 2.0, SpikeRight ® PLUS UltraPak ® , 1000 mL 9871644146 00212414661 B4152 2.0 1000 mL 2000 6 12000 120.00<br />
NUTREN ® GLYTROL ® , Vanilla, 250 mL 9871616275 0065908570 B4154 1.0 250 mL 250 24 6000 60.00<br />
NUTREN ® GLYTROL ® , UltraPak ® SpikeRight ® , 1000 mL 9871622390 00212239061 B4154 1.0 1000 mL 1000 6 6000 60.00<br />
NUTREN ® GLYTROL ® , UltraPak ® SpikeRight ® ,<br />
1500 mL<br />
9871632391 00212239161 B4154 1.0 1500 mL 1500 4 6000 60.00<br />
NUTREN JUNIOR ® , Vanilla, 250 mL 9871616062 0065904370 B4160 1.0 250 mL 250 24 6000 60.00<br />
NUTREN JUNIOR ® , SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
9871677380 00212738061 B4160 1.0 1000 mL 1000 6 6000 60.00<br />
NUTREN JUNIOR ® FIBER, Vanilla, 250 mL 9871616063 0065904570 B4160 1.0 250 mL 250 24 6000 60.00<br />
NUTREN JUNIOR ® FIBER,<br />
SpikeRight ® PLUS UltraPak ® , 1000 mL<br />
9871677400 00212741061 B4160 1.0 1000 mL 1000 6 6000 60.00<br />
NUTREN ® PULMONARY, Vanilla, 250 mL 9871616480 0065914170 B4154 1.5 250 mL 375 24 9000 90.00<br />
NUTREN ® PULMONARY, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
9871622392 00212239261 B4154 1.5 1000 mL 1500 6 9000 90.00<br />
NUTREN ® REPLETE ® , Vanilla, 250 mL - See Replete ® 9871616249 0065902270 B4150 1.0 250 mL 250 24 6000 60.00<br />
NUTREN ® REPLETE ® , UltraPak ® SpikeRight ® ,<br />
1000 mL - See Replete ® 9871626356 00212457914 B4150 1.0 1000 mL 1000 6 6000 60.00<br />
NUTREN ® REPLETE ® FIBER, Vanilla, 250 mL -<br />
See Replete ® Fiber<br />
NUTREN ® REPLETE ® FIBER, UltraPak ® SpikeRight ® ,<br />
1000 mL - See Replete ® Fiber<br />
NUTREN ® REPLETE ® FIBER, UltraPak ® SpikeRight ® ,<br />
1500 mL - See Replete ® Fiber<br />
9871616245 0065902370 B4150 1.0 250 mL 250 24 6000 60.00<br />
9871626358 00212635861 B4150 1.0 1000 mL 1000 6 6000 60.00<br />
9871626359 00212635961 B4150 1.0 1500 mL 1500 4 6000 60.00<br />
NUTRIHEP ® , Unflavored, 250 mL 9871616479 0065907870 B4154 1.5 250 mL 375 24 9000 90.00<br />
NUTRISOURCE ® FIBER Powder, 7.2 oz canister -<br />
New Name, Replaces RESOURCE ® BENEFIBER ®‡ 4390097551 43900097550 B4104 — 205 g 769 4 3076 30.76<br />
NUTRISOURCE ® FIBER Powder, 4 g pkts -<br />
New Name, Replaces RESOURCE ® BENEFIBER ®‡ 4390097648 43900097647 B4104 — 4 g 15 75 1125 11.25<br />
PEPTAMEN ® , Unflavored, 250 mL 9871616269 0065901470 B4153 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN ® , Vanilla, 250 mL 9871616260 0065906770 B4153 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN ® 1.5, Unflavored, 250 mL 9871618192 0065908870 B4153 1.5 250 mL 375 24 9000 90.00<br />
PEPTAMEN ® 1.5, Vanilla, 250 mL 9871618190 0065908770 B4153 1.5 250 mL 375 24 9000 90.00<br />
PEPTAMEN ® 1.5, SpikeRight ® PLUS UltraPak ® , 1000 mL 9871628194 00212819461 B4153 1.5 1000 mL 1500 6 9000 90.00<br />
PEPTAMEN ® 1.5 with PREBIO 1TM , Vanilla, 250 mL 4390034958 43900034958 B4153 1.5 250 mL 375 24 9000 90.00<br />
PEPTAMEN ® 1.5 with PREBIO 1TM , SpikeRight ® PLUS<br />
UltraPak ® , 1000 mL<br />
4390034957 43900034957 B4153 1.5 1000 mL 1500 6 9000 90.00<br />
PEPTAMEN AF ® , Unflavored, 250 mL 9871666370 0065909271 B4153 1.2 250 mL 300 24 7200 72.00<br />
PEPTAMEN AF ® , SpikeRight ® PLUS UltraPak ® , 1000 mL 9871676390 00212639061 B4153 1.2 1000 mL 1200 6 7200 72.00
Product<br />
Product Code<br />
NDC Formatted<br />
Number<br />
HCPCS<br />
Code<br />
kCal/<br />
mL*<br />
Container<br />
Size (mL or g)<br />
kCal/<br />
Container †<br />
Pack<br />
Factor/ Cs kCal/Cs<br />
100 kCal<br />
Units/Case<br />
PEPTAMEN ® BARIATRIC, Unflavored, 250 mL 4390097235 43900097234 B4153 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN ® BARIATRIC, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
4390097267 43900097266 B4153 1.0 1000 mL 1000 6 6000 60.00<br />
PEPTAMEN ® with PREBIO 1TM , Vanilla, 250 mL 9871618185 0065907670 B4153 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN ® with PREBIO 1TM , SpikeRight ® PLUS<br />
UltraPak ® , 1000 mL<br />
PEPTAMEN ® with PREBIO 1TM SpikeRight ® PLUS<br />
UltraPak ® , 1500 mL<br />
9871622804 00212280461 B4153 1.0 1000 mL 1000 6 6000 60.00<br />
9871622805 00212280561 B4153 1.0 1500 mL 1500 4 6000 60.00<br />
PEPTAMEN JUNIOR ® , Unflavored, 250 mL 9871616253 0065906970 B4161 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN JUNIOR ® , Vanilla, 250 mL 9871616252 0065907070 B4161 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN JUNIOR ® , Chocolate, 250 mL 9871660120 0065907071 B4161 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN JUNIOR ® , Strawberry, 250 mL 9871660130 0065907072 B4161 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN JUNIOR ® , SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
9871677360 00212740061 B4161 1.0 1000 mL 1000 6 6000 60.00<br />
PEPTAMEN JUNIOR ® FIBER, Vanilla, 250 mL 9871660210 0065906871 B4161 1.0 250 mL 250 24 6000 60.00<br />
PEPTAMEN JUNIOR ® 1.5, Unflavored, 250 mL 9871617363 00212847315 B4161 1.5 250 mL 375 24 9000 90.00<br />
PEPTAMEN JUNIOR ® 1.5, SpikeRight ® PLUS UltraPak ® ,<br />
1000 mL<br />
9871618543 00212841515 B4161 1.5 1000 mL 1500 6 9000 90.00<br />
PEPTAMEN JUNIOR ® with PREBIO 1TM , Vanilla, 250 mL 9871616261 0065906870 B4161 1.0 250 mL 250 24 6000 60.00<br />
RENALCAL ® , Unflavored, 250 mL 9871616064 0065901370 B4154 2.0 250 mL 500 24 12000 120.00<br />
REPLETE ® , Vanilla, 250 mL -<br />
New Name, Replaces NUTREN ® REPLETE ® 9871616249 0065902270 B4150 1.0 250 mL 250 24 6000 60.00<br />
REPLETE ® , SpikeRight ® PLUS UltraPak ® , 1000 mL -<br />
New Name, Replaces NUTREN ® REPLETE ® 9871626356 00212457914 B4150 1.0 1000 mL 1000 6 6000 60.00<br />
REPLETE ® FIBER, Vanilla, 250 mL -<br />
New Name, Replaces NUTREN ® REPLETE ® Fiber<br />
REPLETE ® FIBER, SpikeRight ® PLUS UltraPak ® , 1000 mL -<br />
New Name, Replaces NUTREN ® REPLETE ® Fiber<br />
REPLETE ® FIBER, SpikeRight ® PLUS UltraPak ® , 1500 mL -<br />
New Name, Replaces NUTREN ® REPLETE ® Fiber<br />
9871616245 0065902370 B4150 1.0 250 mL 250 24 6000 60.00<br />
9871626358 00212635861 B4150 1.0 1000 mL 1000 6 6000 60.00<br />
9871626359 00212635961 B4150 1.0 1500 mL 1500 4 6000 60.00<br />
RESOURCE ® 2.0, Vanilla Crème, 32 fl oz 27600000 00212276065 B4152 2.0 946 mL 1920 12 23040 230.40<br />
RESOURCE ® 2.0, Vanilla Crème, 8 fl oz 18010000 00212180162 B4152 2.0 237 mL 480 27 12960 129.60<br />
RESOURCE ® ARGINAID ® , Orange, 0.32 oz pkts -<br />
See ARGINAID ®<br />
RESOURCE ® ARGINAID ® , Cherry, 0.32 oz pkts -<br />
See ARGINAID ®<br />
RESOURCE ® ARGINAID ® , Lemon, 0.32 oz pkts -<br />
See ARGINAID ®<br />
35983000 00212598375 B4155 0.11 9.2 g 25 56 1400 14.00<br />
35984000 00212598475 B4155 0.11 9.2 g 25 56 1400 14.00<br />
35985000 00212598575 B4155 0.11 9.2 g 25 56 1400 14.00<br />
RESOURCE ARGINAID EXTRA ® , Orange Burst, 8 fl oz 19660000 00212196662 B4102 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ARGINAID EXTRA ® , Wildberry, 8 fl oz 19670000 00212196762 B4102 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ® BENECALORIE ® , 1.5 fl oz cups -<br />
See BENECALORIE ®<br />
RESOURCE ® BENEFIBER ®‡ Powder, 4 g pkts -<br />
See NUTRISOURCE ® FIBER<br />
RESOURCE ® BENEFIBER ®‡ Powder, 7.2 oz canister -<br />
See NUTRISOURCE ® FIBER<br />
28250000 00212282580 B4155 7.5 44.4 g 330 24 7920 79.20<br />
28230000 00212282374 B4104 — 4 g 15 75 1125 11.25<br />
28210000 00212282107 B4104 — 205 g 769 4 3076 30.76
Product<br />
RESOURCE ® BENEPROTEIN ® , 7 g pkts -<br />
See BENEPROTEIN ®<br />
RESOURCE ® BENEPROTEIN ® , 8 oz canister -<br />
See BENEPROTEIN ®<br />
Product Code<br />
NDC Formatted<br />
Number<br />
HCPCS<br />
Code<br />
kCal/<br />
mL*<br />
Container<br />
Size (mL or g)<br />
kCal/<br />
Container †<br />
Pack<br />
Factor/ Cs kCal/Cs<br />
100 kCal<br />
Units/Case<br />
28430000 00212284371 B4155 — 7 g 25 75 1875 18.75<br />
28410000 00212284107 B4155 — 227 g 810 6 4860 48.60<br />
RESOURCE ® BREEZE, Orange, 8 fl oz 18620000 00212186262 B4154 § 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ® BREEZE, Peach, 8 fl oz 18640000 00212186462 B4154 § 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ® BREEZE, Wild Berry, 8 fl oz 18660000 00212186662 B4154 § 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ® BREEZE, Variety Case, 8 fl oz 18600000 00212186062 B4154 § 1.06 237 mL 250 27 6750 67.50<br />
RESOURCE ® DIABETISHIELD ® , Orange Twist, 8 fl oz 34910000 00212349162 B4154 || 0.63 237 mL 150 27 4050 40.50<br />
RESOURCE ® DIABETISHIELD ® , Mixed Berry, 8 fl oz 34930000 00212349362 B4154 || 0.63 237 mL 150 27 4050 40.50<br />
RESOURCE ® GLUTASOLVE ® , 22.5 g pkts -<br />
See GLUTASOLVE ®<br />
28330000 00212283378 B4155 0.65 22.6 g 90 56 5040 50.40<br />
TOLEREX ® , 2.82 oz pkts 04580500 00212458072 B4153 1.0 300 mL 300 60 18000 180.00<br />
VIVONEX ® PEDIATRIC, 1.7 oz pkts 07131000 00212713176 B4161 0.8 250 mL 200 36 7200 72.00<br />
VIVONEX ® PLUS, 2.8 oz pkts 07129800 00212729818 B4153 1.0 300 mL 300 36 10800 108.00<br />
VIVONEX ® RTF, 250 mL 36250000 00212362551 B4153 1.0 250 mL 250 24 6000 60.00<br />
VIVONEX ® RTF, SpikeRight ® PLUS UltraPak ® , 1000 mL 36280100 00212362814 B4153 1.0 1000 mL 1000 6 6000 60.00<br />
VIVONEX ® RTF, SpikeRight ® PLUS UltraPak ® , 1500 mL 4390036283 00212628214 B4153 1.0 1500 mL 1500 4 6000 60.00<br />
VIVONEX ® T.E.N., 2.84 oz pkts 07127400 00212727873 B4153 1.0 300 mL 300 60 18000 180.00<br />
1/1/2012<br />
* 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.<br />
† kCal/Container is based on the label declaration for the product. This is the value that should be used as the basis for calculations.<br />
‡ BENEFIBER ® is the registered trademark of Novartis AG and is used under license.<br />
§ RESOURCE ® BREEZE - HCPCS code formerly B4102 and B4103<br />
|| RESOURCE ® DIABETISHIELD - HCPCS code formerly B4102<br />
Note: Italicized products to be discontinued in 2011/2012<br />
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<br />
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<br />
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<br />
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<br />
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<br />
claim. Persons who submit false or fraudulent claims for reimbursement are subject to significant civil and criminal penalties.<br />
Please be advised that certain <strong>Nestlé</strong> <strong>HealthCare</strong> <strong>Nutrition</strong> products have been assigned NDC Formatted Numbers. NDC Formatted Numbers are not actual National Drug Codes (NDC). NDC Formatted Numbers are product<br />
codes adjusted according to standard industry practice to meet the format requirements of certain suppliers and payers. <strong>Nestlé</strong> <strong>HealthCare</strong> <strong>Nutrition</strong> submits product information including various product codes to the compendia<br />
including First Data Bank, RedBook and Medispan but cannot confirm that the NDC Formatted Numbers submitted have been published by the compendia.<br />
www.nestlenutrition.com/us • 1-800-422-ASK2 (2752)<br />
Florham Park, NJ 07932-1521 USA<br />
Unless otherwise noted, all trademarks are owned by Société des Produits <strong>Nestlé</strong> S.A.,<br />
Vevey, Switzerland or used with permission. ©2012 <strong>Nestlé</strong><br />
HCN 315-11
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