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258x Filetype PDF File size 0.32 MB Source: mn.gov
ENTERAL NUTRITION PRICE LIST
B4149 – B4155
List updated: 11/07/2022
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 12/31/2019 12/31/2020 Current
B4149 NU COMPLEAT $3.17 $3.32 $3.52 $3.52
COMPLEAT ORGANIC
B4149 NU BLENDS PLANT- *By-Report *By-Report *By-Report *By-Report
BASED
B4149 NU COMPLEAT PED $4.62 $4.85 $5.15 $5.15
REDUCE
B4149 NU COMPLEAT $2.78 $2.90 $3.08 $3.08
PEDIATRIC
COMPLEAT ORGANIC
B4149 NU BLENDS CHICKEN *By-Report *By-Report *By-Report *By-Report
BLENDERIZED TF
COMPLEAT
PEDIATRIC ORGANIC
B4149 NU BLENDS CHICKEN *By-Report *By-Report *By-Report *By-Report
GARDEN
BLENDERIZED TF
COMPLEAT
PEDIATRIC ORGANIC
B4149 NU BLENDS PLANT- *By-Report *By-Report *By-Report *By-Report
BASED BLENDERIZED
TF
B4149 NU LIQUID HOPE $5.86 $5.93 $5.82 $5.82
B4149 NU NOURISH *By-Report *By-Report $6.55 $6.55
ORANGE CHICKEN,
CARROTS, AND
B4149 NU BROWN RICE *By-Report *By-Report *By-Report *By-Report
PUREED FOOD
BLEND
B4149 NU REAL FOODS = BEEF *By-Report *By-Report *By-Report *By-Report
POTATOES
B4149 NU REAL FOODS – $4.70 $4.66 *By-Report *By-Report
CHICKEN LIQ MEALS
B4149 NU REAL FOODS – $4.72 $4.65 $4.73 $4.69
SALMON LIQ MEALS
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 12/31/2019 12/31/2020 Current
B4149 NU REAL FOODS $5.00 $4.74 $4.72 $4.69
QUINOA LIQ MEALS
B4149 NU REAL FOODS- EGGS, *By- Report *By-Report *By-Report *By-Report
APPLES, AND OATS
REAL FOODS-
B4149 NU TURKEY, SWEET *By-Report *By-Report *By-Report *By-Report
POTATOES, AND
PEACHES
B4149 NU PEDIASURE HARVEST *By-Report *By-Report *By-Report *By-Report
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 CURRENT 12/31/2020 Current
B4150 NU BOOST $0.94 $.80 $.96 $.76
B4150 NU BOOST CALORIE SMART *By-Report *By-Report *By-Report *By-Report
B4150 NU BOOST HIGH PROTEIN $1.36 $1.14 $1.44 $1.44
B4150 NU CARNATION BREAKFAST *By-Report *By-Report *By-Report *By-Report
ESSENTIALS
B4150 NU ENSURE $0.81 $.86 $.78 $.80
B4150 NU ENSURE ACTIVE HIGH $0.62 $1.05 $.59 $.58
PROTEIN
B4150 NU ENSURE IMMUNE HEALTH $0.66 *By-Report *By-Report *By-Report
B4150 NU ENSURE MUSCLE HEALTH $1.86 *By-Report *By-Report *By-Report
B4150 NU FIBERSOURCE HN *By-Report *By-Report *By-Report *By-Report
B4150 NU ISOSOURCE HN $0.98 $1.03 $1.09 $1.02
B4150 NU JEVITY 1.0 $0.97 $1.17 $.96 $1.12
B4150 NU JEVITY 1.2 $1.53 $1.18 $1.47 $1.32
B4150 NU KATE FARMS STANDARD *By-Report *By-Report *By-Report *By-Report
1.4 PLAIN
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 CURRENT 12/31/2020 Current
B4150 NU KATE FARM STANDARD *By-Report *By-Report *By-Report *By-Report
1.4 VANILLA
B4150 NU KATE FARM STANDARD *By-Report *By-Report *By-Report $1.92
FORMULA 1.0 VANILLA
B4150 NU KATE FARM STANDARD *By-Report *By-Report *By-Report *By-Report
FORMULA 1.0 CHOCOLATE
B4150 NU KATE FARM STANDARD *By-Report *By-Report *By-Report *By-Report
FORMULA 1.0 PLAIN
B4150 NU NUTREN 1.0 WITH FIBER $1.19 $1.24 $1.32 $1.32
B4150 NU NUTREN 1.0 $1.08 $1.13 $1.20 *By-Report
B4150 NU OPTISOURCE HIGH *By-Report *By-Report *By-Report *By-Report
PROTEIN DRINK
ORGAIN VEGAN ALL-IN-
B4150 NU ONE PROTEIN SHAKE *By-Report *By-Report *By-Report *By-Report
CHOCOLATE
ORGAIN VEGAN ALL-IN-
B4150 NU ONE PROTEIN SHAKE *By-Report *By-Report *By-Report *By-Report
VANILLA
B4150 NU OSMOLITE 1.0 $1.28 $1.27 $1.28 $1.38
B4150 NU OSMOLITE 1.2 $0.65 $1.44 $1.53 $1.49
B4150 NU PROMOTE $1.60 $1.68 $1.79 $1.76
B4150 NU PROMOTE WITH FIBER $1.64 $1.27 $1.64 $1.64
B4150 NU REPLETE $1.61 $1.69 1.80 $1.80
B4150 NU REPLETE WITH FIBER $1.13 $3.82 1.04 $1.85
HCPCS REIMB REIMB REIMB REIMB
MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 CURRENT 12/31/2020 Current
B4152 NU BOOST PLUS $0.84 $.87 $.84 $.84
B4152 NU BOOST VHC $0.56 $.85 $.84 $.56
B4152 NU ENSURE COMPLETE $0.46 $.57 *By-Report *By-Report
B4152 NU ENSURE ENLIVE *By-Report *By-Report $.89 $.90
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 CURRENT 12/31/2020 Current
B4152 NU ENSURE PLUS $0.57 $.73 $.54 $.56
B4152 NU ISOSOURCE 1.5 $0.92 $.88 $.92 $1.00
B4152 NU JEVITY 1.5 $1.13 $.96 $1.12 $1.12
B4152 NU NUTREN 1.5 $0.91 $.96 $1.03 $1.03
B4152 NU NUTREN 2.0 $0.79 $.82 $.88 $.88
B4152 NU OSMOLITE 1.5 $0.57 $.52 $.56 $.56
B4152 NU RESOURCE 2.0 $0.92 $.70 $.72 $.72
B4152 NU SCANDISHAKE *By-Report *By-Report *By-Report *By-Report
B4152 NU TWOCAL HN $0.85 $.88 $.83 $.84
REIMB REIMB REIMB REIMB
HCPCS MOD PRODUCT NAME AMOUNT AMOUNT AMOUNT AMOUNT
Code 1/1/2017 – 1/1/2018 – 1/1/2020- 1/1/2021-
12/31/2017 CURRENT 12/31/2020 Current
B4153 NU IMPACT PEPTIDE 1.5 *By-Report $2.10 *By-Report $5.91
B4153 NU KATE FARM PEPTIDE *By-Report *By-Report *By-Report *By-Report
FORMULA 1.5 PLAIN
B4153 NU PEPTAMEN 7.08 $7.41 $7.88 $7.88
B4153 NU PEPTAMEN WITH PREBIO $7.34 $7.69 $8.18 $8.18
B4153 NU PEPTAMEN 1.5 $7.01 $7.41 $7.88 $7.88
B4153 NU PEPTAMEN 1.5 CAL WITH $7.01 $7.41 $5.18 $6.21
PREBIO 1 TM
B4153 NU PEPTAMEN AF $7.69 $8.06 $8.56 $8.56
B4153 NU PEPTAMEN OS *By-Report *By-Report *By-Report *By-Report
B4153 NU PEPTAMEN INTENSE VHP *By-Report *By-Report *By-Report *By-Report
B4153 NU PERATIVE *By-Report *By-Report *By-Report *By-Report
B4153 NU TOLEREX $7.18 $7.71 *By-Report *By-Report
B4153 NU VITAL 1.0 $2.84 $7.03 $2.74 $2.74
B4153 NU VITAL 1.5 $5.21 $1.86 *By-Report *By-Report
B4153 NU VITAL AF 1.2 *By-Report *By-Report *By-Report *By-Report
B4153 NU VITAL HIGH PROTEIN *By-Report *By-Report *By-Report *By-Report
B4153 NU VIVONEX PLUS $8.33 $8.72 *By-Report *By-Report
B4153 NU VIVONEX RTF $7.70 $8.09 $8.60 $8.60
B4153 NU VIVONEX T.E.N. $7.97 $8.34 *By-Report *By-Report
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