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picture1_Nutrition Therapy Pdf 144136 | Enteral Nutrition


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File: Nutrition Therapy Pdf 144136 | Enteral Nutrition
unitedhealthcare commercial coverage determination guideline enteral nutrition guideline number cdg 027 06 effective date july 1 2022 instructions for use table of contents page related commercial policies coverage rationale 1 ...

icon picture PDF Filetype PDF | Posted on 08 Jan 2023 | 2 years ago
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                                                        Enteral nutrition products and 
                                                        food supplements 
                                                        Effective from November 2022 
                                                                                                                                                                                                                                
                                                                              
                                                                             Preparations included in the List of Approved 
                                                                             Medicines (LAM)  
                                                                             For use in Queensland Health public hospitals and institutions, as assessed by QHMAC, with 
                                                                             advice from the Nutrition SubCommittee (NUSCO). 
                                                                                                                  NOTE: A new standing offer arrangement (SOA) commenced on 1 April 2019. To 
                                                                                                                allow existing stocks to be consumed, the SOA brand names below include the 
                                                                                                          names of new SOA items (in bold), existing SOA items (standard font)—and those 
                                                                                                                       which have been removed from the SOA but may currently remain available 
                                                                                                                                                                                                                                                                                (italicised). 
                                                                                                                                                                                                                                                                                                           
                                                                                                                                                                                                              ^^ Categories added in November 2022  
                                                                                                             * Clinicians are reminded to check PBS requirements/criteria before prescribing 
                                                                                                                                                                                                                                                                     products listed. 
                                                                                       Preparations                                                                                                                                                                                                               PBS                                               LAM restriction  
                                                                                       (bolded items show April 2019 amendments)                                                                                                                                                                                  listed*                                           SOA product 
                                                                                                                                                                                                                                                                                                                                                                    incoming/remaining  
                                                                                                                                                                                                                                                                                                                                                                    (outgoing SOA product) 
                                                                                       ADULT LISTINGS 
                                                                                       Enteral Nutrition Product, Adult, Complete,                                                                                                                                                                                                                                  Specialist Staff and Country 
                                                                                       Standard Energy Density, Standard Protein,                                                                                                                                                                                                                                   Medical Superintendents. 
                                                                                       Standard Osmolality, Low Lactose, Low Fibre 
                                                                                       Liquid and Liquid-RTH                                                                                                                                                                                                      No                                                NUTRISON 1000mL RTH; 500mL 
                                                                                                                                                                                                                                                                                                                                                                    bottle 
                                                                                                                                                                                                                                                                                                                                                                     
                                                                                       Enteral Nutrition Product, Adult, Complete,                                                                                                                                                                                                                                  Specialist Staff and Country 
                                                                                       Standard Energy Density, Standard Protein,                                                                                                                                                                                                                                   Medical Superintendents. 
                                                                                       Standard to High Osmolality, Low Lactose, 
                                                                                       Low Fibre 
                                                                             Enteral nutrition products and food supplements - Effective from November 
                                                                             2022                                                                                                                                                                                                                                                                    
                   
                   
                    Powder Oral                                      No         ENSURE POWDER 850g can –  
                    Liquid Oral                                      No         FRESUBIN Original 200mL bottle  
                                                                                  
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Standard Energy Density, Moderately High                    Medical Superintendents. 
                    Protein, Standard to Moderately High                         
                    Osmolality, Low Lactose, Low Fibre 
                    Liquid, Liquid-RTH and Oral                      No         OSMOLITE 1000mL RTH; 250mL can 
                                                                                ISOSOURCE HN 1000mL 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Standard Energy Density, Standard or                        Medical Superintendents. 
                    Moderately High Protein, Standard to 
                    Moderately High Osmolality, Low Lactose, 
                    Moderately High to High Fibre 
                    Liquid                                           No         FIBERSOURCE 1.2 HN 237mL Tetra 
                                                                                Pack 
                    Liquid-RTH                                       No         NUTRISON MULTI FIBRE 1000mL 
                                                                                RTH; 500mL bottle  
                                                                                FIBERSOURCE 1.2 HN 250mL CAN  
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Moderately High Energy Density, Standard or                 Medical Superintendents. 
                    Moderately High Protein, Low Lactose, Low 
                    Fibre  
                    Liquid - oral                                    No         RESOURCE PLUS 237mL tetrapak  
                                                                     No         ENSURE PLUS 200mL tetrapak  
                                                                     No         ENSURE PLUS HN 250mL can 
                                                                                 
                    Liquid - RTH                                     No         ENSURE PLUS HN 1000mL RTH 
                                                                                Nutrison Energy 1000mL 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Moderately High Energy Density, Standard or                 Medical Superintendents. 
                    Moderately High Protein, Low Lactose,                        
                    Moderately High Fibre 
                    Liquid - oral                                    No         JEVITY HICAL 250mL can  
                                                                                FRESUBIN ENERGY FIBRE 200mL—  
                                                                                FORTISIP MULTI FIBRE 200mL BOTTLE –  
                  Enteral nutrition products and food supplements - Effective from November 2022              Page 2  
                   
                   
                    Liquid - RTH                                     No         JEVITY HICAL 500mL, 1000mL RTH 
                                                                                NUTRISON ENERGY MULTI FIBRE 1000mL 
                                                                                PACK RTH 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    High Energy Density, Standard or Moderately                 Medical Superintendents. 
                    High Protein, Low Lactose  
                                                                     No         RESOURCE 2.0 237mL tetrapak  
                                                                     No         RESOURCE 2.0 FIBRE 200mL bottle   
                    Liquid - oral                                                
                                                                     No         FORTISIP MULTI FIBRE 200mL bottle   
                                                                                 
                    Liquid - RTH                                     No         ISOSOURCE ENERGY FIBRE 
                                                                                Smartflex 1000mL 
                                                                     No         ISOSOURCE SOY ENERGY FIBRE 
                                                                                Smartflex 1000mL  
                                                                                ISOSOURCE 2.0 1000mL 
                                                                     No         NOVASOURCE GI Forte Smartflex 
                                                                                1000mL 
                                                                                 
                                                                     No         NUTRISON CONCENTRATED 500mL 
                                                                                RTH 
                                                                     No         NUTRISON ENERGY 1000mL RTH; 
                                                                                500mL bottle 
                                                                     No         NUTRISON ENERGY MULTIFIBRE 
                                                                                1000mL RTH; 500mL bottle 
                    Enteral Nutrition Product, Adult, Complete,                 For use in adults with reduced 
                    Low to Standard Energy Density, High Protein,               energy expenditure but high 
                    Low Lactose                                                 protein requirement. 
                    Liquid                                           No         RESOURCE PROTEIN 200mL bottle 
                                                                     No         NUTRISON 800 Complete Multifibre 
                    Liquid - RTH                                                1000mL RTH 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Standard to Moderately High Energy Density,                 Medical Superintendents for use in 
                    Standard or Moderately High Protein, Lactose                patients with documented dairy or 
                    Free, Fructose Free, Sucrose Free,                          fish protein allergies or patients 
                    Hypoallergenic                                              identified as ovo-vegetarian or 
                                                                                vegan. 
                  Enteral nutrition products and food supplements - Effective from November 2022              Page 3  
                   
                   
                    Liquid - RTH                                     No         NUTRISON ADVANCED DIASON 
                                                                                1000mL RTH 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    High Energy Density, Standard Protein, Low                  Medical Superintendents. 
                    Lactose, Low Electrolyte 
                    Liquid – oral                                    No         NEPRO HP 220mL resealable plastic 
                                                                                bottle –   
                                                                     No         NOVASOURCE RENAL 237mL TETRA 
                                                                                PACK  
                    Liquid - RTH                                     No         NEPRO HP 500mL RTH 
                    Enteral Nutrition Product, Adult, Complete,                 Specialist Staff and Country 
                    Moderately High Energy Density, Moderately                  Medical Superintendents. 
                    High to High Protein, Standard to Moderately 
                    High Osmolality, Low Lactose  
                    Liquid - RTH (with fibre)                        No         (NUTRISON PROTEIN PLUS MULTI 
                                                                                FIBRE 1000mL PACK RTH) 
                    Liquid - RTH (without fibre)                     No         NUTRISON PROTEIN PLUS 1000mL 
                                                                                RTH 
                    Enteral Nutrition Product, Adult, Standard or               Specialist Staff and Country 
                    Moderately High Energy Density, Standard to                 Medical Superintendents. 
                    High Protein, Low Fat  
                    Powder - oral                                    No         SUSTAGEN HOSPITAL FORMULA 
                                                                                840g CAN 
                                                                                ADVITAL ADVANCED NUTRITION 
                                                                                920g 
                                                                                Specialist Staff and Country 
                                                                                Medical Superintendents for 
                                                                                inpatient use only. 
                    Liquid - oral                                    No         SUSTAGEN 250mL tetrapak  
                    Enteral Nutrition Product, Adult, Low Energy                Specialist Staff for inpatient use 
                    Density, High Protein, Very Low Fat, Suitable               only for morbid obesity, or for 
                    for Very Low Energy Diets                                   treatment-resistant obesity. 
                                                                                Caution should be used in growing 
                                                                                patients. 
                    Oral                                             No         OPTIFAST VLCD 53g SACHET  
                  Enteral nutrition products and food supplements - Effective from November 2022              Page 4  
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