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Polymeric; Standard Volume | Polymeric; Concentrated Volume | Hydrolyzed; Standard Volume

Hydrolyzed; Concentrated Volume | Elemental; Standard Volume | Blenderized

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Polymeric; Standard Volume

Composition	Formula Brand Name	Specifics	HCPCS Code	Additional Details
Milk Based	Boost® Kid Essentials, Nestlé Health Science	Contains soy	B4158	Gluten-free, kosher, suitable for lactose intolerance
Milk Based	Boost® Kid Essentails 1.0, Nestlé Health Science		B4158	Gluten-free, kosher, suitable for lactose intolerance
Milk Based	PediaSure® Enteral Formula 1.0 Cal, Abbott		B4160	Gluten-free, halal, kosher, suitable for lactose intolerance
Milk Based	PediaSure® Enteral Formula 1.0 Cal with Fiber, Abbott		B4158	Gluten-free, halal, kosher, suitable for lactose intolerance
Milk and Soy Protein	Nutren Junior®, Nestlé Health Science	Contains soy	B4160	Gluten-free, suitable for lactose intolerance, Kosher
Milk and Soy Protein	Nutren Junior® Fiber, Nestlé Health Science	Contains soy	B4160	Gluten-free, suitable for lactose intolerance, Kosher
Milk and Soy Protein	PediaSure® Grow & Gain Therapeutic Nutrition Shake, Abbott		B4159	Gluten-free, halal, kosher, suitable for lactose intolerance
Milk and Soy Protein	PediaSure® Grow & Gain with Fiber Therapeutic Nutrition Shake, Abbott		B4159	Gluten-free, halal, kosher, suitable for lactose intolerance
Milk and Soy Protein	Pediasure Sidekicks® 0.63 cal Shake, Abbott		B4158	Gluten-free, halal, kosher, suitable for lactose intolerance
Organic Pea protein	Kate Farms Pediatric Standard 1.2, Kate Farms®	Vegan, no milk, no soy, no gluten, no nuts, no corn	B4160	Gluten-free, lactose
Soy protein	Soy Pediatric Drink®, Bright Beginnings	Vegetarian, milk free, may be suitable for cow milk allergy, contains soy		Gluten-free, kosher, lactose
Milk and Soy Protein	PediaSure® Grow & Gain with Fiber, Abbott	Contains soy	B4159	Gluten-free, halal, kosher, suitable for lactose intolerance
Food ingredients	Compleat® Pediatric, Nestlé Health Science	No soy, no corn	B4149	Gluten-free, suitable for lactose intolerance
	Compleat® Pediatric Reduced Calorie, Nestlé Health Science	No soy, no corn	B4149	Gluten-free, suitable for lactose intolerance

Polymeric; Concentrated Volume

Composition	Formula Brand Name, Manufacturer	Specifics	HCPCS Code	Additional Details
Milk Based	Boost® Kid EssentialsTM 1.5, Nestlé Health Science	Contains soy	B4160	Gluten-free, kosher, suitable for lactose intolerance
Milk Based	Boost® Kid EssentialsTM 1.5 with Fiber, Nestlé Health Science	Contains soy	B4160	Gluten-free, kosher, suitable for lactose intolerance
Milk Protein	Pediasure® 1.5 Cal, Abbott	Contains soy	B4160	Gluten-free, halal, kosher, suitable for lactose intolerance
Milk and Soy Protein	PediaSure® 1.5 Cal with Fiber, Abbott	Contains soy	B4160	Gluten-free, halal, kosher, suitable for lactose intolerance

Hydrolyzed; Standard Volume

Composition	Formula Brand Name, Manufacturer	Specifics	HCPCS Code	Additional Details
Whey Protein	Peptamen Junior®, Nestlé Health Science	Contains milk and soy ingredients	B4161	Gluten-free, kosher, suitable for lactose intolerance
Whey Protein	Peptamen Junior® HP, Nestlé Health Science	Contains milk and soy ingredients	B4161	Gluten-free, kosher, suitable for lactose intolerance
Whey Protein	Peptamen Junior® Fiber, Nestlé Health Science	Contains milk and soy ingredients	B4161	Gluten-free, kosher, suitable for lactose intolerance
Whey Protein	Peptamen Junior® with Prebio1TM , Nestlé Health Science	Contains milk and soy ingredients	B4161	Gluten-free, kosher, suitable for lactose intolerance
Whey Protein/Casein	PediaSure® Peptide 1.0 Cal, Abbott		B4161	Gluten-free, halal, kosher, suitable for lactose intolerance
Pea Protein	Kate Farms Pediatric Peptide 1.0, Kate Farms	Vegan, no milk, no soy, no gluten, no nuts, no corn		Gluten-free, suitable for lactose intolerance

Hydrolyzed; Concentrated Volume

Composition	Formula Brand Name, Manufacturer	Specifics	HCPCS Code	Additional Details
Whey Protein	Peptamen Junior® 1.5, Nestlé Health Science	Contains milk and soy ingredients	B4161	Gluten-free, kosher, suitable for lactose intolerance
Whey Protein/Casein	PediaSure® Peptide 1.5 Cal, Abbott		B4161	Gluten-free, halal, kosher, suitable for lactose intolerance
Organic Pea Protein	Kate Farms Pediatric Peptide 1.5®, Kate Farms®	Vegan, no milk, no soy, no gluten, no nuts, no corn	B4161	Gluten-free, suitable for lactose intolerance

Elemental; Standard Volume

Composition	Formula Brand Name, Manufacturer	Specifics	HCPCS Code	Additional Details
Free Amino Acid	EleCare® Jr, Abbott	No milk, no soy, no fructose, no galactose	B4161	Gluten-free, halal, suitable for lactose intolerance
Free Amino Acid	Alfamino® Infant, Nestlé Health Science	No milk ingredients	B4161	Gluten-free, lactose-free
Free Amino Acid	Alfamino® Junior, Nestlé Health Science	No milk ingredients	B4161	Gluten-free, lactose-free
Free Amino Acid	Vivonex® Pediatric, Nestlé Health Science	No milk ingredients	B4161	Gluten-free, kosher, lactose-free
Free Amino Acid	Neocate® Junior: Unflavored, Nutricia	No dairy, no soy oil	B4161	Kosher
Free Amino Acid	Neocate® Junior, Nutricia	No dairy, no soy oil	B4161	Kosher
Free Amino Acid	Neocate® Junior with Probiotics: Unflavored, Nutricia	No dairy, no soy oil	B4161	Kosher
Free Amino Acid	Neocate® Junior with Probiotics: Vanilla, Nutricia	No dairy, no soy oil	B4161	Kosher
Free Amino Acid	Neocate® Junior with Probiotics: Strawberry, Nutricia	No dairy, no soy oil	B4161	Kosher
Free Amino Acid	Neocate® Splash, Nutricia	No dairy, no soy oil, no casein	B4161	Kosher

Blenderized

Composition	Formula Brand Name, Manufacturer	Specifics	HCPCS Code	Additional Details
	Compleat® Pediatric Organic Blends (chicken or garden blend), Nestlé Health Science	Organic, non-GMO, no dairy, soy, corn	B4149	Gluten-free, lactose-free
	Nourish, Functional Formularies®	Organic, vegan, no dairy, no nuts, no soy, no corn	B4149	Gluten-free, lactose
	PediaSure Harvest®, Abbott	No milk	B4149	Gluten-free, suitable for lactose intolerance
	Real Food Blends® -Orange Chicken, Carrots, and Brown Rice, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients
	Real Food Blends® - Salmon, Oats, and Squash, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients
	Real Food Blends® - Quinoa, Kale and Hemp, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients
	Real Food Blends® - Beef, Potatoes, and Spinach, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients
	Real Food Blends®- Eggs, Apples, and Oats, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients
	Real Food Blends® - Turkey, Sweet Potatoes, and Peaches, Real Food Blends®		B4149	Gluten-free, lactose-free, no dairy, No soy, no corn, no added sugar, no nuts, no artificial ingredients