| Peptamen Junior 1.5 |
Pediatric, Oral
|
Special Authorization (RD)
|
Special Authorization (RD)
|
Special Authorization (RD)
|
Special Authorization (RD)
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Pregestimil - Powder |
Infant
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Puramino A+ Junior Oral Powder |
Infant, Pediatric
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Puramino A+ Oral Powder |
Infant
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Special Authorization (MD Only)
|
Regular Benefit - needs Prescription
|
Special Authorization (MD Only)
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| RCF - liquid concentrate |
Infant, Pediatric, Oral
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Not Covered
|
| Resource 2.0 Oral Liquid |
Adult, Oral
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Resource Adult Prisma 2.0 Vanilla Portion |
Adult, Oral
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
| Resource Diabetic |
Pediatric, Adult, Oral
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Special Authorization (RD)
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Resource Kid Essential 1.5 |
Pediatric, Oral
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Not Covered
|
Regular Benefit - needs Prescription
|
Limited Use (NIHB)
|
| Similac Alimentum Liquid |
Infant, Oral
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Regular Benefit - needs Prescription
|
Special Authorization (RD)
|
Not Covered
|
Special Authorization (RD)
|
Limited Use (NIHB)
|