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01-07-2023 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEMS Page 1
LOUISIANA DEPARTMENT OF HEALTH BUREAU OF HEALTH SERVICES - FINANCING
DME ENTERAL NUTRITION FEE SCHEDULE
Price
Per Unit Effective Per
HCPCS NDC Description Measurement Date Unit *
B4100 07249222204 NUTRA BALANCE THIK & CLEAR NECTAR -5GM PACKET - 200/BOX 1 UNIT = PACKET 08-01-2014 0.32
07249222205 NUTRA BALANCE THIK & CLEAR HONEY 5GM PACKET - 200/BOX 1 UNIT = PACKET 08-01-2014 0.32
07249222207 NUTRA BALANCE POWDER UNFLAVORED - 8OZ CAN - 12/CASE 1 UNIT = CAN 08-01-2014 11.56
20513001001 SIMPLY THICK NECTAR INDIVIDUAL SERVING PACKET 15GMS(200 1 UNIT = PACKET 07-01-2012 0.41
PACKETS
20513002001 SIMPLY THICK HONEY INDIVIDUAL SERVING PACKET 30GMS(100 1 UNIT = PACKET 07-01-2012 0.63
PACKETS
20513007005 SIMPLY THICK NECTARSIMPLYTHICK 1 UNIT = 1 12-01-2018 0.49
PACKAGE
20513008005 SIMPLY THICKE HONEYSIMPLYTHICK 1 UNIT = 1 12-01-2018 0.63
PACKAGE
43900022510 CORN STARCHRESOURCE THICKENUP 1 UNIT = CAN 09-01-2015 3.62
72058004075 THICK-IT 2 - 8 OZ CAN -DIAFOODS THICK-IT 1 UNIT = CAN 07-01-2012 6.28
72058061079 THICK-IT POWDER - 36 OZ CANTHICK-IT 1 UNIT = CAN 02-02-2013 19.53
B4102 43900018600 LACTOSE-FREE FOOD BOOST BREEZEBOOST BREEZE 1 UNIT = BRIK 09-01-2015 1.28
43900018629 LACTOSE-FREE FOOD BOOST BREEZEBOOST BREEZE 1 UNIT = BRIK 09-01-2015 1.28
43900018649 LACTOSE-FREE FOOD BOOST BREEZEBOOST BREEZE 1 UNIT = BRIK 09-01-2015 1.28
* UNITS ARE SPECIFIC TO NDC, NOT HCPC. ONE UNIT MAY BE EQUAL TO 100 CALORIES, ONE PACKET, ONE CAN, ONE BRIK, OR ONE BOTTLE.
01-07-2023 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEMS Page 2
LOUISIANA DEPARTMENT OF HEALTH BUREAU OF HEALTH SERVICES - FINANCING
DME ENTERAL NUTRITION FEE SCHEDULE
Price
Per Unit Effective Per
HCPCS NDC Description Measurement Date Unit *
B4102 43900018666 BOOST BREEZE WILD BERRY-8OZ RESOURCEBREEZE 1 UNIT = BRIK 09-01-2015 1.28
43900019660 WHEY PROTEIN/ARGININE/C/E/ZINCARGINAID EXTRA 1 UNIT = BOTTLE 09-01-2015 1.05
43900034910 NUT SUP GLUCOSE INTOLERANT #1RESOURCE DIABETISHIELD 1 UNIT = 100 KCAL 09-01-2015 0.87
43900050593 BOOST SOOTHE STRAWBERRY-KIWIBOOST 1 UNIT - 100 KCAL 12-01-2019 0.54
43900050924 BOOST SOOTH PEACH-MINTBOOST SOOTHE 1 UNIT = 100 KCAL 12-01-2019 0.54
70074056641 ENSURE CLEAR - APPLEENSURE 1 UNIT = BRIK 11-01-2013 1.06
70074056643 ENSURE CLEAR - MIXED BERRYENSURE 1 UNIT = BRIK 11-01-2013 1.06
70074064899 NUT.TX.IMPAIRED DIGEST FXNENSURE CLEAR/APPLE ENSURE 1 UNIT = 1 11-14-2016 1.06
CARTON
70074064901 NUT.TX.IMPAIRED DIGEST FXNENSURE CLEAR/APPLE ENSURE 1 UNIT = 1 11-14-2016 1.06
CARTON
B4103 00074024501 ELECTROLYTE ORAL PEDIALYTEPEDIALYTE 1 UNIT = SLEEVE 07-01-2012 1.08
00074647032 PEDIATRIC NUTRITIONALPEDIALYTE READY TO FEED UNF 1 UNIT = BOTTLE 07-01-2012 5.47
43900050593 BOOST SOOTHE STRAWBERRY-KIWIBOOST 1 UNIT - 100 KCAL 12-01-2019 0.54
43900050924 BOOST SOOTH PEACH-MINTBOOST SOOTHE 1 UNIT = 100 KCAL 12-01-2019 0.54
* UNITS ARE SPECIFIC TO NDC, NOT HCPC. ONE UNIT MAY BE EQUAL TO 100 CALORIES, ONE PACKET, ONE CAN, ONE BRIK, OR ONE BOTTLE.
01-07-2023 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEMS Page 3
LOUISIANA DEPARTMENT OF HEALTH BUREAU OF HEALTH SERVICES - FINANCING
DME ENTERAL NUTRITION FEE SCHEDULE
Price
Per Unit Effective Per
HCPCS NDC Description Measurement Date Unit *
B4103 70074024501 PEDIALYTE FROZEN POPS - 2.1 OZSLEEVE - 8/16 SLEEVES 1 UNIT = SLEEVE 07-01-2012 1.08
BOXES/C
70074051753 PEDIALYTE BUBBLE GUM-1 LTR BOTTLE-8/CASE 1 UNIT = BOTTLE 07-01-2012 5.70
70074054982 PEDIALYTE CHERRY - 8 OZ BOTTLE- 8/4 PACKS/CASE 1 UNIT = BOTTLE 07-01-2012 1.92
70074057426 PEDIALYTE APPLE - 8 OZ BOTTLE- 8/4 PACKS/CASE 1 UNIT = BOTTLE 07-01-2012 1.92
70074064899 NUT.TX.IMPAIRED DIGEST FXNENSURE CLEAR/APPLE ENSURE 1 UNIT = 1 11-14-2016 1.06
CARTON
70074064901 NUT.TX.IMPAIRED DIGEST FXNENSURE CLEAR/APPLE ENSURE 1 UNIT = 1 11-14-2016 1.06
CARTON
70074080240 PEDIALYTE GRAPE-1 LTR BOTTLE-8/CASEPEDIALYTE 1 UNIT = BOTTLE 07-01-2012 5.70
70074080336 PEDIALYTE UNFLAVORED-1 LTR BOTTLE-8/CASE 1 UNIT = BOTTLE 07-01-2012 5.70
70074080365 PEDIALYTE FRUIT-1 LTR BOTTLE-8/CASEPEDIALYTE 1 UNIT = BOTTLE 07-01-2012 5.70
B4104 00212282107 RESOURCE BENEFIBER UNFLAVOREDPOWDER - 7.2 CANISTER - 1 UNIT = CAN 07-01-2012 10.49
4/CASE
00212282374 RESOURCE BENEFIBER UNFLAVORED- 4G PACKET - 75/CASE 1 UNIT = PACKET 07-01-2012 1.28
43900097550 NUTRISOURCE FIBER POWDER 7.2 OZ CANISTER 1 UNIT = CAN 07-01-2012 10.49
43900097647 NUTRISOURCE FIBER POWDER 4G PKTSNUTRISOURCE FIBER 1 UNIT = BOX 07-01-2012 10.49
* UNITS ARE SPECIFIC TO NDC, NOT HCPC. ONE UNIT MAY BE EQUAL TO 100 CALORIES, ONE PACKET, ONE CAN, ONE BRIK, OR ONE BOTTLE.
01-07-2023 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEMS Page 4
LOUISIANA DEPARTMENT OF HEALTH BUREAU OF HEALTH SERVICES - FINANCING
DME ENTERAL NUTRITION FEE SCHEDULE
Price
Per Unit Effective Per
HCPCS NDC Description Measurement Date Unit *
B4104 58914080044 SCANDISHAKE VANILLA - 3 OZ PACK - 4/BOX - 9/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914080084 SCANDISHAKE VANILLA - 3 OZ PACK - 24/BOX - 1/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914080144 SCANDISHAKE CHOC - 3 OZ PACK -4/BOX - 9/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914080184 SCANDISHAKE CHOC - 3 OZ PACK -24/BOX - 1/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914080244 SCANDISHAKE STRAWBERRY - 3 OZPACK - 4/BOX - 9/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914080284 SCANDISHAKE STRAWBERRY - 3 OZPACK - 24/BOX - 1/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914081044 SCANDISHAKE LF VANILLA - 3 OZPACK - 4/BOX - 9/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914081084 SCANDISHAKE LF VANILLA - 3 OZPACK - 24/BOX - 1/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914081144 SCANDISHAKE LF CHOC - 3 OZ PACK - 4/BOX - 9/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914081184 SCANDISHAKE LF CHOC - 3 OZ PACK - 24/BOX - 1/CASE 1 UNIT = PACKET 08-01-2016 6.98
58914082018 SCANDISHAKE VANILLA WITH ASPERTION - 18 OZ CAN - 6/CASE 1 UNIT = CAN 07-01-2012 6.98
58914082118 SCANDISHAKE CHOC WITH ASPERTION - 18 OZ CAN - 6/CASE 1 UNIT = CAN 07-01-2012 6.98
58914083008 SCANDICAL CALORIE BOOSTER - 8OZ CAN - 6/CASE 1 UNIT = 100 KCAL 07-01-2012 0.39
B4149 43900014010 LACTOSE-FREE FOODCOMPLEAT 1 UNIT = 100 KCAL 09-01-2015 1.34
* UNITS ARE SPECIFIC TO NDC, NOT HCPC. ONE UNIT MAY BE EQUAL TO 100 CALORIES, ONE PACKET, ONE CAN, ONE BRIK, OR ONE BOTTLE.
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