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Sample Letters of Medical Necessity:

• KetoCal 2.5:1 (Microsoft^© Word File)
• KetoCal 3:1 (Microsoft^© Word File)
• KetoCal 4:1 Powder (Microsoft^© Word File)
• KetoCal 4:1 LQ (Microsoft^© Word File)
• Liquigen (Microsoft^© Word File)

 

Reimbursement Information and Product Codes:

The following information may be requested by your insurance company or government program (WIC, Medicaid) when requesting coverage for KetoCal.

	KetoCal 2.5:1 Liquid, Vanilla Product Code Reimbursement Code HCPCS Code Packaging Calories Per 8 fl oz Prism 137246 49735-01-7246 B4154 27 x 237 mL (8fl oz) 363
	KetoCal® 3:1 Powder, Unflavored Product Code Reimbursement Code HCPCS Code Packaging Calories Per Can 16672 49735-0166-72 B4154 6 x 300 g (11 oz) 2097
	KetoCal® 4:1 Powder, Vanilla Product Code Reimbursement Code HCPCS Code Packaging Calories Per Can 101777 49735-0166-70 B4154 6 x 300 g (11 oz) 2103
	KetoCal® 4:1 Liquid, Unflavored Product Code Reimbursement Code HCPCS Code Packaging Calories Per 8 fl oz Prism 80183 49735-0130-54 B4154 27 x 237 mL (8 fl oz) 356
	KetoCal® 4:1 Liquid, Vanilla Product Code Reimbursement Code HCPCS Code Packaging Calories Per 8 fl oz Prism 80180 49735-0187-96 B4154 27 x 237 mL (8 fl oz) 356
	Liquigen® Product Code Reimbursement Code HCPCS Code Packaging Calories Per 8.5 fl oz Bottle Case (12 Bottles) 71957 49735-0119-57 B4155 3 x 4 x 250 mL (8.5 fl oz) 1125 Unit (3 bottles) 71957-3 49735-0195-73 B4155 4 x 250 mL (8.5 fl oz) 1125