Reimbursement
Resources You Can Use


 

Sample Letters of Medical Necessity:

 

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® 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