NEWBORN SCREENING BENEFITS CONTRACTOR PROCEDURES MANUAL SUPPLEMENT ALLOWABLE BENEFITS LIST The lists below are the approved medications, formulas, dietary supplements, and vitamins that are indicated for the various screened disorders in the Newborn Screening Program. The physician specialist will determine the course of treatment and will prescribe the appropriate medical management for the patient. The patient/client is responsible for obtaining the prescriptions from the selected contract provider. There are monthly benefit limitations per client: • $1,500.00 per month for dietary supplements • $300.00 per month for vitamins • Other limits may be assessed if the price of the item affects available funding for priority populations Medical foods (formulas), dietary supplements and vitamins are reimbursable at wholesale plus 15%. Items not listed in these tables must have approval from NBS Benefits prior to dispensing or billing. AMINO ACID DISORDERS DISORDER ITEMS MANUFACTURER HCY Homocystinuria Formulas Hominex-1 Abbott Nutrition Hominex-2 Abbott Nutrition HCY 1 Mead Johnson HCY 2 Mead Johnson HOM 2 Milupa HCU Anamix Early Years Nutricia HCU Anamix Next Nutricia XMet Maxamaid – orange flavor Nutricia XMet Maxamum – orange flavor Nutricia HCU Gel Vitaflo HCU Express Vitaflo Pro-Phree Abbott Nutrition Super Soluble Duocal Nutricia PFD 1 Mead Johnson PFD 2 Mead Johnson Metanx Complex Essential MSD HCU Cooler 15 NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 1 Dietary Supplements Cystine AA Supplement Vitaflo Medications Cystadane Powder (Betaine) AnovoRx Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Cyanocobalamin (vitamin B12) Pyridoxine Tablets (50 mg) Vitamin B6 tablets Vitamin B12 tablets MSUD Maple Syrup Formulas Urine Disease MSUD Analog Nutricia New: MSUD Anamix Early Years Nutricia MSUD Maxamaid – orange flavor Nutricia MSUD Maxamum – orange flavor Nutricia MSUD 2 Mead Johnson BCAD 1 Mead Johnson BCAD 2 Abbot Nutrition Ketonex-1 Abbott Nutrition Ketonex-2 Nutricia Nutricia Complex MSUD Drink Mix – Nutricia Vanilla Nutricia Complex MSUD AA Bar – Vitaflo Chocolate Vitaflo Complex MSUD AA Blend Vitaflo MSUD Gel Nutricia MSUD Express Abbott Nutrition MSUD Express Cooler Mead Johnson MSUD Amino Acid Mix Mead Johnson Pro-Phree Nutricia PFD 1 PFD 2 Super Soluble Duocal Metanx Complex Essential MSD Dietary Supplements Nutricia L-Valine AA Nutricia L-Isoleucine AA Vitaflo Isoleucine50 Vitaflo Isoleucine1000 Vitaflo Valine50 Vitaflo Valine1000 Vitamins Thiamin NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 2 Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets PKU Phenylketonuria Formulas Phenex-1 Abbott Nutrition Phenex-2 Abbott Nutrition Phenex-2 – vanilla Abbott Nutrition Prophree Abbott Nutrition Super Soluble Duocal Nutricia Nutricia PhenylAde Drink Mix – chocolate Nutricia PhenylAde 40 Drink Mix – Nutricia unflavored Nutricia PhenylAde 40 Drink Mix – citrus Nutricia PhenylAde 60 Drink Mix – Vanilla Nutricia PhenylAde Essential Drink Mix – Nutricia All flavors Nutricia PhenylAde Amino Acid Blend- Nutricia pouches Nutricia PhenylAde MTE Amino Acid Nutricia Blend-can Nutricia PhenylAde Amino Acid Bar- All Nutricia flavors Nutricia PhenylAde PheBLOC Tablet Nutricia PhenylAde GMP Milupa Phenyl-Free 1 Milupa Phenyl-Free 2 Prekulab Phenyl-Free 2HP Prekulab PKU 2 Nutricia PKU 3 Nutricia PreKUnil Nutricia Neophe Nutricia PheBloc Nutricia XPhe Maxamaid – All flavors Nutricia Periflex LQ- All flavors Nutricia New: PKU Periflex Early Years Nutricia Phlexy-10 Drink Mix – All flavors Nutricia Phlexy-10 Tablets Vitaflo Phlexy-10 Capsules Vitaflo Phlexy-10 Vitaflo Lophlex Drink Mix – All flavors Nutricia PKU Easy Liquid Nutricia PKU Easy Microtabs PKU Gel PKU Express PKU Express Cooler PKU Cooler 20 Periflex Advance Periflex Jr Plus- All Flavors Periflex LQ- All Flavors NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 3 Glytactin Bettermilk 15 Cambrooke Glytactin Build 10 Cambrooke Glytactin Swirl Cambrooke Glytactin RTD 10 Cambrooke Glytactin RTD 15 Cambrooke Glytactin Complete 10 Cambrooke Glytactin Complete 15 Cambrooke Glytactin Restore 10 Cambrooke Glytactin Restore Lite 10 Cambrooke Camino Pro 15 Cambrooke Metanx Complex Essential MSD Dietary Supplements Tyrosine1000 L-Tyrosine Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo MVW Complete Formulation + MVW Nutritionals D3000 MVW Complete Formulation + MVW Nutritionals D5000 Vitamin B6 tablets Vitamin B12 tablets Tyrosinemia Formulas TYR I Type I Tyrex-1 Abbott Nutrition TYR II Type II Tyrex-2 Abbott Nutrition TYR III Type III New: TYR Anamix Early Years Nutricia Nutricia TYR Anamix Next Nutricia XPhe, XTyr Maxamaid Nutricia Super Soluble Duocal Milupa TYR 2 Mead Johnson TYROS 1 Mead Johnson TYROS 2 Abbott Nutrition Prophree Vitaflo TYR Gel TYR Vitaflo Express Cambrooke Tylactin RTD 15 Cambrooke Tylactin Restore 10 Metanx Complex Essential MSD Medications Nitisinone (Orfadin) Tablets NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 4 Vitamins Vitamin D Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets ARG Argininemia Formulas Solcarb Solace Nutrition CIT II Citrullinemia Polycal Nutricia Type II Super Soluble Duocal Nutricia UCD Trio Vitaflo EAA Supplement Vitaflo Metanx Complex Essential MSD Dietary Supplements Arginine 500 Vitaflo Arginine 2000 Vitaflo Citrulline 200 Vitaflo Citrulline 1000 Vitaflo Leucine100 Vitaflo Valine50 Vitaflo Valine1000 Vitaflo Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 Tablets MET Hyper- methioninemia Benign HPhe Hyperphenyla- laninemia BioptReg Biopterin Reg BioptBS Biopterin BS UREA CYCLE DISORDERS DISORDER ITEMS MANUFACTURER CIT Citrullinemia Formulas Cyclinex-1 Abbott Nutrition NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 5 ASA Argininosuccinic Cyclinex-2 Abbott Nutrition Acidemia Pro-Phree Abbott Nutrition WND 1 Mead Johnson WND 2 Mead Johnson PFD 1 Mead Johnson PFD 2 Mead Johnson UCD 2 Milupa Super Soluble Duocal Nutricia Essential Amino Acid Mix Nutricia Metanx Complex Essential MSD Dietary Supplements L-Arginine Nutricia L-Leucine Nutricia L-Isoleucine Nutricia L-Valine Nutricia Citrulline Citrulline 200 Vitaflo Citrulline 1000 Vitaflo Arginine 2000 Vitaflo Arginine 500 Vitaflo Isoleucine 50 Vitaflo Isoleucine 1000 Vitaflo Leucine 100 Vitaflo Valine 50 Vitaflo Valine 1000 Vitaflo Medications Buphenyl Powder Buphenyl Tablets Sodium Benzoate Powder (Spectrum) Na Benzoate Powder Na Benzoate 10% Solution (100 mg/ml) Acetyl Carnitine L-Carnitine (100 mg/ml) Omeprazole Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 6 ORGANIC ACIDEMIAS DISORDERS DISORDER ITEMS MANUFACTURER BKT Beta- Formulas Ketothiolase MSUD Anamix Early Years Nutricia Deficiency MSUD Anamix Next Nutricia MSUD Maxamaid – orange Nutricia MSUD Maxamum – orange Nutricia MSUD 2 Nutricia BCAD 1 Mead Johnson BCAD 2 Abbott Nutrition Ketonex-1 Abbott Nutrition Ketonex-2 Nutricia Nutricia Complex Junior MSD w/ DHA - Nutricia ARA Nutricia Complex MSD Drink Mix Nutricia Complex MSD Amino Acid Bar Nutricia Complex MSD Amino Acid Blend Vitaflo MSUD Gel Vitaflo MSUD Express Abbott Pro-Phree PFD 1 PFD 2 Nutricia Super Soluble Duocal Metanx Complex Essential MSD Dietary Supplements Nutricia L-isoleucine Nutricia L-valine Vitaflo Isoleucine50 Vitaflo Isoleucine1000 Vitaflo Valine50 Vitaflo Valine1000 Vitamins Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets GA1 Glutaric Formulas Aciduria, Type I Glutarex-1 Abbott Nutrition Glutarex-2 Abbott Nutrition Pro-Phree Abbott Nutrition GA Mead Johnson GA Gel Vitaflo GA Express 15 Vitaflo PFD 1 Mead Johnson PFD 2 Mead Johnson NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 7 Super Soluble Duocal Nutricia GA-1 Anamix Early Years Nutricia GA1 Anamix Next Nutricia XLys, XTrp Maxamaid – orange Nutricia XLys, XTrp Maxamum – orange Nutricia GlutarAde Essential GA-1 Nutricia GlutarAde Jr GA-1 Nutricia GlutarAde Amino Acid Blend Nutricia Metanx Complex Essential MDS Medications Baclofen L-Carnitine Acetyl Carnitine Vitamins Riboflavin Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets Holocarboxylas Vitamins MCD e Synthetase Biotin Deficiency/ Nano VM (1-3) Solace Multiple Nano VM (4-8) Solace Carboxylase Nano VM (9-18) Solace Deficiency Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets IVA Isovaleric Formulas Acidemia I-Valex-1 Abbott Nutrition I-Valex-2 Abbott Nutrition IVA Anamix Early Years Nutricia Nutricia IVA Anamix Next Nutricia XLeu Maxamaid – orange Nutricia XLeu Maxamum – orange Mead Johnson