ALLOWABLE BENEFITS LIST
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1 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, per month for dietary supplements $ 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 Hominex-1 Hominex-2 HCY 1 HCY 2 HOM 2 HCU Anamix Early Years HCU Anamix Next XMet Maxamaid orange flavor XMet Maxamum orange flavor HCU Gel HCU Express PFD 1 PFD 2 Milupa HCU Cooler 15 NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 1
2 Cystine AA Supplement Cystadane Powder (Betaine) AnovoRx MSUD Maple Syrup Urine Disease Cyanocobalamin (vitamin B12) Pyridoxine Tablets (50 mg) MSUD Analog New: MSUD Anamix Early Years MSUD Maxamaid orange flavor MSUD Maxamum orange flavor MSUD 2 BCAD 1 BCAD 2 Ketonex-1 Ketonex-2 Complex MSUD Drink Mix Vanilla Complex MSUD AA Bar Chocolate Complex MSUD AA Blend MSUD Gel MSUD Express MSUD Express Cooler MSUD Amino Acid Mix PFD 1 PFD 2 Abbot Nutrition L-Valine AA L-Isoleucine AA Isoleucine50 Isoleucine1000 Valine50 Valine1000 Thiamin NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 2
3 PKU Phenylketonuria Phenex-1 Phenex-2 Phenex-2 vanilla Prophree PhenylAde Drink Mix chocolate PhenylAde 40 Drink Mix unflavored PhenylAde 40 Drink Mix citrus PhenylAde 60 Drink Mix Vanilla PhenylAde Essential Drink Mix All flavors PhenylAde Amino Acid Blendpouches PhenylAde MTE Amino Acid Blend-can PhenylAde Amino Acid Bar- All flavors PhenylAde PheBLOC Tablet PhenylAde GMP Phenyl-Free 1 Phenyl-Free 2 Phenyl-Free 2HP PKU 2 PKU 3 PreKUnil Neophe PheBloc XPhe Maxamaid All flavors Periflex LQ- All flavors New: PKU Periflex Early Years Phlexy-10 Drink Mix All flavors Phlexy-10 Tablets Phlexy-10 Capsules Phlexy-10 Lophlex Drink Mix All flavors PKU Easy Liquid PKU Easy Microtabs PKU Gel PKU Express PKU Express Cooler PKU Cooler 20 Periflex Advance Periflex Jr Plus- All Flavors Periflex LQ- All Flavors Milupa Milupa Prekulab Prekulab NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 3
4 Glytactin Bettermilk 15 Glytactin Build 10 Glytactin Swirl Glytactin RTD 10 Glytactin RTD 15 Glytactin Complete 10 Glytactin Complete 15 Glytactin Restore 10 Glytactin Restore Lite 10 Camino Pro 15 Tyrosine1000 L-Tyrosine TYR I TYR II TYR III Tyrosinemia Type I Type II Type III MVW Complete Formulation + D3000 MVW Complete Formulation + D5000 Tyrex-1 Tyrex-2 New: TYR Anamix Early Years TYR Anamix Next XPhe, XTyr Maxamaid TYR 2 TYROS 1 TYROS 2 Prophree TYR Gel TYR Express Tylactin RTD 15 Tylactin Restore 10 MVW Nutritionals MVW Nutritionals Milupa Nitisinone (Orfadin) Tablets NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 4
5 ARG CIT II Argininemia Citrullinemia Type II Vitamin D Solcarb Polycal UCD Trio EAA Supplement Nutrition Arginine 500 Arginine 2000 Citrulline 200 Citrulline 1000 Leucine100 Valine50 Valine1000 MET Hypermethioninemia Benign Vitamin B12 Tablets HPhe Hyperphenylalaninemia BioptReg Biopterin Reg BioptBS Biopterin BS UREA CYCLE DISORDERS DISORDER ITEMS MANUFACTURER CIT Citrullinemia Cyclinex-1 NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 5
6 ASA Argininosuccinic Acidemia Cyclinex-2 WND 1 WND 2 PFD 1 PFD 2 UCD 2 Essential Amino Acid Mix Milupa L-Arginine L-Leucine L-Isoleucine L-Valine Citrulline Citrulline 200 Citrulline 1000 Arginine 2000 Arginine 500 Isoleucine 50 Isoleucine 1000 Leucine 100 Valine 50 Valine 1000 Buphenyl Powder Buphenyl Tablets Sodium Benzoate Powder (Spectrum) Na Benzoate Powder Na Benzoate 10% Solution (100 mg/ml) (100 mg/ml) Omeprazole NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 6
7 ORGANIC ACIDEMIAS DISORDERS DISORDER ITEMS MANUFACTURER BKT Beta- Ketothiolase MSUD Anamix Early Years MSUD Anamix Next MSUD Maxamaid orange MSUD Maxamum orange MSUD 2 BCAD 1 BCAD 2 Ketonex-1 Ketonex-2 Complex Junior MSD w/ DHA - ARA Complex MSD Drink Mix Complex MSD Amino Acid Bar Complex MSD Amino Acid Blend MSUD Gel MSUD Express PFD 1 PFD 2 Abbott L-isoleucine L-valine Isoleucine50 Isoleucine1000 Valine50 Valine1000 GA1 Glutaric Aciduria, Type I Glutarex-1 Glutarex-2 GA GA Gel GA Express 15 PFD 1 PFD 2 NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 7
8 GA-1 Anamix Early Years GA1 Anamix Next XLys, XTrp Maxamaid orange XLys, XTrp Maxamum orange GlutarAde Essential GA-1 GlutarAde Jr GA-1 GlutarAde Amino Acid Blend Complex Essential MDS Baclofen MCD IVA Holocarboxylas e Synthetase / Multiple Carboxylase Isovaleric Acidemia Riboflavin Biotin I-Valex-1 I-Valex-2 IVA Anamix Early Years IVA Anamix Next XLeu Maxamaid orange XLeu Maxamum orange LMD PFD 1 PFD 2 Glycine 500 NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 8
9 (100mg/ml) MMA Cbl AB Methylmalonic Acidemia Cobalamin A B/ Homocystinuria Propimex-1 Propimex-2 OA 1 OA 2 MMA/PA Anamix Early Years MMA/PA Anamix Next XMTVI Maxamaid orange XMTVI Maxamum orange Milupa OS 2 MMA/PA Gel MMA/PA Express PFD 1 PFD 2 (100 mg/ml) Hydroxocobalamin IM (1 mg/ml) Cystadane (Betaine) MMA (MUT) Methylmalonic Acidemia (Mutase ) - MUT Cyanocobalamin Solcarb Polycal MMA/PA Anamix Early Years NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 9
10 MMA/PA Anamix Next XMTVI Maxamaid XMTVI Maxamum PA (PROP) Propionic Acidemia Cyanocobalamin Propimex-1 Propimex-2 OA 1 OA 2 MMA/PA Anamix Early Years MMA/PA Anamix Next XMTVI Maxamaid XMTVI Maxamum MMA/PA Gel MMA/PA Express 15 MMA/PA Cooler 15 PFD 1 PFD 2 SOS 20 Nestle L- Leucine L- Isoleucine L- Valine Isoleucine50 Isoleucine1000 Leucine100 Valine50 Valine1000 NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 10
11 HMG 3-MCC Hydroxymethyl -glutaric Aciduria 3-Methylcro tonyl-coa Carboxylase Biotin Cbl C Cbl C Solcarb Polycal MMA/PA Anamix Early Years MMA/PA Anamix Next XMTVI Maxamaid XMTVI Maxamum MMA/PA Gel MMA/PA Express 15 MMA/PA Cooler 15 Cystadane Powder (Betaine) Cbl D Cbl D Folinic Acid Hydroxocobalamin, liquid injection MAL Malonic Acidemia NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 11
12 IBG 2MBG 3MGA 2M3HBA Isobutyrylglycinuria 2MBG 3MGA 2M3HBA FATTY ACID OXIDATION DISORDERS DISORDER ITEMS MANUFACTURER CUD Carnitine Uptake Defect MCAD Medium-chain acyl-coa dehydrogenase LCHAD Long-Chain Hydroxy- Acyl- CoA Dehydrogenase Vitamin MCT Procal Lipistart Liquigen MCT MCT Oil Medication NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 12
13 TFP Trifunctional Protein VLCAD Very-Long-Chain Acyl-CoA Dehydrogenase MCT Procal Lipistart Liquigen MCT MCT Oil SCAD HADH M/SCHAD Short-Chain acyl-coa dehydrogenase Medium-Short- ChainL-3- hydroxyacl-coa dehydrogenase deficiency MCT Procal MCT Oil Enfaport Lipistart Liquigen MCT Monogen Portagen Nuitricia GA II Glutaric Acidemia Type II Glycine500 MCKAT Medium-chain ketoacyl-coa NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 13
14 thiolase deficiency 2,4 Dienoyl-CoA reductase CPT I CPTII CACT DE RED Carnitine palmitoyltransferase type I deficiency Carnitine palmitoyltransfer ase type II deficiency Carnitine acylcarnitine translocase deficiency 2,4 Dienoyl-CoA reductase deficiency ENDOCRINE DISORDERS DISORDER MEDICATIONS MANUFACTURER CH Hypothyroidism Synthroid Levothroid Levoxyl Abbott Laboratories Forest Pharmaceuticals Jones Pharma CAH Congenital Adrenal Hyperplasia NaCl (salt) Cortisone Florinef HEMOGLOBIN DISORDERS DISORDER Sickling Hemoglobinopathies TREATMENT Penicillin Oxygen IV Fluids Antibiotics Analgesics Hydroxyurea Desferrin OTHER DISORDERS DISORDER MEDICATIONS MANUFACTURER BIOT Biotinidase Biotin GALT Galactosemia Neocate Infant DHA/ARA NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 14
15 Enfamil ProSobee Lipil Similac Isomil Advance Good Start Supreme Soy Parent s Choice Soy Infant Formula with a Blend of Lipids Nestle PBM Nutritionals Calcium Vitamin D CYSTIC FIBROSIS DISORDER ITEMS PediaSure PediaSure Enteral Ensure Ensure Plus Scandishakes Peptamen Jr Peptamen Jr 1.5 TwoCal HN Neocate Neocate Junior EleCare Nutren 1.5 Nutren 2.0 Nutren Jr Carnation Instant Breakfast Plus Carnation Instant Breakfast Very High Calorie Boost Kids Essentials Boost Kids Essentials 1.5 Boost Boost Chocolate Boost Plus Enlive Enlive Apple Benecalorie Scandical Zantac Albuterol Creon Nexium Ultrase Ultrase MT Zenpep Pancrecarb MANUFACTURER Axcan Scandipharm, Inc AstraZeneca Pharmaceuticals, LP Sepracor, Inc Eurand NV Wyeth Pharmaceuticals Axcan Scandipharm, Inc Axcan Scandipharm, Inc Solvay Pharmaceuticals Digestive Care, Inc. NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 15
16 Pancreaze Pancreaze MT Pancrecarb MS Viokase tablets Ursodiol Actigall Prevacid Prilosec Protonix Tobramycin (TOB 1) Pulmozyme Azithromycin Xopenex Atrovent Spiriva Brovana Pulmicort Pro Air Ventolin Flovent Advair Symbicort Duocal Benecalorie Scandical Hypertonic Saline (Sodium Chloride) Lantus Novolog Humalog NPH Vitamin D Vitamin D2 Vitamin D3 Vitamin E Vitamin K (Mephyton) Cholecalciferol AquADEK (liquid or chewable tablets) Source CF Vitamax Dekas Plus Calcium Beta Carotene Ortho-McNeil Pharmaceutical, Inc Ortho-McNeil Pharmaceutical, Inc Digestive Care, Inc. Axcan Scandipharm, Inc Teva Pharmaceuticals USA Novartis Pharmaceuticals TAP Pharmaceuticals Inc GlaxoSmithKline AstraZeneca Pharmaceuticals, LP Wyeth Genentech Sunovion GlaxoSmithKline Boehringer-Ingelheim Pharmaceuticals Boehringer Ingelheim Pharmaceuticals Sepracor, Inc AstraZeneca Teva Specialty Pharmaceuticals GlaxoSmithKline GlaxoSmithKline GlaxoSmithKline AstraZeneca Canada Inc. Cardinal Health Pharmaceuticals Aventis Pharmaceuticals, Inc Novo Nordisk Pharmaceuticals Inc Eli Lily and Company Aton Pharma Inc Cardinal Health Pharmaceuticals Natures Products Axcan Scandipharm, Inc NBS Benefits Contractor Procedures Manual Supplement Medical Management Services July 2018 Page 16
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