Sample Letter for
Neocate^® Infant

DATE:
TO: (Insurance Company)
FROM:
SUBJECT:

I am requesting insurance coverage and reimbursement for my patient, Patient's name, for whom I have prescribed the use of Neocate^® Infant (manufactured by Nutricia North America).

I feel that Neocate is a medical necessity and will provide the proper dietary management for this patient, who has been diagnosed with Diagnosis. Without the use of Neocate, my patient may experience complications of the condition, which may result in hospitalization and/or costly parenteral nutrition.

Neocate is specifically designed to meet the nutritional needs of infants with severe cow milk protein allergy or multiple food protein allergies who are unable to ingest a normal diet or other hypoallergenic products. Its unique formulation (100% free amino acids, milk free, gluten free, and soy protein free) provides complete nutrition and can be the sole source of nutrition for the first year of life. Neocate's elemental composition requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.

Clinical trials have shown that the use of Neocate ensures a normal growth pattern for infants who would otherwise experience failure to thrive. The FDA classifies Neocate as an "Exempt Infant Formula" which must be used under medical supervision and is not sold over the counter or at the retail level. Therefore, Neocate is only available through a pharmacy or through Nutricia North America directly (with medical consent). For additional reimbursement codes and information, please see the reverse side.

Your approval of this request for insurance coverage and reimbursement of the Neocate Infant would make a significant impact on this patient's health.

Sincerely,

__________________________________

Third-party payers such as Medicaid and HMOs will reimburse for the cost of Neocate. To process claims for Neocate, payers require a reimbursement code to identify the nutritional product/category. Some states have enacted legislation, which require that reimbursement be provided based on the patient's diagnosis.

Claims are usually processed in one of two ways. A code is used to identify Neocate through the HCFA Common Procedure Coding System (HCPCS), or through the National Drug Code (NDC) system. Most states will use one of these systems to classify Neocate for reimbursement purposes. Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.

CODING SYSTEMS:

MEDICARE (HCPCS)
Neocate Infant is classified under Category III (hydrolyzed protein/amino acids), Code # B4161.

NATIONAL DRUG CODE (NDC)
Neocate Infant is not a drug but is classified by the FDA as an "Exempt Infant Formula", which requires usage under strict medical supervision. The NDC code for the Neocate Infant is 49735-0108-04.