Sample Letter for
Pepdite^® Junior

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

I am requesting insurance coverage and reimbursement for my patient, ___________________________________, for whom I have prescribed the use of Pepdite® Junior (manufactured by Nutricia North America).

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

Pepdite Junior is a semi-elemental medical food consisting of free amino acids and low molecular weight peptides. It is specifically designed for children over one year of age with gastrointestinal impairment due to multiple food protein intolerance or other medical conditions affecting the gastrointestinal tract. Its unique formulation provides complete nutrition and can be the sole source of nutrition. Pepdite Junior has a semi-elemental composition, which requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.

The FDA classifies Pepdite Junior as a "medical food" which must be used under medical supervision and is not sold over the counter or at the retail level. Therefore, Pepdite Junior 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 Pepdite Junior would make a significant impact on this patient's health.

Sincerely,

________________________________

Pepdite Junior and Reimbursement

Third-party payers such as Medicaid and HMOs will reimburse for the cost of Pepdite Junior. To process claims for Pepdite Junior, 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 Pepdite Junior through the HCFA Healthcare Procedure Coding System (HCPCS), or through the National Drug Code (NDC) system. Most states will use one of these systems to classify Pepdite Junior for reimbursement purposes. Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.

CODING SYSTEMS:

MEDICARE (HCPCS)
Pepdite Junior is classified under code # B4161.

NATIONAL DRUG CODE (NDC)
Pepdite Junior is not a drug but is classified by the FDA as a "medical food", which requires usage under strict medical supervision. The NDC code for the Pepdite Junior is:
49735-011766 Pepdite Junior, unflavored
49735-011780 Pepdite Junior, banana flavored