Billing Information

Liquid Hope

(ADULT FORMULA)

HCPCS Code: B4149
Insurance Data Bank & Billing Code:
57858-0004-11*
SID#: 201306012001, 20200224001
Product: LHWS124

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Liquid Hope Peptide

ADULT FORMULA

HCPCS Code: B4153
Insurance Data Bank & Billing Code:
57858-0004-28*
SID#: 20130612001
Product: LHPWS124

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Liquid Hope Peptide High Protein

ADULT FORMULA

HCPCS Code: B4153
Insurance Data Bank & Billing Code:
57858-0004-32
SID#: 20161118001
Product: LHHPWS124

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Nourish

PEDIATRIC FORMULA

HCPCS Code: B4149
Insurance Data Bank & Billing Code:
57858-0004-12*
SID#: 20161118001, 20200224001
Product: NWS124

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Nourish Peptide

PEDIATRIC FORMULA

HCPCS Code: B4161
Insurance Data Bank & Billing Code:
57858-0004-27*
SID#: 20161118001
Product: NOUPWS124

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Nourish Peptide Berry Medley

PEDIATRIC FORMULA

HCPCS Code: B4161
Insurance Data Bank & Billing Code:
57858-0004-44
SID#: 20161118001
Product: NOUPBWS124

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Keto

Ketogenic Formula

HCPCS Code: B4153, B4161
Insurance Data Bank & Billing Code:
57858-0004-24*
SID#: 20200131002
Product: KEWS124

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*Medicare, Medicaid and health insurers may ask you to provide a National Drug Code / NDC number for insurance claims, billing or reimbursement purposes. Because our products are whole foods and do not constitute “drugs”, we have an Insurance Data Bank and Billing Code that you should use when asked for an NDC number for our products.

We Can Help

At Functional Formularies we have patient advocates available to help assist you in gaining insurance
coverage for our products. Please fill out the form or call us at 937-433-4673
and we will set up an appointment for you with a patient advocate.