HIGH FAT FORMULA WITH VITAMINS, MINERALS AND TRACE ELEMENTS AND LOW IN PROTEIN AND CARBOHYDRATE
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (4:1 ratio long chain fat to carbohydrate plus protein) oral liquid,
32 x 200 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 5 | Max qty units: 5 | # of repeats: 5 | DPMQ: $940.33 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoCal 4:1 LQ | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (4:1 ratio medium chain fat to carbohydrate plus protein) oral liquid,
30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 6 | Max qty units: 6 | # of repeats: 5 | DPMQ: $1,597.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoVie 4:1 | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (3:1 ratio medium chain fat to carbohydrate plus protein) oral liquid,
30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 6 | Max qty units: 6 | # of repeats: 5 | DPMQ: $1,087.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoVie 3:1 | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate oral semi-solid, 36 x 100 g tubs
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $795.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| K.Yo | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (4:1 ratio medium chain fat to carbohydrate plus protein) oral liquid,
30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 6 | Max qty units: 6 | # of repeats: 5 | DPMQ: $1,809.84 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoVie Peptide 4:1 | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (3:1 ratio long chain fat to carbohydrate plus protein) powder for oral
liquid, 300 g
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 24 | Max qty units: 24 | # of repeats: 5 | DPMQ: $840.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoCal 3:1 | |||||
high fat formula with vitamins, minerals and trace elements and low in protein and
carbohydrate (4:1 ratio long chain fat to carbohydate plus protein) powder for oral
liquid, 300 g
Body System:
Manner of administration:Oral
Restriction
Indication: Ketogenic diet
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 24 | Max qty units: 24 | # of repeats: 5 | DPMQ: $878.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| KetoCal 4:1 | |||||