Billing Information

Liquid Hope

(ADULT FORMULA)

• HCPCS Code: B4149
• Insurance Data Bank & Billing Code:
  57858-0004-11*
• SID#: 201306012001, 20200224001
• Product: 212477 (12 Pack) | 212798 (24 Pack)

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Liquid Hope Peptide

ADULT FORMULA

• HCPCS Code: B4153
• Insurance Data Bank & Billing Code:
  57858-0004-28*
• SID#: 20130612001
• Product: 212501 (12 Pack) | 212504 (24 Pack)

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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: 212500 (12 Pack) | 212503 (24 Pack)

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Liquid Hope Peptide Berry Medley

ADULT FORMULA

• HCPCS Code: B4153
• Insurance Data Bank & Billing Code:
  57858-0004-50
• SID#: 2022-0809/002
• Product: 212509 (12 Pack) | 212505 (24 Pack)

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Nourish

PEDIATRIC FORMULA

• HCPCS Code: B4149
• Insurance Data Bank & Billing Code:
  57858-0004-12*
• SID#: 20161118001, 20200224001
• Product: 212510 (12 Pack) | 212797 (24 Pack)

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Nourish Peptide

PEDIATRIC FORMULA

• HCPCS Code: B4161
• Insurance Data Bank & Billing Code:
  57858-0004-27*
• SID#: 20161118001
• Product: 212511 (12 Pack) | 212796 (24 Pack)

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Nourish Peptide Berry Medley

PEDIATRIC FORMULA

• HCPCS Code: B4161
• Insurance Data Bank & Billing Code:
  57858-0004-44
• SID#: 20161118001
• Product: 212512 (12 Pack) | 212506 (24 Pack)

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Keto

Ketogenic Formula

• HCPCS Code: B4153, B4161
• Insurance Data Bank & Billing Code:
  57858-0004-24*
• SID#: 20200131002
• Product: 212756 (12 Pack) | 212824 (24 Pack)

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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.

Liquid Hope

HCPCS Code: B4149

Nourish

HCPCS Code: B4149

Liquid Hope
Peptide & Peptide Berry Medley & High Protein

HCPCS Code: B4153

Nourish
Peptide & Berry Medley

HCPCS Code: B4161

Keto
Peptide

HCPCS Code: B4161 & B4153

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