Att N-IDOH Metabolic Formulary - COPY .xlsx

This is a Metabolic Formulary document for the Idaho Department of Health and Welfare (IDOH) listing approved medical nutrition products for inherited metabolic disorders. The formulary includes specialized amino acid-based powders, ready-to-drink beverages, and supplemental products from major manufacturers including Abbott, Ajinomoto Cambrooke, Mead Johnson, Nutricia, and Vitaflo. Products are organized by manufacturer and clinical condition, including treatments for phenylketonuria (PKU), maple syrup urine disease (MSUD), tyrosinemia, homocystinuria, urea cycle disorders, glutaric aciduria, isovaleric acidosis, and other rare metabolic conditions. The formulary provides comprehensive product specifications including item numbers, unit sizes, quantities per case, and applicable HCPCS and NDC codes for each product.

Pricing in the formulary is presented on a per-unit and per-case basis, with prices effective September 1, 2026, and no price changes indicated for metabolic products from the previous contract period. Products are categorized by condition and manufacturer, enabling healthcare providers to identify covered medical nutrition products for eligible patients with diagnosed inherited metabolic disorders. The document serves as a reference tool for prescribers, patients, and insurance administrators to ensure appropriate product selection and pricing consistency across the state. Multiple product variations are listed for most conditions, offering options in different flavors, formulations, and delivery formats to accommodate patient preferences and clinical requirements.