Age Product Packaging Calories per NDC HCPCS can Format Code Code 0-12 6-400 gm 1976 B4161 Alfamino™ months Infant cannisters 1-13 years 6-400 gm 1840 B4161 Alfamino™ Junior cannisters Sincerely, Signature: Name: Title: Attachments: If relevant, include pertinent information supporting evidence of medical necessity and product information. Please refer to for product information.
Age Product Packaging Calories per can NDC Format Code HCPCS Code 0-12 months Alfamino™ Infant 6-400 gm cannisters 1976 B4161 1-13 years Alfamino™ Junior 6-400 gm cannisters 1840 B4161 Sincerely, Signature: Name: Title: Attachments: If relevant, include pertinent information supporting evidence of medical necessity and product information. Please refer to for product information.