MedicaidCoverageMedium impact
\u201cExempt\u201d and \u201cNutritionals\u201d Infant Formula Coverage
Nebraska Medicaid·NE · Pediatrics, OB-GYN, Family Medicine +1 more·Medical Policy
Effective date
Aug 11, 2026
We identified it
Aug 12, 2026
Summary
Nebraska Medicaid has expanded Provider Bulletin 26-05 to clarify coverage for both "exempt" and "nutritionals" infant formula as primary payer. These formulas must be prescribed by a physician, determined medically necessary, and billed using HCPCS codes B4100-B4162 through the DME fee schedule. Beneficiaries must exhaust their monthly Medicaid limit before accessing WIC benefits for these formulas.
Action Required
Immediately: (1) Billing team must update billing system to bill exempt and nutritionals infant formula claims using appropriate HCPCS codes B4100-B4162 from the DME fee schedule, not standard formula codes. (2) Verify all claims include physician prescription and medical necessity documentation before submission. (3) Implement system logic to ensure Medicaid monthly limits are exhausted before any formula is billed; flag claims that violate this sequencing rule. (4) Update encounter forms and provider communication templates to remind ordering physicians that formula requires medical necessity documentation. (5) Reference the approved formula list at https://dhhs.ne.gov/Pages/WIC-Health-Care-Providers.aspx and cross-check all formula requests against this list before billing. (6) Contact Sara Lawless at dhhs.mltcmaternalhealth@nebraska.gov and copy health plan contract managers for clarification on borderline cases. Claims submitted without proper documentation, using incorrect codes, or that fail to respect monthly limit sequencing will be denied.