Blue Cross Blue Shield Oklahoma prior authorization B4159

Blue Cross Blue Shield Oklahoma prior authorization for B4159: Enteral Formula For Pediatrics Nutritionally Complete Soy Based With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit

Code: B4159
Description: Enteral Formula For Pediatrics Nutritionally Complete Soy Based With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit
Source: 2026 Commercial Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 200 Original policy

Blue Cross Blue Shield Oklahoma prior authorization

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