Chapter Four Food Package – Formula - Arizona · PDF fileChapter Four Food Package ... 4 -6 Medical ... enteral nutrition support for individuals with a qualifying condition,

Chapter Four Food Package – Formula

Chapter Four – Food Package – Formula

Arizona WIC Program Original: March 1997 Policy and Procedure Manual 4-2 Revision: July 2017

Contents Chapter Four Food Package – Formula ................................................................................................ 4-2

Section A Formula Terminology ............................................................................................................. 4-4

Contract Formula .......................................................................................................................... 4-4

Standard Contract Formulas ......................................................................................................... 4-4

Nineteen kcal/oz Contract Formulas ............................................................................................ 4-4

Non-Contract Formula .................................................................................................................. 4-4

Special Formula ............................................................................................................................. 4-5

WIC-Eligible Nutritionals ............................................................................................................... 4-5

Conditionally Special Formula....................................................................................................... 4-5

Section B Medical Documentation ........................................................................................................ 4-6

Medical Documentation is Required for: ...................................................................................... 4-6

Acceptable Forms of Written Medical Documentation ................................................................ 4-6

Prescriptive Authority ................................................................................................................... 4-6

Written Medical Documentation Requirements .......................................................................... 4-7

Verbal Medical Documentation .................................................................................................... 4-7

Verbal Medical Documentation Requirements ............................................................................ 4-7

Partially Complete Medical Documentation ................................................................................. 4-8

Invalid Medical Documentation/No Medical Documentation Exists............................................ 4-8

Section C Formula Approval/Issuance ................................................................................................. 4-10

Formula for Women and Children with Medical Documentation .............................................. 4-10

Supplemental Food Tailoring for Infants, Children, and Women with Medical Documentation ... 4-11

Absence of Local Agency WIC Clinic RD/State-Approved Nutritionist ....................................... 4-11

Approval/Issuance of Standard Contract Formulas .................................................................... 4-11

Approval/Issuance of Routine 19 kcal/oz Contract Formulas .................................................... 4-11

Approval/Issuance of Non-Contract Formulas ........................................................................... 4-12

Approval/Issuance of Special Formulas ...................................................................................... 4-13

Approval/Issuance of WIC-Eligible Nutritionals .......................................................................... 4-15

Approval/Issuance of Conditionally Special Formulas ................................................................ 4-15

Formula Changes ........................................................................................................................ 4-16

Section D Issuance of Formula for the Premature Infant .................................................................... 4-18

Section E Issuance of Powder/Concentrate/Ready-to-Feed Formula ................................................. 4-19

Section F Issuance of Liquid Formula for Premature, Low Birth Weight, and Immunocompromised Infants .................................................................................................................................................. 4-20



Section G Formula Calorie Adjustments .............................................................................................. 4-21

Section H Tailoring Formula and Food Packages ................................................................................. 4-22

Formula Tailoring ........................................................................................................................ 4-22

Section I ................................................................................................................................................ 4-23

Appendix A: Arizona WIC Program’s Formula and Food Request Form .............................................. 4-24

Appendix B: Request for New Food Package Form ............................................................................. 4-26

Appendix C: AHCCCS Referral Letter and Form ................................................................................... 4-29

Appendix D: Formula Tailoring Chart ................................................................................................... 4-32

Appendix E: Formula Calorie Adjustment Charts................................................................................. 4-34

Appendix F: Formula Color Chart ......................................................................................................... 4-38

Appendix G: Formula Descriptions ...................................................................................................... 4-40

Appendix H: Arizona WIC Program’s Formulary .................................................................................. 4-46

Index................................................................................................................................................... 4-172



Section A Formula Terminology

Contract Formula Contract formulas are formulas for which the Arizona WIC program has contracted with the formula manufacturer to receive a rebate when purchased by a WIC participant. Standard Contract Formulas Standard contract formulas (20 kcal/oz) are routine contract formulas provided by the Arizona WIC Program that do not require medical documentation. The Arizona WIC Program provides the two following standard contract formulas:

• Similac Advance • Gerber Good Start Soy

Nineteen kcal/oz Contract Formulas Nineteen kcal/oz contract formulas are a type of contract formula that require medical documentation since they do not meet the USDA’s definition of infant formula due to lower kcal/oz concentration. The Arizona WIC Program provides the three following 19 kcal/oz contract formulas:

• Similac Sensitive • Similac For Spit-Up • Similac Total Comfort

Non-Contract Formula Non-contract formulas are formulas that are nutritionally equivalent to contract formulas, but for which the Arizona WIC Program does not receive a manufacturer’s rebate. Cost containment measures significantly restrict the approval/issuance of these formulas. Approval/issuance of these formulas requires medical documentation and they are reserved only for specific situations. The Arizona WIC Program’s non-contract formulas include, but are not limited to:

• Enfamil Infant • Gerber Good Start Gentle • Similac Soy Isomil • Enfamil Prosobee • Enfamil Gentlease • Gerber Good Start Soothe • Enfamil Reguline • Enfamil AR



Special Formula Special formulas are formulas for which the Arizona WIC program does not receive a manufacturer’s rebate, and are intended for use by participants who have inborn errors of metabolism, premature or low birth weight infants, or participants who otherwise have a documented medical or dietary condition. The Arizona WIC Program’s special formulas include, but are not limited to:

• Similac Alimentum • Nutramigen with Enflora LGG • Gerber Extensive HA • Similac Neosure • Enfamil Enfacare • Elecare for Infants • Pregestimil • PurAmino • Alfamino Infant • Neocate Infant

For a list of Arizona WIC Program’s special formulas, reference the Arizona WIC Program’s Formulary. WIC-Eligible Nutritionals WIC-eligible nutritionals are a subcategory of special formulas that are specifically formulated to provide enteral nutrition support for individuals with a qualifying condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible nutritionals shall serve the purpose of a food, meal, or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food, drug, flavoring, or enzyme. The Arizona WIC Program’s WIC-eligible nutritionals include, but are not limited to:

• Elecare Junior • Alfamino Junior • Neocate Junior • Carnation Breakfast Essentials • Ensure • Glucerna Meal Bars • Glucerna Shake

For a list of Arizona WIC Program’s WIC-eligible nutritionals, reference the Arizona WIC Program’s Formulary. Conditionally Special Formula Conditionally special formulas are a subcategory of WIC-eligible nutritionals that must also meet additional Arizona WIC conditions for approval. The Arizona WIC Program provides the three following conditionally special formulas:

• Pediasure • Pediasure with Fiber • Boost Kid Essentials



Section B Medical Documentation

Medical Documentation is Required for:

• 19 kcal/oz contract formulas • Non-contract formulas • Special formulas • Conditionally special formulas • WIC-eligible nutritionals • Any formula prescribed to a child or adult • Any supplemental foods issued to participants receiving FFPIII, unless deferred to RD or State-

Approved Nutritionist by prescriptive authority • Standard contract formulas only when:

o Requested for a child/adult o Approved, current medical documentation for another formula exists in HANDS

• For infants 6-11 months, higher amounts of formula and no infant foods • The following milk alternatives:

o Skim/1% milk for children one year of age o Whole milk for participants two years of age and older

Note: For more information regarding the issuance of milk alternatives, review Chapter 3, Section N. Acceptable Forms of Written Medical Documentation

• Formula and Food Request • Doctor’s Prescription Form • Doctor’s Letterhead with Prescription

Prescriptive Authority Domestic and international medical documentation shall only be accepted if completed by medical professionals with one or more of the following credentials, which signify them as prescriptive authorities:

• Medical Doctor (M.D.) • Doctor of Osteopathy (D.O.) • Naturopathic Physician (N.M.D.) • Physician Assistant (P.A.) • Nurse Practitioner (N.P)

Examples of providers without prescriptive authority in the Arizona WIC Program include, but are not limited to:

• C.E.D. Prof. – Professional ID Card (Mexico) • C.E.D. Especialista (Mexico) • D.C. - Chiropractors • M.A. - Medical Assistant

http://azdhs.gov/documents/prevention/azwic/manuals/policy/chapter-03-foodpackage-general.pdf



Written Medical Documentation Requirements Any written form of medical documentation shall include the following as found on the Formula and Food Request: • Patient (WIC Participant) name* • Patient (WIC Participant) date of birth* • Date that medical documentation was completed • Name of formula • Form of formula (e.g., ready-to-feed, powder, or concentrate) • Amount of formula requested per day • Diagnosis or explanation of need • Length of time for food and/or formula request • Allowable supplemental foods and prescribed amounts, or acknowledgement that the prescriptive

authority has deferred the authorization of supplemental foods to the agency’s Registered Dietitian or State-Approved Nutritionist

• Signature of the prescriptive authority requesting the formula (signature stamps and facsimiles are acceptable)

• Contact information for the prescriptive authority requesting the formula • Indication of credentials signifying prescriptive authority

Note: * May be completed by authorized representative even after signed by prescriptive authority. Verbal Medical Documentation Verbal medical documentation shall be obtained following the steps that apply when Invalid Medical Documentation/No Medical Documentation Exists, and is acceptable when received from a prescriptive authority. Verbal medical documentation shall be recorded in the participant’s Notes with all the requirements listed below, and written medical documentation shall be requested to be received from the prescriptive authority within 30 days. Verbal Medical Documentation Requirements • Patient (WIC Participant) name • Patient (WIC Participant) date of birth • Date that medical documentation was completed • Name of formula • Form of formula (e.g., ready-to-feed, powder, or concentrate) • Amount of formula requested per day • Diagnosis or explanation of need • Length of time for food and/or formula request • Allowable supplemental foods and prescribed amounts, or acknowledgement that the prescriptive

authority has deferred the authorization of supplemental foods to the agency’s Registered Dietitian or State-Approved Nutritionist

• Name of the prescriptive authority requesting formula • Contact information for the prescriptive authority requesting the formula • Indication of credentials signifying prescriptive authority



Partially Complete Medical Documentation Medical documentation is considered partially complete if it is missing one or more of the written medical documentation requirements, but contains, at a minimum:

• Name of formula requested • Diagnosis • Prescriptive authority’s signature

If partially complete medical documentation is received, RDs, RNs, and State-Approved Nutritionists shall take the following steps.

1) Attempt to contact the prescriptive authority that completed the medical documentation to obtain the missing required information verbally. If successful, scan the medical documentation into HANDS and issue the requested formula for up to three months. Document in HANDS the missing information obtained in addition to the name of the person that verbally provided the information. Also request that the prescriptive authority provide the complete written medical documentation within 30 days (e.g., via fax).

1a) If the complete written medical documentation has not been received after the original

issuance period (up to three months), the Local Agency shall not issue additional formula without first contacting the State Food Package Specialist or a WIC Nutrition Consultant for consent to do so.

2) If the prescriptive authority cannot be reached, scan the partially complete medical

documentation into HANDS and issue one month of the requested formula. Continue to take steps to obtain complete written medical documentation:

• Continue attempts to contact the prescriptive authority and/or • Ask the participant to return with complete written medical documentation

2a) If complete written medical documentation has not been received after the original one-

month issuance period, the Local Agency shall not issue additional formula without first contacting the State Food Package Specialist or a State WIC Nutrition Consultant for consent to do so.

Invalid Medical Documentation/No Medical Documentation Exists Written medical documentation is considered invalid if it is missing one or more of the following requirements:

• Name of formula requested • Diagnosis • Prescriptive authority’s signature



Additionally, complete written medical documentation may be deemed invalid by RDs, RNs, and State-Approved Nutritionists for reasons including, but not limited to:

• The type of formula requested is contraindicated for the participant • The diagnosis doesn’t correspond to the type of formula requested • The medical documentation is received after the “Length of time for Food and/or Formula

Request” has expired (e.g., medical documentation was completed in February and the formula was requested for three months, but the medical documentation wasn’t received until June.)

If the RD/RN /State-Approved Nutritionist has received invalid medical documentation or no medical documentation exists, they shall take the following steps:

1) Attempt to contact the prescriptive authority who provided the invalid medical documentation, or a prescriptive authority indicated by the participant in cases where no medical documentation exists, to obtain verbal medical documentation. If successful, issue one month of the requested alternative formula. Document the required information in HANDS in addition to the name of the person that verbally provided the information. Also request that the prescriptive authority provide complete medical documentation within 30 days (e.g., via fax). Invalid medical documentation is not required to be scanned into HANDS.

2) If the prescriptive authority cannot be reached, issue one month of the requested formula (when appropriate), but if the formula requested is contraindicated, or no formula name has been requested, consider the same factors that apply when changing formulas to select and issue one month of an indicated formula. Continue taking steps to obtain complete written medical documentation: a. Continue attempts to contact the prescriptive authority and/or b. Ask the participant to return with complete written medical documentation

2a) If complete written medical documentation has not been received after the original one-

month issuance period, the Local Agency shall not issue additional formula without first contacting the State Food Package Specialist or a WIC Nutrition Consultant for consent to do so.



Section C Formula Approval/Issuance

All medical documentation for requested formulas/foods shall be evaluated and approved by Local Agency designated Registered Dietitians (RDs)/State-Approved Nutritionists or Registered Nurses (RNs). RDs/State-Approved Nutritionists shall meet the requirements as defined in Chapter 7. Registered Nurses shall have a four-year degree and specialize in infant and child health. Registered Nurses shall also have been trained in HANDS and approved by the Local Agency’s State Nutrition Consultant. In order for medical documentation to be approved, it must contain all medical documentation requirements. WIC staff shall not write on written medical documentation after it has been signed by a prescriptive authority including, but not limited to, the completion of required information. All contract formulas appropriate for a condition shall be considered before approval/issuance of special, or non-contract formulas. The RD/RN/State-Approved Nutritionist must also critically evaluate the written medical documentation before approval. For example:

• Is the written medical documentation complete? o If not, would it be considered partially complete or invalid?

• If a special formula or non-contract formula has been requested, is there a contract formula for the medical concern that would be an appropriate alternative?

• Is the medical documentation current (received within the length of time requested)? • Is the type of formula requested appropriate for the medical condition and age of the

participant? (e.g., a WIC-eligible nutritional that is designed for use at one year of age or older is requested for an infant, this would not be appropriate.)

• Does the diagnosis or explanation of need correspond with the type of formula requested? (e.g., Similac PM 60/40 requested for a diagnosis of “formula intolerance” would not be appropriate)

If the RD, RN, or State-Approved Nutritionist has received complete, accurate written medical documentation, the medical documentation shall be scanned into the HANDS Food Package screen, and the requested formula/foods shall be located, approved, and issued in HANDS. If a food package cannot be located in HANDS that meets the client’s needs, the RD, RN, or State-Approved Nutritionist shall submit information required from the Request for New Food Package in HANDS form to the State Food Package Specialist. Formula for Women and Children with Medical Documentation Women and children with special dietary needs may receive formula if a physician determines that the participant has a medical condition which precludes or restricts the use of conventional foods and necessitates the use of formula. New medical documentation for these women and children is required for all standard contract formulas, 19 kcal/oz contract formulas, non-contract formulas, special formulas, WIC-eligible nutritionals, conditionally special formulas, and supplemental foods requiring medical documentation at least yearly.

http://azdhs.gov/documents/prevention/azwic/manuals/policy/chapter-07-participant-staff-education.pdf



Supplemental Food Tailoring for Infants, Children, and Women with Medical Documentation When medical documentation has been received, only RDs, RNs, or State-Approved Nutritionists shall tailor WIC supplemental foods for infants and children. Supplemental food tailoring shall correspond to the indications selected by the prescriptive authority on the medical documentation provided. If the prescriptive authority has deferred to the RD/Nutritionist for the selection of appropriate foods to issue to the participant, the RD, RN, or State-Approved Nutritionist shall complete a nutritional assessment to determine foods that are appropriate with consideration to the participant’s health condition(s). In the event that the RD, RN, or State-Approved Nutritionist believes that the supplemental foods requested by the prescriptive authority are contraindicated for the participant, they shall coordinate with the prescriptive authority to determine which food items the participant can safely consume. Local Agency RDs, RNs, or State-Approved Nutritionists shall coordinate with the participant’s health care provider whenever they believe that the supplemental foods issued to the participant should change. Absence of Local Agency WIC Clinic RD/State-Approved Nutritionist In the absence of an RD/RN/State-Approved Nutritionist from the Local Agency WIC clinic, the Local Agency staff member shall take the following steps upon receipt of medical documentation:

1) Attempt to contact an RD/RN/State-Approved Nutritionist at another WIC clinic within the local agency for approval.

2) If an RD/RN/State-Approved Nutritionist at another WIC clinic within the local agency cannot be reached, attempt to contact a WIC Nutrition Consultant at the AZ WIC State Office for approval.

3) Only in the event that an RD/RN/State-Approved Nutritionist/WIC Nutrition Consultant is not able to be reached for approval, issue a one-month supply of the requested formula (may be any formula type listed in Section A with the exception of non-contract formulas) and foods pending the Local Agency RD/RN/State-Approved Nutritionist’s approval.

Approval/Issuance of Standard Contract Formulas WIC Competent Professional Authorities (CPAs) ( Nutrition Education Specialists (NESs), Community Nutrition Workers (CNWs), Registered Dietitians (RDs) etc.) may issue standard contract formulas to infant participants without medical documentation (or in the event that medical documentation has been received for a standard contract formula and no current, approved medical documentation exists in HANDS) until the participant reaches one year of age. However, when medical documentation for a standard contract formula has been provided, and current, approved medical documentation exists in HANDS, it must be approved by an RD, RN, or State-Approved Nutritionist, who may approve it for up to the length of time requested by the prescriptive authority. Approval/Issuance of Routine 19 kcal/oz Contract Formulas Nineteen kcal/oz contract formulas require medical documentation, but do not require specific medical diagnoses to be indicated and, therefore, may be approved for determinations such as “formula intolerance” or “inappropriate growth patterns.” Medical documentation for these formulas must be approved by an RD, RN, or State-Approved Nutritionist, who may approve them for up to the length of time requested by the prescriptive authority.



Approval/Issuance of Non-Contract Formulas Issuance of non-contract formula is reserved to the following circumstances with complete medical documentation:

1) Transition to an alternate contract formula is medically contraindicated for pre- or post-operative recovery where formula transition would put the participant at risk for compromised nutritional status impacting growth and development.

2) NICU discharge warrants continuation of a tolerated non-contract formula to avoid weight loss in the recovery of a previous Failure to Thrive infant (WIC code 134) or infant who has experienced inadequate growth (WIC code 135).

3) Participants with a genetic or congenital disorder (WIC code 349) where formula transition would put infant at risk for compromised nutritional status impacting growth and development.

4) Participants diagnosed with central nervous system disorders (WIC code 348) and/or genetic/congenital disorders (WIC code 349) where formula transition would put the participant at risk for compromised nutritional status impacting growth and development.

After assessment, if a participant meets one of the four previously mentioned criteria for non-contract formula with valid medical documentation, the Local Agency shall contact the State Food Package Specialist or a State WIC Nutrition Consultant for consent for approval. Local Agencies’ policies differ regarding which individuals may contact the State WIC Office to discuss the approval of Non-Contract Formulas, so it is recommended that WIC staff be familiar with Local Agency policy before contacting the State WIC Office. After consent is provided by the State employee and approved in HANDS, all relevant medical information shall be documented in the notes section in HANDS. If medical documentation has been received, but the infant does not meet the criteria for non-contract formula issuance, the Local Agency RD/RN/State-Approved Nutritionist shall take the same steps that apply when invalid/no medical documentation exists. One month of any non-contract formula shall not be issued without prior consent for approval from the State Food Package Specialist or a State WIC Nutrition Consultant. Out-of-state transfer using non-contract formula

1) If a participant transfers from another state and requests a non-contract formula (without medical documentation), explain to the participant or caregiver transferring into Arizona that each state may have different contract formulas.

2) If the participant is consuming a formula for which there is a comparable standard contract formula, the Local Agency CPA shall recommend transitioning to the comparable standard contract formula and issue it to the participant if agreed upon by the participant.

3) If problems arise with the comparable standard contract formula, or if the participant is consuming a formula for which the comparable formula for the non-contract formula is a 19 kcal/oz contract formula, then the Local Agency RD/RN/State-Approved Nutritionist shall take the same steps that apply when invalid/no medical documentation exists.



Approval/Issuance of Special Formulas Special formulas require medical documentation to specify medical diagnoses that correspond to the formula requested. Medical documentation for these formulas must be approved by an RD, RN, or State-Approved Nutritionist, who may approve them for up to the length of time requested by the prescriptive authority. Special formulas are not authorized for participants receiving Food Package III whose conditions can be successfully managed by contract formulas, or one of the standard food packages. They shall also not be authorized for non-specific food or formula intolerance and are not to be authorized for the sole purpose of enhancing nutrient intake or managing body weight without an underlying medical condition. For any special formula issuance, participants shall be instructed on how to obtain the formula. WIC staff shall ensure participants know whether the formula can be found on the retail shelf or must be ordered through a store pharmacy. Refer to the Formula Color Chart or the Arizona WIC Program’s Formulary for more information regarding where formulas may be typically obtained. For pharmacy special order products, WIC staff shall assist the participant in finding a pharmacy that can order the product. The first time a product is ordered for a client, it may be necessary to order the product for them. Staff approving special formulas must also consider if the participant may qualify to receive the formula from the Arizona Health Care Cost Containment System (AHCCCS). If a participant requiring a special formula is participating in AHCCCS, it is the responsibility of the WIC RD/RN/State-Approved Nutritionist to review the following criteria for AHCCCS Special Formula coverage and explain the process of receiving the formula from AHCCCS to the participant if they qualify.

A) AHCCCS tube feeding 1) When a request comes in for medical nutritional therapy for a tube feeding for a WIC

participant who is also participating in the Arizona Health Care Cost Containment System (AHCCCS), WIC staff shall refer the client back to their AHCCCS primary care doctor for coordination. The tube feeding formula is a covered AHCCCS expense and shall be processed as a prior authorization. (Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form is not required)

2) If the AHCCCS client receives both tube feeding formula and oral supplemental nutritional feeding, both products are a covered AHCCCS expense and shall be processed as a prior authorization. (Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form is not required)



B) AHCCCS commercial oral nutritional supplements (special formulas)

AHCCCS defines a commercial oral nutritional supplement as a formula that provides nourishment and increased calorie intake of other age-appropriate foods or as the sole source of nutrition. WIC refers to these nutritional supplements as special formulas.

1) When a request comes in for a special formula for an AHCCCS client, WIC staff shall follow

the below procedures: a) The WIC RD, RN, or State-Approved Nutritionist shall assess if the client meets the

following criteria from the AHCCCS EPSDT Policy 430 Requirements to determine medical necessity:

Member Meets the Criteria in the Left Column OR Meets at Least Two Criteria in the Right Column • Member has been diagnosed with a

chronic disease or condition, is below the recommended BMI percentile (or weight-for-length percentile for members less than two years of age) for the diagnosis per evidence-based guidance as issued by the American Academy of Pediatrics, and there are no alternatives for adequate nutrition.

Member is at or below the 10th percentile for weight-for-length/BMI, on the appropriate growth chart for their age and gender, for 3 months or more. • Member has reached a plateau in

growth and/or nutritional status for more than 6 months, or more than 3 months if member is an infant less than 1 year of age.

• Member has already demonstrated a

medically significant decline in weight within the 3-month period prior to the assessment.

• Member is able to consume/eat no

more than 25% of nutritional requirements from age-appropriate food sources.

Additionally, Both of the Following Requirements Must be Met • The member has been evaluated and treated for medical conditions that may cause

problems with growth (such as feeding problems, behavioral conditions or psychosocial problems, endocrine or gastrointestinal problems, etc.), AND

• The member has had a trial of higher caloric foods, blenderized foods, or commonly available products that may be used as dietary supplements for a period no less than 30 days in duration.



b) If a client meets the AHCCCS criteria, WIC staff shall refer them back to their primary care doctor to process and submit the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form to the Health Care Plan. Staff may also provide the client with a copy of the AHCCCS referral letter (see Appendix D). (1) WIC staff shall issue a supply of formula each month until AHCCCS approval is

completed. (2) If special formula coverage is denied by the health care plan, but the RD, RN, or

State-Approved Nutritionist believes that the client should have qualified to receive the formula from AHCCCS, they shall contact the State Food Package Nutritionist for assistance

c) If the criteria are not met, the WIC RD/RN/State-Approved Nutritionist shall tailor an appropriate package to meet the client’s needs.

NOTE: WIC participants may receive formula from AHCCCS and a food package from the Arizona WIC Program. Approval/Issuance of WIC-Eligible Nutritionals Since WIC-eligible nutritionals are a subcategory of special formulas, all of the same considerations that apply to the Approval/Issuance of Special Formulas also apply to WIC-eligible nutritionals. Additionally, most WIC-eligible nutritionals are intended for children one year of age or older and women. Therefore, any WIC-eligible nutritional intended for participants one year of age and older shall not be provided to infants. Approval/Issuance of Conditionally Special Formulas Since conditionally special formulas are a subcategory of WIC-eligible nutritionals, all of the same considerations that apply to the Approval/Issuance of Special Formulas and the Approval/Issuance of WIC-Eligible Nutritionals also apply to the approval/issuance of conditionally special formulas. Issuance of Pediasure, Pediasure with Fiber, and Boost Kid Essentials also requires the Local Agency RD, RN, or State-Approved Nutritionist to:

• Complete a thorough assessment and document all medical, nutritional, or psychosocial risk factors in the Notes section in HANDS.

• Obtain a current height and weight for accuracy in growth assessment. • Provide nutrition education on nutrient-dense foods to help promote weight gain. This shall be

documented in the Notes section in HANDS.



Additionally, medical documentation for Pediasure, Pediasure with Fiber, and Boost Kid Essentials can only be approved and food benefits issued when at least one of the following conditions exist:

• At or below the 5th percentile 1. Children one year of age measured recumbently, if weight for length is at or below the 5th

percentile on the “WHO - WEIGHT FOR LENGTH” growth chart in HANDS (Risk code 103.1 or 103.2).

2. Children two to five years old measured standing, if BMI for age is at or below the 5th percentile on the “CDC – BMI FOR AGE” growth chart in HANDS (Risk Code 103.1).

3. Children 24-36 months measured recumbently (indicate recumbent measurement in HANDS), if weight for length is at or below the 5th percentile on the “CDC – WEIGHT FOR LENGTH 24-36” growth chart in HANDS.

• Weight curve has crossed more than two percentile lines on the growth charts after having achieved a previously stable pattern (e.g., the child has dropped from the 75th to the 25th percentile over time)

• Other medical conditions for the management of nutrition-related disorders For all other questionable conditions, contact the State office for technical assistance. NOTE: Pediasure, Pediasure with Fiber, and Boost Kid Essentials cannot be issued for the following reasons:

• In response to picky eaters. • For the sole purpose of enhancing nutrient intake or managing body weight without an

underlying medical condition. Formula Changes When approved medical documentation exists in HANDS and new approved medical documentation has been received, the new medical documentation will supersede the previously approved medical documentation. If however, approved medical documentation exists in HANDS and new medical documentation has not been received, an alternative formula cannot be issued during the approved medical documentation length of time without following the same steps that apply when No Medical Documentation Exists.This includes situations when a participant requests a different formula or a WIC staff member believes a different formula is indicated (e.g., premature infant has gained a significant amount of weight and RD believes that Neosure is no longer indicated and Similac Advance would now be appropriate). Sometimes formula changes also occur when no medical documentation has been received at all, such as a client requesting another formula after their child experiences signs of formula intolerance to a standard contract formula, or when a WIC client transferring from another state requests that their child remains on an Arizona WIC non-contract formula.



Other than situations when new, valid medical documentation has been received, whenever an alternative formula is being considered, it is important to complete a nutrition assessment, evaluate several factors, and obtain medical documentation (if required for the formula). Factors include but are not limited to:

• How is the current formula being prepared? • How is the current formula being stored after preparation? • After the baby has been fed, what is done with formula left in the bottle? • How many ounces of the current formula is the baby drinking during the day? • In what position is the baby being held during feedings? • How often is the baby burped during feedings? • Have any solid foods been started? • Family history of allergies (e.g., milk, corn, soy, etc.) • Medications the infant is taking • The patient’s symptoms such as:

o Diarrhea o Vomiting o Watery, frothy stools o Abdominal distension o Bloody stools o Abdominal pain o Skin rash o Congestion o Chronic runny nose o Wheezing o Coughing

• How long the infant has been experiencing symptoms • Other recent infant illnesses

Note: Any time a food package change occurs (including a formula change), include the information and the reason for the change in the Notes tab in HANDS.



Section D Issuance of Formula for the Premature Infant

Feeding recommendations for infants born <37 weeks gestation include introduction to cow’s milk at 12 months corrected age (CA). CA is based on the age the infant would be if the pregnancy had gone to term. The CA is calculated by subtracting the number of weeks premature from the actual age. Remember that each month has an average of 4.35 weeks. Example 1: If an infant was 6 weeks premature and the infant’s actual age is 13 weeks, then the infants corrected age would be 7 weeks.

(actual age) – (weeks premature) = (corrected age) 3 months (13 weeks) – 6 weeks = 7 weeks

Example 2: If an infant was 10 weeks premature and the infant’s actual age is 1 year 6 weeks, then the infants corrected age would be 11 months (48 weeks).

(actual age) – (weeks premature) = (corrected age) 1 year 6 weeks (58 weeks) – 10 weeks = 11 months (48 weeks)

The Local Agency WIC RD, RN, or State-Approved Nutritionist shall base feeding recommendations of the premature infant on birth weight, nutritional status, developmental stage, and continued monitoring of growth. It is at the Local Agency RD/RN/State-Approved Nutritionist or referring medical provider’s discretion to extend the use of infant formula up to one year (52 weeks) CA. If the need for continued formula past one year corrected age is apparent, medical documentation is required.



Section E Issuance of Powder/Concentrate/Ready-to-Feed Formula

Local Agencies must issue all formula in concentrated liquid or powder physical forms with the exception of the following scenarios that permit the issuance of ready-to-feed formula. Ready-to-feed formula for standard contract formulas may be issued without medical documentation when a CPA determines and documents that one of the following situations applies:

• The participant’s household has an unsanitary or restricted water supply • There is poor or no refrigeration available • The caregiver may have difficulty correctly diluting concentrated liquid or powdered formula

In addition to the scenarios listed above, ready-to-feed formulas may also be issued to participants with medical documentation when the RD/RN/State-Approved Nutritionist determines and documents that one of the following situations applies:

• No other forms of the prescribed formula are available • A ready-to-feed formula better accommodates the participant’s condition • A ready-to-feed formula improves the participant’s compliance in consuming the prescribed WIC

formula



Section F Issuance of Liquid Formula for Premature, Low Birth Weight, and

Immunocompromised Infants Although liquid infant formula is commercially sterile, powdered infant formula is not. Powdered infant formula contains low levels of Cronobacter bacteria. These bacteria have been associated with sepsis, meningitis, cerebritis and necrotizing enterocolitis. Premature infants, low birth weight infants or immunocompromised infants are at particular risk. Improper preparation and refrigeration of powdered infant formula can cause an increase in the level of contamination of Cronobacter in powdered formula. The Arizona WIC Program shall issue liquid concentrate infant formula, which is commercially sterile, to premature (<37 weeks gestational age), low birth weight infants (less than 2,500 grams (5.5 pounds)), and/or immunocompromised infants until six months corrected age. When liquid concentrate is not available in a requested formula, ready-to-feed formula shall be chosen. Powdered formula shall only be issued to premature, low-birth weight, and/or immunocompromised infants when a prescriptive authority’s medical documentation indicates the request for powdered formula.



Section G Formula Calorie Adjustments

Participants should adjust the calories of a formula as indicated by their prescriptive authority. It is recommended to review the calorie adjustments provided by the prescriptive authority with the participant to verify the participant’s understanding/ability to prepare the formula as indicated and to verify that the doctor’s formula preparation instructions are correct for the desired kcal/oz concentration. Please reference the Formula Calorie Adjustment Charts in these situations.



Section H Tailoring Formula and Food Packages

Formula Tailoring CPAs shall tailor the amount of formula that a participant receives to reflect the amount of formula that the participant will most likely consume during the benefit issuance period. The formula tailoring calculation and associated example below provide an outline of how to estimate the amount of formula a participant is consuming, but it is important to ask probing questions to more clearly establish approximately how much formula the participant is expected to consume during the benefit issuance period. It is also important to consider the age and category of the participant since these factors play an important role in the maximum quantity of infant formula provided monthly by WIC. Please refer to the infant sections in Chapter 3 for maximum formula volumes by age and category. The Formula Tailoring Chart may also be used as a tool to help tailor the most common formulas and help determine the appropriate participant category to assign, based on the participant’s formula needs during the issuance period. Formula Tailoring Calculation

1. Calculate the approximate amount of formula (in ounces) the client consumes each day and multiply it by the number of days in the month to give the total monthly volume.

2. Determine the ounces of prepared formula that one can of formula shall provide. Prepared ounces vary by formula.

3. Divide the total monthly volume by the ounces one can of prepared formula provides to establish the approximate number of cans the client shall need for the month.

Example: An infant is partially breastfed and consuming about 12 ounces of prepared Similac Advance

powdered formula each day. The Similac Advance powdered formula can size is 12.4 ounces and reconstitutes to 90 fl. ounces per can.

1. 12 ounces per day x 31 days = 372 fl. ounces per month 2. 1 -12.4 ounce can of Similac Advance = 90 fl. ounces per can 3. 372 fl. ounces per month/90 fl. ounces per can = 4.133 cans per month 4. Round 4.1333 cans per month up to 5 cans per month.

http://azdhs.gov/documents/prevention/azwic/manuals/policy/chapter-03-foodpackage-general.pdf



Section I Issuance of Low Iron Formula

Low iron infant formula may only be issued to medically fragile infants in Food Package III and requires medical documentation with a corresponding medical condition. Conditions include, but aren’t limited to, renal insufficiency and iron storage disorders. NOTE: Spitting up, diarrhea, constipation, and colic are not acceptable reasons for issuing low iron formula.



Appendix A: Arizona WIC Program’s Formula and Food Request Form





Appendix B: Request for New Food Package Form



Request for New Food Package in HANDS If an appropriate food package isn’t available for a client in HANDS, it may need to be built. Please email the state Food Package Specialist with this request using the following form: Information: * = indicates required fields Local Agency/Clinic: * Date of Request: * Date needed by: Nutritionist Contact: Phone number: Email: * Participant ID: * Participant’s Age: * Category: Name of WIC Participant: Is this a tube-fed participant? Yes No Doctor’s Prescription: Yes No * Formula info: Formula(s) Requested: Form: Powder Concentrate Ready-to-Use Amount of formula requested/day: Special mixing instructions: * Foods: For Infants (6 to 11 months):

only jarred foods only cereal both neither (no foods)



For Children and Women: ____ No foods appropriate OR All foods except (check all that apply): Category WIC Foods Please EXCLUDE Children (1-5 yr.) and Women

Beans Cereal Cheese Cow's milk Eggs Juice Peanut butter Whole grains* Vegetables/fruits Yogurt

Exclusively Breastfeeding Women

Canned fish

* Grains include whole wheat bread, brown rice, whole wheat pasta and tortillas (whole wheat and corn). Specialty items to include: WIC Foods Check if desired: Soymilk __ 8th Continent/Silk __ Pacific Ultra Soy Tofu __ 1 lb __ 2 lb __ 3 lb __ 4 lb Goats milk Infant cereal Infant fruits & vegetables

If EN, please indicate if additional cheese desired: ___ 2 lb ___ 3lb Indicate other requests or comments: ____________________________________________________ Note: Upon the creation of a food package it shall be available for use in HANDS. Local agency shall be

notified by E-mail or phone of the new food package number.



Appendix C: AHCCCS Referral Letter and Form



Date: Re: (WIC Participant) Dear Doctor, Based on AHCCCS policy 430, WIC is referring AHCCCS covered WIC participants who receive enteral feedings or who qualify for medically necessary commercial oral nutritional supplements to their Primary Care Physician (PCP) for nutritional therapy. According to AHCCCS policy 400 Section 430.C.6, if an AHCCCS covered EPSDT member qualifies for nutritional therapy due to a medical condition, AHCCCS Contractors are the primary payor for special formulas and commercial oral nutritional supplementation. AHCCCS covers nutritional therapy for EPSDT-Eligible members on an enteral, parenteral, or oral basis when determined medically necessary to provide either complete daily dietary requirements, or to supplement a member’s daily nutritional and caloric intake. Prior authorization (PA) is required for commercial oral nutritional supplements. The PCP or attending physician must complete and submit the AHCCCS approved form, “Certificate of Medical Necessity for Commercial Oral Nutritional Supplements” (Exhibit 430-2) to obtain PA from the Contractor. If the member meets two of the seven criteria listed on the form, AHCCCS supplies the commercial oral nutrition supplements. Please complete the enclosed form and process the form as a prior authorization. Thank you for working with us on this procedure. (Name) ______________________________ (WIC Nutritionist) (Local WIC clinic address) (Phone number)





Appendix D: Formula Tailoring Chart





Appendix E: Formula Calorie Adjustment Charts









Appendix F: Formula Color Chart



Formula Color Chart: Green (standard contract): Competent Professional Authorities (NESs, CNWs, RDs, etc.) can issue until an infant’s first birthday without medical documentation. Blue (19 kcal/oz contract): RDs, RNs, and State Approved Nutritionists can approve medical documentation for the full duration, or issue for one month without medical documentation. Orange (special): RDs, RNs, and State Approved Nutritionists can approve medical documentation for the full duration, or issue for one month without medical documentation. Purple (conditionally special): RDs, RNs, and State Approved Nutritionists can approve medical documentation for the full duration, or issue one month without medical documentation, if the client meets WIC criteria. Red (non-contract): Local agencies may only approve medical documentation after contacting the state office for consent. No formula shall be issued without medical documentation. Grey: Unable to issue. (*) – Pharmacy Special Order

Similac Enfamil Gerber Neocate Nestle Use

•Similac Advance •Similac Pro- Advance

Enfamil Infant Good Start Gentle Regular

Similac Soy Isomil Enfamil Prosobee Gerber Good Start Soy

Lactose intolerance, or dairy free diet

•Similac Sensitive •Similac Pro- Sensitive

Enfamil Gentlease Good Start Soothe Lactose intolerance

Similac Total Comfort

Enfamil Reguline Digestive discomfort, lactose intolerance.

Similac for Spit-Up Enfamil AR Reflux, GERD, or GER Alimentum Nutramigen with

Enflora LGG Gerber Extensive HA

Severe food allergies

•Neosure •Similac Special Care 24*

•Enfacare •Enfamil Premature 24*

Prematurity, low birth weight

•Elecare for Infants* •Elecare Junior* •PediaSure Peptide 1.0*

•Pregestimil* •PurAmino*

•Alfamino Infant* •Alfamino Junior*

•Neocate Infant* •Neocate Jr.*

Protein maldigestion, malabsorption, severe food allergies, short-bowel syndrome, eosinophilic GI disorders, GI-tract impairment.

Similac PM 60/40* Impaired renal function Similac Human Milk Fortifier*

Enfamil Human Milk Fortifier*

Prematurity, low birth weight

Go & Grow Enfagrow Toddler Transitions (milk and soy based)

Increased vitamins and nutrients for toddlers

•Pediasure •Pediasure w/ Fiber •Pediasure 1.0* •Pediasure 1.5*

Duocal* •Boost Kid Essentials •BKE 1.0* •BKE 1.5*

For FTT, poor oral intake, malnutrition, oral surgery

Similac for Supplementation

For breastfeeding supplementation



Appendix G: Formula Descriptions



Formula: Description: Forms: Similac Products (Abbott)

Similac Advance • Formula infant standard. Powder (12.4oz cans) Conc (13oz cans) RTF (32oz bottles)

Similac Sensitive • Lactose-reduced standard infant formula.

Powder (12.0oz cans) RTF (32oz bottles)

Similac for Spit-Up • Contains added Rice Starch • Milk based, lactose-reduced • Good for GER, GERD or reflux


Similac Soy Isomil • Soy based standard infant formula. • Lactose-free

Powder (12.4oz cans) Conc (13oz cans) RTF (32oz bottles)

Similac for Diarrhea • Dietary management for diarrhea • Soy formula • Low osmolality • For infants 6 mo and older

RTF (8 fl oz can or 32oz bottles)


• For digestive discomfort • 100% whey hydrolyzed proteins • Lactose-reduced

Powder (12.0oz can)

Similac Alimentum • Hypoallergenic – contains a predigested protein • Lactose-free • RTF formula is corn-free • Good for infants with milk protein allergy

Powder (12.1oz cans) RTF (8oz cans or 32oz bottles)

Similac Neosure • 22 kcal/fl oz • For premature infants • Supports catch up growth • Higher levels of protein, vitamins and minerals

compared to standard formulas


Elecare for Infants • Nutritionally complete elemental formula for infants • Protein broken down to amino acids • Does not contain milk protein, soy protein, fructose,

galactose, lactose or gluten • Unflavored • Good for infants that cannot tolerate intact or

hydrolyzed proteins • Good for infants with protein maldigestion,

malabsorption, severe food allergies, short-bowel syndrome, eosinophilic GI disorders, GI-tract impairment.

Powder (14.1oz can unflavored)

Brief Formula Description



Similac Special Care 24 with Iron

• 24 kcal/fl oz • For low birth weight and preterm infants • Not intended for infants once they reach 8 lbs.

RTF (2oz nursettes)

Similac PM 60/40 • 60:40 ratio of whey to casein (similar to human milk) • Low iron • For infants who need lower mineral intake, including

those with impaired renal function. • Good for infants with hypercalcemia and

hypocalcemia due to hyperphosphatemia

Powder (14.1oz cans)

Similac Human Milk Fortifier

• Intended for low birth weight infants as a supplement to preterm human milk

• 3.5 kcal/packet • Usually only used in the hospitals

Powder (.90g packets)

Pediasure • Supplemental drink • Milk based • Suitable for lactose intolerance • 237kcal per 8oz serving

RTF (8oz cans in vanilla, strawberry, chocolate, banana, and berry

Pediasure with Fiber

• Supplemental drink • Milk based • Suitable for lactose intolerance • 237kcal per 8oz serving

RTF (8oz cans in vanilla and strawberry)

Pediasure Enteral Formula 1.0 Cal

• Specially formulated for tube feeding • Milk based • Suitable for lactose intolerance • For kids aged 1-13 years old • 240 kcal per 8oz serving

RTF (8oz cans vanilla flavor)

PediaSure Peptide 1.0 (also a 1.5 kcal version available)

• Hydolyzed proteins for better/easier absorption • Semi-elemental formula • Suitable for lactose intolerance • For kids ages 1-13 years old • 1.0 = 240kcal per 8oz serving • 1.5 = 350kcal per 8oz serving • Designed for kids with malabsorption, maldigestion

and other GI conditions

Pediasure Peptide 1.0 = RTF (8oz cans in unflavored, vanilla and strawberry flavors) Pediasure Peptide 1.5 = RTF (8oz cans in vanilla flavor)

Enfamil Products (Mead Johnson)

Enfamil Infant • Standard infant formula Powder (12.5oz cans) Conc (13oz cans) RTF (13oz bottles)

Enfamil Gentlease • Easily digested proteins that are partially hydrolyzed • 20% Lactose (reduced levels) • Good for lactose intolerance

Powder (12.4oz cans) RTF (32oz can)



Enfamil Prosobee • Soy based standard infant formula • Good for milk protein allergy or lactose intolerance

Powder (12.9oz cans) Conc (13oz cans) RTF (32oz cans)

Enfamil AR • “Added rice” or AR in formula – thickens formula so infant has less reflux

• Good for reflux, GERD or GER

Powder (12.9oz cans) RTF (32oz cans)

Enfacare • 22 kcal/oz • Milk based • Higher levels of protein and some vitamin and

minerals • Good for premature or low birth weight infants

Powder (12.8oz cans) RTF (32oz cans)

Enfamil Premature 24 kcal

• 24 kcal/fl oz • For VLBW and ELBW premature infants • Extra calories for premature or FTT.

RTF (2oz nursettes)

Nutramigen w/Enflora LGG

• Hypoallergenic for milk protein allergies. • Lactose free • extensively hydrolyzed protein • Enflora LGG to promote immune system balance

and GI tract. • Good for milk protein allergy and soy allergy


PurAmino • Amino acid based (proteins broken down) • Hypoallergenic • Scientifically designed for infants and toddlers with

severe cow's milk protein allergies and/or multiple food protein allergies

• May be good for babies that don’t tolerate regular Nutramigen or other hydrolyzed protein formulas


Pregestimil • Hypoallergenic. • Contains MCT oil, which is more easily absorbed by

babies with some GI problems • Lactose-free and sucrose (table sugar) free • Good for fat malabsorption. • Good for infants with cystic fibrosis, short bowel

syndrome, intractable diarrhea, and severe protein calorie malnutrition. Also ok for infants with galactosemia.

Powder (16oz cans) RTF (2oz nursettes)

Enfamil Human Milk Fortifier Acidified Liquid

• For use with premature and low birth weight infants • Use as a supplement in human breast milk • Milk based • Increases levels of protein, energy, calcium,

phosphorous, and other nutrients

Concentrate (5 mL vials)

Enfagrow Toddler Transitions (also available in Gentlease and Soy)

• For toddlers 10-36 months • Increased vitamins and nutrients for toddlers • Gentlease form contains partially broken downs

proteins, and decreased lactose content • Soy form is lactose free

Powder (24oz cans) RTF (32oz cans) – Premium Toddler only



Nutricia Neocate Infant • Infant formula (0-12 months)

• Hypoallergenic • Amino acid based – easy to digest • Good for cow and soy milk allergy, short bowel

syndrome (SBS), Eosinophilic esophagitis (EE), GERD, and other gastrointestinal tract impairment

Powder (14oz cans)

Neocate Junior • Formula for ages 1-10 years • Hypoallergenic • Amino acid based – easy to digest • Extra vitamins and minerals for malabsorptive

conditions • Good for cow and soy milk allergy, short bowel

syndrome (SBS), Eosinophilic esophagitis (EE), GERD, and other gastrointestinal tract impairment

Powder (14oz cans)

Duocal • 42 kcal/Tbsp – very high calorie • Duocal powder is completely soluble and mixes

easily in liquids and moist foods • Milk-protein free • Appropriate for oral and tube feeding • 59% CHO, 41% fat • Good for disorders of protein and amino acid

metabolism, protein restricted diets, electrolyte restricted diets, electrolyte restricted diets, high energy diets, and catabolic states (e.g. burns, trauma, post-operative stress)

Powder (14oz cans)

Gerber Gerber Extensive HA

• 100% whey protein extensively hydrolyzed • Probiotic B. lactis to help promote a balanced

microbiota • 49% MCT to facilitate fat absorption • DHA for brain and eye development

Powder (14.1oz can)

Gerber Good Start Gentle

• Standard infant formula • Comfort proteins – broken down 100% whey

proteins

Powder (12.7oz cans) Conc (12.1oz carton) RTF (four pack containing 8.45oz containers each)

Gerber Good Start Soothe

• Contains probiotic L. reuteri • Standard lactose reduced formula

Gerber Good Start Soy

• Soy based standard infant formula • Good for milk protein allergy or lactose intolerance

Powder (12.9oz cans) Conc (12.1oz carton) RTF (four pack containing 8.45oz containers each)



Nestle Alfamino Infant • Nutritionally complete, hypoallergenic amino acid-

based formula for infants • 43% of fat as MCT to facilitate fat absorption • DHA to support visual and cognitive development • Easy to digest


Alfamino Junior • Nutritionally complete, hypoallergenic amino acid-based formula for children ages 1-13 years

• 65% of fat as MCT to facilitate fat absorption • For oral supplementation or tube feeding

Boost Kids Essentials (retail)

• Probiotic straw • 1 kcal/mL • Lactose free • For ages 1-8 years old • Increased vitamins and nutrients for the older child

RTF (four pack containing 8.45oz containers each)

Boost Kids Essentials 1.0 (pharmacy special order only)

• 1 kcal/mL • Lactose free • For ages 1-8 years old • Increased vitamins and nutrients for the older child

RTF (8 fl oz cartons – 27ea/case)

Boost Kids Essentials 1.5 (pharmacy special order only)

• Used to be called Resource Just for Kids 1.5 • 1.5 kcal/mL • For ages 1-13 years old • Increased vitamins and nutrients for the older child,

lactose free, low residue • May be consumed orally or used as a tube feeding

RTF (8 fl oz cartons - 27/case)



Appendix H: Arizona WIC Program’s Formulary



Arizona WIC Formulary FFY 2018 (Intended for use by AZ WIC Nutritionists/RDs only in combination with other resource materials)

Product Name

Manufacturer Category

Yes

No Description Indications Product

Type Issuance

Information Conc. Powder Ready -to- Use

Alfamino Infant Nestle

Special Infant

Formula X Nestle

For infants and children with a cow milk allergy, multiple food protien allergies or malabsorptive states.

Metabolic Pharmacy

special order

400gm can

Alfamino Junior Nestle

WIC-eligible

Nutritional

X Nestle

For infants and children with a cow milk allergy, multiple food protien allergies or malabsorptive states.

Metabolic Pharmacy

special order

400gm can

Arginine 2000

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Amino acid powder product. Nutritionally incomplete.

For the dietary management of individuals (suitable from one year of age) with inborn errors of metabolism. Should be used under medical supervision.

Metabolic Pharmacy

special order

4gm

packets - 30/case



Product Name


Yes


Type Issuance


BCAD 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Isoleucine-, Leucine- and Valine-free iron fortified diet powder.

Inborn error of metabolism: For the dietary management of infants and toddlers with maple syrup urine disease (MSUD) under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

16oz (1lb) can

BCAD2

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

Dietary powder free of the branched chain amino acids, isoleucine, leucine, and valine.

Inborn error of metabolism: For the dietary management of children and adults with MSUD or other inborn errors of branched chain amino acid metabolism under direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

16oz (1lb) can



Product Name


Yes


Type Issuance


Benecalorie

Nestle HealthCare Nutrition

WIC-eligible

Nutritional

X

Low-volume, calorie and protein supplement; allows for flexible serving options and helps reduce taste fatigue. Low residue, lactose-free, gluten-free, kosher.

For patients with unintended weight loss and/or increased nutritional needs, such as those with cancer, HIV/AIDS, burns, COPD, fluid restriction and/or anorexia.

Adult/Older Child

Supplements

Pharmacy special order

1.5oz cups - 24

caups/case

Beneprotein Instant Protein Powder


WIC-eligible

Nutritional

X

Whey protein supplement. Lactose-free, gluten-free, kosher.

For those individuals who require additional protein to bolster their regular diet, help promote skin health, wound healing and immune support.

Milk-Based,

Lactose-Free


8oz canister - 6 canister/ case; 7gm packets -

75 packets/ca

se

Boost Nestle

HealthCare Nutrition

WIC-eligible

Nutritional

X

Nutritionally complete oral drink. Lactose-free, gluten-free, kosher.

For patients with general oral supplement needs because they are not consuming meals or may need more for meals; for geriatric patients.

Adult/Older Child

Supplements

Retail

8oz (237mL)

bottles - 6 pack



Product Name


Yes


Type Issuance


Boost Breeze


WIC-eligible

Nutritional

X

Fruit-flavored, clear-liquid nutritional supplement for individuals who cannot consume a sufficient intake of food to meet their nutritional requirements. Low residue, lactose-free, gluten-free, kosher.

For use in patients with oncology, geriatrics, cerebrovascular accident, oral surgery, bowel preparation, anorexia, protein-calorie malnutrition, pressure ulcers, pre- and post-operative, fat malabsorption, HIV/AIDS, clear liquids.

Adult/Older Child

Supplements


8oz box - 27ea/case

Boost Glucose Control


WIC-eligible

Nutritional

X

Nutritional Drink specifically formulated to meet the unique nutritional needs of people with diabetes. Lactose-free, gluten-free, kosher.

For adults with diabetes mellitus, glucose intolerance, or stress-induced hyperglycemia.

Adult/Older Child

Supplements

Retail

8oz (237mL)

bottles - 6 pack



Product Name


Yes


Type Issuance


Boost High Protein


WIC-eligible

Nutritional

X

High protein, nutritionally balanced oral supplement; lactose-free, gluten-free, kosher.

For adult participants with supplemental protein requirements such as those recovering from illness including HIV/AIDS, cancer, or wounds (including pressure wounds) and surgery.

Adult/Older Child

Supplements

Retail

8oz (237mL)

bottles - 6 pack

Boost Kid Essentials (retail)


WIC-eligible

Nutritional

X

Nutritionally complete, oral supplement that meets the DRI levels of 25 vitamins and minerals for children 1 to 13 years of age. Lactose-free, gluten-free, kosher.

For children 1 to 13 years of age who require supplementation to achieve optimal growth and to meet nutritional requirements. Can be used for failure to thrive, oral supplementation, increased energy needs, celiac disease, growth failure, malnutrition

Adult/Older Child

Supplements

Retail 8.25oz

containers - 4 pack



Product Name


Yes


Type Issuance


Boost Kid Essentials 1.0


WIC-eligible

Nutritional

X



Adult/Older Child

Supplements


Ready to Feed

8oz (237mL) box - 27

boxes/case

BOOST Kid Essentials 1.5


WIC-eligible

Nutritional

X



Adult/Older Child

Supplements


8oz (237mL) box - 27

boxes/case



Product Name


Yes


Type Issuance


BOOST Kid Essentials 1.5 with Fiber


WIC-eligible

Nutritional

X


For children 1 to 13 years of age who require supplementation to achieve optimal growth and to meet nutritional requirements. Can be used for failure to thrive, oral supplementation, increased energy needs, celiac disease, growth failure, malnutrition and

Adult/Older Child

Supplements


8oz (237mL) box - 27

boxes/case

Boost Nutritious Pudding


WIC-eligible

Nutritional

X Supplemental food in ready-to-serve cups.

To prevent unintended weight loss or malnutrition in patients with protein-calorie malnutrition, dysphagia, pureed, full liquid, or medication pass diet orders and risk of wounds.

Adult/Older Child

Supplements


5oz cup -

48 cups/case

Boost Plus Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, high calorie, high protein oral supplement; lactose-free,

For patients with volume restriction (cancer, anorexia, chronic obstructive lung disease), fluid restriction (heart

Adult/Older Child

Supplements

Retail

8oz (237mL)

bottles - 6 pack



Product Name


Yes


Type Issuance


gluten-free, kosher.

failure, liver disease) or weight gain requirements due to medical conditions.

Boost Pudding


WIC-eligible

Nutritional

X

Nutritional Pudding. Low residue, lactose-free, gluten-free and kosher. Thicker consistency for greater control in chewing and swallowing.

For patients with dysphagia, facial nerve damage, cancer, HIV/AIDS, chewing or swallowing difficulties, fluid or volume restricted diets, or need for alternative to liquid formula.

Adult/Older Child

Supplements


5oz cup -

48 cups/case

Boost Thickenup Thickened Juice


WIC-eligible

Nutritional

X

Ready-to-serve vitamin fortified thickened juice; available in nectar and honey consistency.

For use in patients with dysphagia.

Adult/Older Child

Supplements


250mL container

- 27cups/case; 1liter cartons -

12 cartons/ca

se

Boost VHC Very High Calorie


WIC-eligible

Nutritional

X

Nutritionally complete, calorically dense oral drink. Lactose-free, gluten-free, low residue, and kosher.

Generally for adults and children at least 10 years of age who require very high calories and/or a severe fluid restriction.

Adult/Older Child

Supplements


8oz (237mL) box - 27

boxes/case



Product Name


Yes


Type Issuance


Bright Beginnings Soy Pediatric Drink

PBM Products,

LLC

WIC-eligible

Nutritional

X

Nutritionally-complete, Kosher, lactose-free, gluten-free and cow's milk protein-free snack drink; can be used as supplement or as total nutrition support (with doctor's supervision).

For children 1 to 10 years old who are allergic to cow's milk protein and/or are lactose intolerant.

Adult/Older Child

Supplements


8oz (237mL)

can - 6cans/pac

k; 24cans/ca

se

Calcilo XD Abbott Nutrition

Special Infant

Formula X

Nutritionally complete low-calcium/vitamin D-free infant formula.

For use in patients with Williams syndrome or osteoporosis.

Metabolic Pharmacy

special order

3.2oz powder (375gm)

can

Carbzero Vitaflo USA LLC

WIC-eligible

Nutritional

X

For use in ketogenic diet or in the dietary management of conditions requiring LCT (long chain triglycerides). Nutritionally incomplete.

For use in chidlren three years of age and older. Should be used under medical supervision to provide specific amounts based on age, body weight, and medical condition.

Metabolic Pharmacy

special order

250mL carton -

18 ea/case



Product Name


Yes


Type Issuance


Carnation Breakfast Essentials


WIC-eligible

Nutritional

X

Complete and balanced nutritional drink for oral feeding, providing 240kcal, 10g protein, and 21 vitamins and minerals per 8 fl oz. Gluten-free and suitable for lactose intolerance.

For use in children and adults with a medical condition or disease resulting in decreased food intake or increased nutrient requirements. Can be used to meet energy or protein needs associated with malnutrition, celiac disease or impaired growth.

Adult/Older Child

Supplements

Retail Ready to Feed

8oz (237mL) -

6 pack

Citrulline1000 Amino Acid Supplement

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered citrulline amino acid supplement on a carbohydrate base.

Provide dietary citrulline for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gm

packets - 30/case

Citrulline200

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Amino acid powder product. Nutritionally incomplete.

Dietary management of individuals (suitable from one year of age) with inborn errors.

Metabolic Pharmacy

special order

4gm

packets - 30/case



Product Name


Yes


Type Issuance


Compleat Nestle


WIC-eligible

Nutritional

X

Blenderized tube feeding formulated from real food such as tomato paste, peach, green bean, pea, carrot, and cranberry juice concentrate, and fiber blend. Nutritionally complete; milk protein concentrate, dehydrated chicken powder, pea protein isolate.

For use in patients with intolerance (diarrhea, abdominal distention, constipation, nausea) to standard intact protein formulas.

Adult/Older Child

Supplements


250mL containers

- 24 containers

/case

Compleat Pediatric


WIC-eligible

Nutritional

X

Blenderized tube feeding from real food (pea, tomato paste, green bean, peach, carrot, and cranberry juice concentrate, and fiber blend. Nutritionally complete; protein from chicken powder,

For use in children ages 1-13 with special health needs, failure to thrive, developmental disabilities, chronic illnesses or intolerance to intact protein pediatric formulas.

Adult/Older Child

Supplements


250mL containers

- 24 containers

/case



Product Name


Yes


Type Issuance


milk protein concentrate and pea protein isolate. 1 kcal/mL.

Compleat Pediatric Reduced Calorie


WIC-eligible

Nutritional

X

Blenderized tube feeding from real food (pea, tomato paste, green bean, peach, carrot, and cranberry juice concentrate, and fiber blend. Nutritionally complete; protein from chicken powder, milk protein concentrate and pea protein isolate. 0.6 kcal/mL.

For use in children ages 1-13 with special health needs, failure to thrive, developmental disabilities, chronic illnesses or intolerance to intact protein pediatric formulas.

Adult/Older Child

Supplements


250mL containers

- 24 containers

/case



Product Name


Yes


Type Issuance


Complete Amino Acid Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Powdered mixture of essential and non-essential amino acids. Not suitable as sole source of nutrition.

For the dietary management of conditions in which a nutritionally complete feed is not suitable or a modular approach is required. For individuals over 1 year of age.

Metabolic Pharmacy

special order

7oz (200gm can)

Complex Essential MSD Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; improved nutrient profile, contains flax & fiber; can be used for oral and/or tube feeding; does not contain Isoleucine, Leucine or Valine.

Inborn errors of metabolism: Maple Syrup Urine Disease Diagnosis Code 270.3 -Can be used by children & adults -Not for infants under one year old -Not for parenteral use.

Metabolic Pharmacy

special order

1lb

(454gm) can



Product Name


Yes


Type Issuance


Complex Junior MSD Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula specially formulated for toddlers and young children; nutritionally incomplete; can be used for oral and/or tube feeding; does not contain Isoleucine, Leucine or Valine. Used for patients of all ages to manage days of illness or a metabolic condition

Inborn errors of metabolism: Maple Syrup Urine Disease Diagnosis Code 270.3 -Can be used by toddlers and young children and patients of all ages to manage days of illness or metabolic crisis.-Not for infants under one year old -Not for parenteral use.

Metabolic Pharmacy

special order

1lb

(454gm) can

Complex Junior MSD Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula specially formulated for toddlers and young children; nutritionally incomplete; can be used for oral and/or tube feeding; does not contain Isoleucine,

Inborn errors of metabolism: Maple Syrup Urine Disease Diagnosis Code 270.3 -Can be used by toddlers and young children and patients of all ages to manage days of illness or metabolic crisis.-Not for infants under one year old -Not for

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


Leucine or Valine. Used for patients of all ages to manage days of illness or a metabolic condition

parenteral use.

Complex MSD Amino Acid Bars

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; can be used for oral feeding; does not contain Isoleucine, Leucine or Valine.

Inborn errors of metabolism: Maple Syrup Urine Disease Diagnosis Code 270.3 -Can be used by children & adults -Not for infants under one year old.

Metabolic Pharmacy

special order

47gm bars -

12each/box

Complex MSD Amino Acid Blend

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; can be used for oral and/or tube feeding ; does not contain Isoleucine, Leucine or Valine.

Inborn errors of metabolism: Maple Syrup Urine Disease Diagnosis Code 270.3 -Can be used by children & adults -Not for infants under one year old -Not for parenteral use.

Metabolic Pharmacy

special order

1lb

(454gm) can



Product Name


Yes


Type Issuance


Cyclinex-1 Abbott Nutrition

Special Infant

Formula & WIC-eligible

Nutritional

X Free of non-essential amino acids.

Inborn errors of metabolism: Nutrition support of infants and toddlers with: urea cycle enzyme defects, Gyrate atrophy of the choroids and retina, HHH syndrome.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Cyclinex-2 Abbott Nutrition

WIC-eligible

Nutritional

X Free of non-essential amino acids.

Inborn errors of metabolism: Nutrition support of infants and toddlers with: urea cycle enzyme defects, Gyrate atrophy of the choroids and retina HHH syndrome.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Cystine500 Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered cystine amino acid supplement on a carbohydrate base.

Provide dietary cystine for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gm

packets - 30/case

DocOmega Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered Docosahexaenoic acid (DHA) supplement on a carbohydrate base.

Provide dietary DHA for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gm

packets - 30/case



Product Name


Yes


Type Issuance


EAA Supplement

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Tropical flavored powder containing essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a low-volume drink.

For the dietary management of protein metabolism where essential amino acids are required; Suitable for urea cycle disorders; for patients 3 years of age and older.

Metabolic Pharmacy

special order

12.5gm packets -

50 packets/car

ton

Elecare Infant

Abbott Nutrition

Special Infant

Formula X

Nutritionally complete amino-acid based WIC-eligible Nutritional for oral or tube feeding.

For the dietary management of protein maldigestion, malabsorption, severe food allergies, short-bowel syndrome, esoinophilic GI disorders, GI-tract impairment, or other conditions jin which an amino acid-based diet is required. For birth to 12 months.

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


Elecare Jr. Abbott Nutrition

WIC-eligible

Nutritional

X

Nutritionally complete amino-acid based WIC-eligible Nutritional for oral or tube feeding.

For the dietary management of protein maldigestion, malabsorption, severe food allergies, short-bowel syndrome, esoinophilic GI disorders, GI-tract impairment, or other conditions jin which an amino acid-based diet is required. For ages 1+

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Enfagrow Toddler Next Step

Mead Johnson

Nutritionals

Infant Formula X

Infant or toddler formula intended to replace milk; provides 25 nutrients including iron, vitamins C, D and E and calcium; includes DHA and ARA.

For infants and toddlers (12-36 months).

Milk-Based Retail 24oz (680g)

can

8oz -six pack; 32oz

bottles



Product Name


Yes


Type Issuance


Enfagrow Toddler Transitions Gentlease

Mead Johnson

Nutritionals

Infant Formula X

Infant or toddler formula will include the same easy-to-digest proteins as Gentlease in a formulation specifically designed for toddler growth and development.

For infants and toddlers (9-18 months).

Milk-Based Retail 21oz can

Enfagrow Toddler Transitions Soy

Mead Johnson

Nutritionals

Infant Formula X

Infant or toddler formula intended to replace milk; made with soy protein instead of milk protein; provides 25 nutrients including iron, vitamins C, D and E and calcium; includes DHA and ARA.

For infants and toddlers (6-18 months) when soy is preferred.

Soy-Based,

Lactose-Free

Retail 21oz can



Product Name


Yes


Type Issuance


Enfamil (Premium) Gentlease*

Mead Johnson

Nutritionals

Infant Formula X

Milk-based, partially hydrolyzed proteins, iron fortified formula. About 1/5 the lactose of a full lactose formula; includes DHA and ARA.

For infants 0 - 12 months with fussiness or gas.

Milk-Based Retail 12.4 oz can

32oz bottle; 8oz

six pack; 2oz bottle - case of

48ea.

Enfamil (Premium) Infant*

Mead Johnson

Nutritionals

Infant Formula X

A milk-based formula that has Natural Defense Dual Prebiotics. Supports baby's brain and eye development, and immune system.

For full-term infants who do not have special nutritional needs.

Milk-Based Retail 22.2 oz

powder

32oz bottle; 8oz

six pack; 2oz bottle - case of

48ea.

Enfamil (Premium) Newborn

Mead Johnson

Nutritionals

Infant Formula X

A milk-based infant formula that is designed specifically for newborns through 3 months and has Natural Defense Dual Prebiotics. Delivers 400 IU of vitamin D in just 27 fl oz - close to the

For full-term newborns through 3 months who do not have specific nutritional needs.

Milk-Based Retail 22.2oz tub

8oz bottle-

6pack; 6oz RTF 2oz

nursette - 48ea/case



Product Name


Yes


Type Issuance


approximate daily intake of a newborn through 3 months.

Enfamil 24

Mead Johnson

Nutritionals

Infant Formula X

A term feeding infant formula for infants the require increased caloric density.

Infants who have increased calorie needs

Milk-Based

with Iron


2oz

nursette - 48ea/case

Enfamil A.R.*

Mead Johnson

Nutritionals

Infant Formula X

Thickened formula with added rice starch. Formula includes DHA and ARA.

For infants who spit up frequently.

Milk-Based Retail 12.9oz

powder

8oz bottles -

6pack; 2oz nursette- 48ea/case

Enfamil EnfaCare

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based discharge formula; provides more calories, protein, vitamins and

For infants who were born premature or with low birth weight.


8oz bottle-

6pack; 2 oz bottle -

case of 48ea.



Product Name


Yes


Type Issuance


minerals than routine starter formulas. Formula includes DHA and ARA.

Enfamil Human Milk Fortifier

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based powder to be added to breast milk.

For low-birthweight or premature infants.

Milk-Based


0.71gm packets -

100packets/case

Enfamil Human Milk Fortifier Acidified Liquid

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based, ultra-concentrated liquid to be added to breast milk.

For low-birthweight or premature infants.

Milk-Based


5mL - 100 vials/pack

Enfamil Premature (20 cal, 24 cal, and 30 cal)

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based infant formula; includes added nutrition and DHA and ARA.

For use in hospitals as sole nutrition for premature infants.

Metabolic Pharmacy

special order

2oz bottles case of 48ea.

Enfamil Premature High Protein 24

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based premature infant formula with more protein than other premature formulas.

For use in hospitals for premature infants.

Milk-Based


2oz bottles case of 48ea.



Product Name


Yes


Type Issuance


Enfamil ProSobee*

Mead Johnson

Nutritionals

Infant Formula X

Soy-based formula; has DHA and ARA; lactose-free; sucrose (table sugar)-free.

For babies when a soy formula is preferred.

Soy-Based,

Lactose-Free

Retail 13oz can 12.9oz can

32oz bottle, 8oz bottle - 6-

pack

Enfamil Reguline*

Mead Johnson

Nutritionals

Infant Formula X

A milk-based formula that is designed to promote comfortable stools and digestion with a blend of two prebiotics.

Infants Milk-Based Retail 12.4oz can;

20.4 oz tub 8oz bottle

6-pack

Enfaport

Mead Johnson

Nutritionals

Special Infant

Formula X

Milk-based, 30 Calorie per fluid ounce formula; with 84% of fat as MCT oil, including essential fatty acids, linolenic and alpha-linolenic acid.

For infants with chylothorax or LCHAD deficiency.

Milk-Based


6oz bottle;

24 per case

Ensure Abbott Nutrition

WIC-eligible

Nutritional

X

A nutritionally complete, lactose-free, low-residue formula for oral or tube feeding.

For adults and children age 4 and older. Prescribed due to a medical condition (i.e. Cancer, HIV, cerebral palsy, etc.) that restricts or

Adult/Older Child

Supplements

Retail Ready to Feed 8oz bottle

- 6 pack



Product Name


Yes


Type Issuance


precludes the use of conventional foods.

Ensure Clear

Abbott Nutrition

WIC-eligible

Nutritional

X

High-calorie, fat-free oral supplement. Fat-free, clear liquid nutrition containing high-quality protein and fortified with 20 essential vitamins and minerals.

Nutrition support for people with cancer, heart disease, pancreatitis, and hyperlipidemia. Ideal choice for people on clear liquid, pre- and postsurgical, bowel-prep, fat-malabsorptive, and fat-restricted diets.

Adult/Older Child

Supplements


6.8oz containers

- 32 per case

Ensure High Protein

Abbott Nutrition

WIC-eligible

Nutritional

X

High-protein, nutritionally complete, lactose-free and gluten free formula. Excellent source of 24 wssential vitamins and minerals.

For people who need extra protein and other nutrients in their diet. For people recovering from general surgery.

Adult/Older Child

Supplements

Retail Ready to Feed 8oz bottle

6 pack



Product Name


Yes


Type Issuance


Ensure Plus

Abbott Nutrition

WIC-eligible

Nutritional

X

Complete balanced nutrition with 350 calories and Immune Balance - a unique blend of prebiotic fiber to help promote digestive tract health and antioxidants to support the immune system. Excellent source of plant-based omega-3 fatty acid ALA to support h

Nutrition support primarily due to a medical condition (i.e. Cancer, HIV, cerebral palsy, etc.) that requires extra calories, corresponding higher concentrations of protein, and othe rnutrients to achieve a required caloric intake.

Adult/Older Child

Supplements

Retail 8oz bottle - 6 pack

Ensure Powder

Abbott Nutrition

WIC-eligible

Nutritional

X

A low-residue powder that, when reconstituted with water, is a low-residue formula.

For the dietary management of a medical condition (i.e. Cancer, HIV, cerebral palsy, etc.) that restricts or precludes the use of conventional foods and which may require a low-residue diet.

Adult/Older Child

Supplements

Retail 14oz

(397gm) can



Product Name


Yes


Type Issuance


Ensure Pudding

Abbott Nutrition

WIC-eligible

Nutritional

X

Complete, balanced nutrition in pudding form.

For adults with dysphasia. Prescribed due to a medical condition (i.e. Cancer, HIV, cerebral palsy, etc.) that restricts or precludes the use of conventional foods.

Adult/Older Child

Supplements


4oz cups - 48cups/case

Essential Amino Acid Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Powdered mixture of essential amino acids, including cystine and histidine.

For the dietary management of urea cycle disorders and other conditions where a nutritionally complete feed is not suitable or a modular approach is required. For individuals over 1 year of age.

Metabolic Pharmacy

special order

7oz (200gm can)

Fibersource HN


WIC-eligible

Nutritional

X

Nutritionally complete, high-protein, with a blend of soluble and insoluble fiber (15.2 g fiber/1000 mL) and 20% of the fat source coming from MCT oil.

For use in patients with elevated protein requirements, abnormal bowel function, extended inactivity, developmentally disabled, neurological impairment, long-

Adult/Older Child

Supplements


8.45oz (250Ml)

container -

24containers/case



Product Name


Yes


Type Issuance


term tube feeding.

GA

Mead Johnson

Nutritionals

Special Infant

Formula X

Lysine- and Tryptophan-free iron fortified dietary powder.

Inborn error of metabolism: For the dietary management of infants, children, and adults with glutaric acidemia type I under direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1lb (454gm) can - 4 cans/case

GA Express 15

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Lysine free, low tryptophan protein substitute.

Inborn errors of metabolism: intended for use in dietary management of Glutaric Aciduria Type 1 (GA1). Suitable from 3 years of age.

Metabolic Pharmacy

special order

25gm sachets -

30 sachets/cas

e

GA GEL Vitaflo USA LLC

WIC-eligible

Nutritional

X

Lysine free, low tryptophan protein substitute.

Inborn errors of metabolism: intended for use in dietary management of Glutaric Aciduria

Metabolic Pharmacy

special order

24gm sachets -

30 sachets/cas

e



Product Name


Yes


Type Issuance


Type 1 (GA1).

GA1 Anamix Early Years

Nutricia X

Comes in powdered form in 14.1 oz ( 400 grams ) cans providing 1892 calories. When reconstituted according to directions, produces 90 oz of fluid.

For infant 0-12 months with diagnosed Glutaric Aciduria Type 1

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Gerber Extensive Hypoallergenic (HA)

Gerber Special X

100% whey protein that has been extensively hydrolyzed to reduce the antigenicity of the protein. The formula also includes a fat blend of 49% medium chain triglycerides. The probiotic Bifidobacterium lactis BB12 is added to

For infants who have allergies to the intact proteins in cow's milk and soy formulas.

Infant Special

Formula


14.1oz can



Product Name


Yes


Type Issuance


support infant microbiota.

Gerber Good Start Gentle*

Nestle Infant

Nutrition (Gerber)

Infant Formula X

Milk-based formula with easy to digest 100% whey protein, partially hydrolyzed; contains DHA and ARA, and prebiotics.

For infants 0 - 12 months.

Milk-Based Retail 12.1oz

carton 12.7oz can 8.45oz

carton - 4 pack

Gerber Good Start Gentle 2

Nestle Infant

Nutrition (Gerber)

Infant Formula X

Milk based older-infant and toddler formula with easy to digest 100% whey protein, partially hydrolyzed; contains DHA and ARA, and prebiotics.

For use in healthy infants 9-24 months of age.

Milk-Based Retail

1.73lb ( g) tub

Gerber Good Start Grow 3

Nestle Infant

Nutrition (Gerber)

WIC-eligible

Nutritional

X

Milk based older-infant and toddler formula with easy to digest 100% whey protein, partially hydrolyzed;

12-24 months Milk-Based Retail 24oz (680g)

can



Product Name


Yes


Type Issuance


contains DHA and ARA, and probiotics.

Gerber Good Start Soothe*

Nestle Infant

Nutrition (Gerber)

Infant Formula X

A lower-lactose formula. Milk-based powdered infant formula w/ 100% partially hydrolyzed whey protein, has the probiotic L. reuteri. 20 kcal per fluid ounce

Infants 0 - 12 months


Gerber Good Start Soothe 2

Nestle Infant

Nutrition (Gerber)

Infant Formula X

A lower-lactose formula. Milk-based powdered infant formula w/ 100% partially hydrolyzed whey protein, has the probiotic L. reuteri. 20 kcal per fluid ounce

Infants 6 -12 months

Milk-Based Retail 1.38lb tub



Product Name


Yes


Type Issuance


and provides 2 mg iron per 100 calories

Gerber Good Start Soy

Nestle Infant

Nutrition (Gerber)

Infant Formula X

Milk-free, lactose-free, soy-based formula with partially hydrolyzed soy protein; contains DHA and ARA.

For infants 0 - 12 months who require a soy-based or lactose-free formula.

Soy-Based,

Lactose-Free

Retail 12.1oz carton 12.9 oz can

8.45oz carton - 4

pack

Gerber Good Start Soy 3

Nestle Infant

Nutrition (Gerber)

Infant Formula X

Milk-free, lactose-free, soy-based older-infant and toddler formula; contains DHA and ARA.

For use in infants 9-24 months of age who require a soy-based or lactose-free formula.

Soy-Based,

Lactose-Free

Retail 24oz (680g) can

Glucerna Meal Bars

Abbott Nutrition

WIC-eligible

Nutritional

X

Nutritionally complete meal or snack replacement/supplement.

For people with diabetes or abnormal glucose tolerance.

Adult/Older Child

Supplements

Retail

2.04oz bars

(58gm) - 4 bars/box (8.16oz

box)



Product Name


Yes


Type Issuance


Glucerna Shake

Abbott Nutrition

WIC-eligible

Nutritional

X

Low carbohydrate, complete balanced nutrition for oral use only.


Adult/Older Child

Supplements

Retail 8oz - six pack

Glucerna Snack Bar

Abbott Nutrition

WIC-eligible

Nutritional

X Between meal snack.


Adult/Older Child

Supplements

Retail

0.70oz bars -

6bars/box (4.2oz box)

GlutarAde Essential GA-1 Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

A lysine-free and low tryptophan powdered WIC-eligible Nutritional.

for the dietary management of Glutaric Aciduria Type 1 (GA-1) in toddlers, children, and adults, including pregnant women and women of child bearing age.

Adult/Older Child

Supplements


GlutarAde GA-1 Amino Acid Blend

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; can be used for oral and/or tube feeding; does not contain lysine and low in tryptophan.

Inborn errors of metabolism: Glutaric Aciduria Type 1 Diagnosis Code 270.7. Can be used by children, adults and pregnant women - not for infants under one year old. Not for parental use. Must be used under

Metabolic Pharmacy

special order

1lb

(454gm) can



Product Name


Yes


Type Issuance


medical supervision.

GlutarAde Junior GA-1 Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula specially formulated for toddlers and young children; nutritionally incomplete; can be used for oral and/or tube feeding; does not contain lysine and low in tryptophan. Can be used for patients for all ages if needed for additional calories

Inborn errors of metabolism: Glutaric Aciduria Type 1 Diagnosis Code 270.7. Can be used by children, adults and pregnant women - not for infants under one year old. Not for parental use. Must be used under medical supervision.

Metabolic Pharmacy

special order

1lb

(454gm) can

Glutarex-1 Abbott Nutrition

Special Infant

Formula X

Amino acid-modified WIC-eligible Nutritional with iron.

Nutrition support of infants and toddlers with glutaric aciduria type I. Give only to infants and toddlers with proven glutaric

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


aciduria type I who are under medical supervision. Must be supplemented with intact protein and fluid in prescribed amounts to

Glutarex-2 Abbott Nutrition

WIC-eligible

Nutritional

X

Amino acid-modified WIC-eligible Nutritional.

Nutrition support of children and adults with glutaric aciduria type I. Give only to children and adults with proven glutaric aciduria type I who are under medical supervision. Must be supplemented with intact protein in prescribed amounts to completely m

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Glycine500 Vitaflo USA LLC

WIC-eligible

Nutritional

X

Amino acid protein powder. Nutritionally incomplete.

For the dietary management of individuals (suitable from one year of age) with inborn errors of metabolism. Should be used under medical supervison.

Metabolic Pharmacy

special order

4gm packets -

30 packets/bo

x



Product Name


Yes


Type Issuance


Glylactin Bettermilk

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

Amino-acid based elemental formula. Can be taken via tube feeding or orally.

For ages 1 and up for the dietary management of phenylketonuria.

Metabolic Pharmacy

special order

1.7oz (49gm)

packets - 30packets/

pack

Glytactin RTD (10 and 15)

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

The beverage is ready to use and comes in flavors original and chocolate. It can be purchased with either 10 g of protein or 15g. It is sold in cases of 28 cartons each containing 8.5 fl oz.

for infants over 12 months of age to treat diagnosed phenylalanine hydroxlase deficiency or phenylketonuria as well as hyperphenylalanimia.

Adult/Older Child

Supplements


8.5oz containers

- 30 containers

/case

Glytrol Nestle


WIC-eligible

Nutritional

X

Complete liquid formula specifically formulated for adults with diabetes.

For use in patients with diabetes mellitus, glucose intolerance, stress-induced hyperglycemia.

Adult/Older Child

Supplements


250mL containers

- 24 containers

/case

HCU Anamix Early Years

Nutricia

WIC-eligible

Nutritional

X

Comes in powdered form in 14.1 oz (400 grams) cans providing 1892 calories. When reconstituted according to

For diagnosed B6 nonresponsive homocystinuria or hypermethioninaemia.

Metabolic Pharmacy

special order

14oz

(400gm) can



Product Name


Yes


Type Issuance


directions, produces 90 oz of fluid

HCU Anamix Infant

Anamix Nutricia Formula X

Methionine free formula for the dietary management of proven vitamin B6 non-responsive homocystinuria or hypermethioninaemia. Intended for infants who are a year old and up. Comes in a can of 400g of powder.

WIC-eligible Nutritional Metabolic


14oz

(400gm) can

HCU Cooler (10, 15, and 20)

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Methionine-free protein substitute consumed by people with proven homocystinuria.

For the dietary management of individuals (suitable from three years of age) with inborn errors of metabolism. Nutritionally incomplete. Should be used under strict

Metabolic Pharmacy

special order

87mL, 130mL,

and 174mL

pouches - 30

pouches/case



Product Name


Yes


Type Issuance


medical supervision.

HCU Express Powder (15 and 20)

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered methionine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a low-volume drink.

For use in the dietary management of Homocystinuria for people from 8 years of age.

Metabolic Pharmacy

special order

25gm and 34gm

packets - 30

packets/case



Product Name


Yes


Type Issuance


HCU Gel Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered methionine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a smooth gel or drink.

For use in the dietary management of Homocystinuria for people from 8 years of age.

Metabolic Pharmacy

special order

24gm sachets -

30 sachets/cas

e

HCU Lophlex LQ

Nutricia North

America

WIC-eligible

Nutritional

X

Nutritionally incomplete, methionine free.

Inborn errors of metabolism: intended for use in dietary management of Homocystinuria (HCU).

Metabolic Pharmacy

special order

125mL pouches - 30pouche

s/case

HCY 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Methionine-free iron fortified diet powder.

Inborn error of metabolism: For the dietary management of infants and toddlers with homocystinuria under direct and continuing supervision of a

Metabolic Pharmacy

special order

1lb

(454gm) can



Product Name


Yes


Type Issuance


doctor.

HCY 2

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X Methionine-free dietary powder.

Inborn errors of metabolism: For adults and children with homocystinuria; to be used under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1lb

(454gm) can

Hi-Cal Abbott Nutrition

WIC-eligible

Nutritional

X

High-calorie supplement fortified with vitamins and minerals.

For people needing extra calories/nutrition. Ideal for Med Pass.

Adult/Older Child

Supplements


33.8fl oz bottle

Homactin AA Plus

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

For the dietary management of individuals with homocystinuria (HCU).

Inborn errors of metabolism: For the dietary management of proven homocystinuria in children over 1 and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

8.5oz containers (250mL) -

30 containers

/case

Hominex-1 Abbott Nutrition

Special Infant


Nutrition

X Methionine-free formula.

Inborn errors of metabolism: Nutrition support for infants and toddlers with homocystinuria due

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


al to cystathione B-synthase deficiency.

Hominex-2 Abbott Nutrition

WIC-eligible

Nutritional

X Methionine-free formula.

Inborn errors of metabolism: Nutrition support for children and adults with homocystinuria due to cystathione B-synthase deficiency.

Metabolic Pharmacy

special order

14.1oz (400gm)

can

Isoleucine 50 and 1000 Amino Acid Supplement

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered isoleucine amino acid supplement on a carbohydrate base.

Provide dietary isoleucine for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gm sachets -

30 sachets carton

Isosource 1.5 Cal


WIC-eligible

Nutritional

X

Nutritionally complete, high calorie formula and 20 percent of the fat source comes from MCT oil.

Can be used for oral feedings and/or tube feedings; adults with medical conditions requiring fluid restriction; and lactose-intolerance, but not for galactosemia.

Metabolic.


250mL containers

- 24 containers

/case

Isosource HN


WIC-eligible

Nutritional

X

Nutritionally complete, high-protein, with 20% of the fat source coming

For use in patients with elevated protein requirements, malnutrition,

Adult/Older Child

Supplements


Ready to Feed

250mL containers

- 24 containers

/case



Product Name


Yes


Type Issuance


from MCT oil. inadequate oral intake, transitional feeding.

Isovactin AA Plus

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

For the dietary management of individuals with isovaleric acidemia (IA).

Inborn errors of metabolism: For the dietary management of proven isovaleric acidemia in children over 1 and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

8.5oz (250mL) -

30 cartons/ca

se

IVA Anamix Early Years

Nutricia Special Infant

Formula X

Comes in powdered form in 14.1 oz ( 400 grams ) cans providing 1892 calories. When reconstituted according to directions, produces 90 fluid oz/can

For infants 0-12 months with diagnosed Isovalericacidemia

Pharmacy

special order

14oz

(400gm) can

I-Valex-1 Abbott Nutrition

Special Infant


Nutrition

X Leucine-free formula.

Inborn errors of metabolism: Nutrition support of infants and toddlers with disorders of leucine catabolism.

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


al

I-Valex-2 Abbott Nutrition

WIC-eligible

Nutritional

X Leucine-free formula.

Inborn errors of metabolism: Nutrition support of infants and toddlers with disorders of leucine catabolism.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Jevity 1 Cal Abbott Nutrition

WIC-eligible

Nutritional

X Isotonic nutrition with fiber.

For patients who have intolerance of hyperosmolar feeding or altered taste perception.

Adult/Older Child

Supplements


8oz (237mL) carton -

24 cartons/ca

se

Jevity 1.2 Cal

Abbott Nutrition

WIC-eligible

Nutritional

X

High protein nutrition with fiber and NutraFlorascFos.

For patients who may benefit from a moderate-osmolality, high protein, fiber containing formula.

Metabolic Pharmacy

special order


24 cartons/ca

se

Jevity 1.5 Abbott Nutrition

WIC-eligible

Nutritional

X

High-protein nutrition with fiber and NutraFlora scFOS.

For tube feeding or oral feeding of patients with altered taste perception. CAUTION: When used for tube

Adult/Older Child

Supplements



24 cartons/ca

se



Product Name


Yes


Type Issuance


feeding, follow physician's instruction.

KetoCal 3:1

Nutricia North

America

WIC-eligible

Nutritional

X

WIC-eligible Nutritional that contains a 3:1 (fat: carbohydrate + protein) ratio enabling an individual to achieve and maintain a high level of ketosis; high in fat and low in carbohydrate.

Provide complete or supplemental nutritional support for children over one year of age with intractable epilepsy.

Milk-Based


Powder

KetoCal 4:1

Nutricia North

America

WIC-eligible

Nutritional

X

WIC-eligible Nutritional that contains a 4:1 (fat: carbohydrate + protein) ratio enabling an individual to achieve and maintain a high level of ketosis; high in fat and low in

Provide complete or supplemental nutritional support for children over one year of age with intractable epilepsy.

Metabolic Pharmacy

special order

11oz

(300gm) can



Product Name


Yes


Type Issuance


carbohydrate.

KetoCal 4:1 LQ

Nutricia North

America

WIC-eligible

Nutritional

X

WIC-eligible Nutritional that contains a 4:1 (fat: carbohydrate + protein) ratio enabling an individual to achieve and maintain a high level of ketosis; high in fat and low in carbohydrate. Contains a multi-fiber system: a blend of insoluble and soluble fiber. Supple

Nutritionally complete 4 to 1 ratio (4:1) liquid ketogenic formula for the dietary management of intractable epilepsy. Provides complete nutritional support or supplementary feeding from 1-10years of age. May be used for supplementary feeding over the age

Metabolic Pharmacy

special order

8oz (237mL)

container - 27

containers/case

Ketonex-1 Abbott Nutrition

Special Infant

Formula & WIC-

X Isoleucine-, leucine-, valine-, free formula.

Inborn errors of metabolism: Nutrition support of children and adults

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


eligible Nutrition

al

with: maple syrup urine disease or B-ketothiolase deficiency.

Ketonex-2 Abbott Nutrition

WIC-eligible

Nutritional

X Isoleucine-, leucine-, valine-, free formula.

Inborn errors of metabolism: Nutrition support of children and adults with: maple syrup urine disease or B-ketothiolase deficiency.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

KetoVie 4.1

Cambrook Theraputic

s

Children 1 years or older

X

4:1 ratio of Fat to Protein + Carbohydrate for the medical management of intractable epilepsy, glucose transporter type 1 deficiency syndrome, pyruvate dehydrgenase deficiency and other disorders that require a ketogenic diet.

For children one year and older, only use underthe supervision of a physician.

Formula Pharmacy

special order

8.5oz (250mL)

containers - 30

containers/case



Product Name


Yes


Type Issuance


KetoVie Peptide

Cambrooke

Theraputics

WIC-eligible

Nutritional

X

Ready-to-drink product formulated for tube-feeding or can be fed orally.

For ages 1 and up for the dietary management of intractable epilepsy and other conditions where a ketogenic diet is indicated.

Metabolic Pharmacy

special order

8.5oz (250mL)

containers - 30

containers/case

KetoVolve 4:1

MetaGenes

WIC-eligible

Nutritional

X

KetoVolve is a 4 to 1 ratio (fat to carbohydrate + protein) powder formula; very high fat, adequate protein and low carbohydrate formula. KetoVolve is a WIC-eligible Nutritional designed to maintain the high level of ketosis for those with epilepsy.

For children 1-8 years Metabolic


300gm can

KeyOmega Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered blend of Arachidonic acid (AA) and Docosahexaenoic acid (DHA) supplement on a carbohydrate

Provide dietary AA & DHA for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gm sachets -

30 sachets carton



Product Name


Yes


Type Issuance


base.

L-Emental Hormel Health Labs

WIC-eligible

Nutritional

X

Elemental 100% free amino acid diet (adult) for oral or complete tube feeding; lactose free, gluten free, low residue.

For use in patients with inflammatory bowel disease, bowel resection, chronic diarrhea, Crohns disease, irradiated bowel, malabsorption, GI fistula, short bowel syndrome, pancreatic disorder, limited gut function.

Metabolic Pharmacy

special order

50gram bottle

Lipistart Vitaflo USA LLC

WIC-eligible

Nutritional

X

Nutritionally complete, powdered formula containing whole protein, carbohydrate, fat high in medium chain triglycerides and low in long chain triglycerides, vitamins, minerals, trace

For the dietary management of fat malabsorption, disorders of long chain fatty acid oxidation, Type 1 hyperlipidemia and chylothorax and disorders requiring dietary management using a high MCT, low LCT formula; for patients 1 years of age and older.

Metabolic Pharmacy

special order

400gram can



Product Name


Yes


Type Issuance


elements and essential fatty acids; mixed with water.

LMD

Mead Johnson

Nutritionals

Special Infant

Formula X

Leucine-free iron fortified dietary powder.

Inborn error of metabolism: For the dietary management of infants, children, and adults with inborn errors of Leucine Metabolism, including Isovaleric Acidemia, under direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1lb

(454gm) can

MCT Oil Nestle


WIC-eligible

Nutritional

X

Modular source of MCT (Medium Chain Triglycerides).

For patients with problems hydrolyzing, absorbing and/or transporting conventional fats.

Metabolic Pharmacy

special order

1 quart (32oz)



Product Name


Yes


Type Issuance


MCTprocal Vitaflo USA LLC

WIC-eligible

Nutritional

X

Neutral tasting powder containing protein, carbohydrate and fat high in medium chain triglycerides; can be mixed with liquid or food.

For use in the dietary management of malnutrition, fat malabsorption, disorders of long chain fatty acid oxidation, Type 1 hyperlipidemia and chylothorax; for patients 1 year of age and older.

Metabolic Pharmacy

special order

16gram packets/

30packets/carton

MCTprocal Vitaflo USA LLC

WIC-eligible

Nutritional

X

Neutral tasting powder containing protein, carbohydrate and fat; can be mixed with liquid or food.

For use in the dietary management of disease related malnutrition, malabsorption states and other conditions requiring fortification with protein, carbohydrate and fat; for patients 1 year of age and older.

Metabolic Pharmacy

special order

16gram packets -

30packets/box

Methionine Amino Acid Supplement

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered methionine amino acid supplement on a carbohydrate base.

Provide dietary methionine for patients 1 year of age and older.

Metabolic Pharmacy

special order

4gram packet -

30packets/carton



Product Name


Yes


Type Issuance


Microlipid Nestle


WIC-eligible

Nutritional

X

50% fat emulsion (safflower oil emulsion) for special dietary use in oral or tubeâ€“feeding formulas; high in linoleic acid.

For patients with increase caloric requirements, anorexia, decreased carbohydrate tolerance, or fluid/volume restriction.

Metabolic Pharmacy

special order

3oz bottles -

48bottles/case

MMA/PA Cooler15

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Methionine, threonine, valine free protein substitute.

Inborn errors of metabolism: intended for use in dietary management of Methylmalonic academia/Propionic academia (MMA/PA). Suitable from 3 years of age.

Metabolic Pharmacy

special order

130mL pouches - 30pouches/carton

MMA/PA Express Powder15

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered methionine, threonine, valine free and isoleucine low protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and

For use in the dietary management of Methylmalonic Acidemia and Proprionic Acidemia for patients 8 years of age and older.

Metabolic Pharmacy

special order

25gram packets -

30packets/carton



Product Name


Yes


Type Issuance


trace elements; can be blended with water into a low-volume drink.

MMA/PA Gel

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered methionine, threonine, valine free and isoleucine low protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a smooth gel or drink.

For use in the dietary management of Methylmalonic Acidemia and Proprionic Acidemia for patients 1 year of age and older.

Metabolic Pharmacy

special order

Powder

24gram packets -

30packets/case



Product Name


Yes


Type Issuance


MMA-PA Anamix Early Years


formula X

Comes in powdered form in 14.1 oz ( 400 grams ) cans providing 1892 calories. When reconstituted according to directions, produces 90 oz of fluid

For infsants ages 0-12 months with diagnosed Methylmalonic or Propionic Acidemia

Metabolic Pharmacy

special order

400gram can

Monogen Nutricia North

America

WIC-eligible

Nutritional

X

Milk-protein based powder, low in fat and high in medium chain triglycerides. Contains DHA and ARA.

For the dietary management of gastrointestinal, lymphatic and metabolic disorders.

Metabolic Pharmacy

special order

400gram can

MSUD Aid Nutricia North

America

WIC-eligible

Nutritional

X

Isoleucine-, leucine- and valine-free drink mix that contains a balanced mixture of all other essential and some non-essential amino acids. Contains minerals and trace elements and some

Inborn errors of metabolism: For the dietary management of proven maple syrup urine disease in individuals over one year of age.

Metabolic Pharmacy

special order

200gram can



Product Name


Yes


Type Issuance


water-soluble vitamins. Not suitable as sole source of nutrition.

MSUD Analog

Nutricia North

America

Special Infant

Formula X

Valine-, leucine- and isoleucine-free formula; contains a balanced mixture of other essential and non-essential amino acids, carbohydrate, fat and micronutrients. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven maple syrup urine disease in infants.

Metabolic Pharmacy

special order

14oz

(400gm) can

MSUD Anamix Early Years


Formula X

For diagnosed Maple Syrup Urine Disease

Age 0-12 months Metabolic Pharmacy

special order

14.1 oz (400

grams) cans



Product Name


Yes


Type Issuance


MSUD Cooler (10, 15, and 20)

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Leucine, isoleucine and valine free protein substitute for the dietary management of maple syrup urine disease (MSUD). Nutritionally incomplete.

For the dietary management of individuals (suitable from three years of age) with inborn errors of metabolism. Should be used under strict medical supervision.

Metabolic Pharmacy

special order

87mL, 130mL, and 174mL pouches - 30puches/case

MSUD Express (15 and 20) Powder

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered leucine, isoleucine and valine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a low-volume drink.

For use in the dietary management of Maple Syrup Urine Disease for people 8 years of age and older.

Metabolic Pharmacy

special order

25gm and 34gm

sachets - 30

sachets/case

MSUD Gel Vitaflo USA LLC

WIC-eligible

NutritionX

Powdered leucine, isoleucine and

or use in the dietary management of Maple Syrup Urine

Metabolic Pharmacy

special order

24gram

packets - 30packets/



Product Name


Yes


Type Issuance


al valine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins, minerals and trace elements; can be blended with water into a smooth gel or drink.

Disease for people 1 year of age and older.

case

MSUD Lophlex LQ

Nutricia North

America

WIC-eligible

Nutritional

X

Nutritionally incomplete, leucine and valine free.

Inborn errors of metabolism: intended for use in dietary management of Maple Syrup Urine Disease (MSUD).

Metabolic Pharmacy

special order

4.2oz (125mL)

pouches - 30pouches/carton

MSUD Maxamum

Nutricia North

America

WIC-eligible

Nutritional

X

Isoleucine-, leucine-, and valine-free powdered drink mix that contains a balanced mixture of all other essential and non-essential amino

Inborn errors of metabolism: For the dietary management of proven maple syrup urine disease in older children and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

1lb

(454gm) can



Product Name


Yes


Type Issuance


acids, carbohydrate and micronutrients. Not suitable as sole source of nutrition.

Neocate Infant

Nutricia North

America

Special Infant

Formula X

Hypoallergenic. Complete nutritional support for infants with cow milk allergy and multiple food protein intolerance. Contains 100% free amino acids; includes DHA and ARA.

An infant formula for infants with cow and soy milk allergy, multiple food protein intolerance, food allergy-related Gastroesophageal Reflux Disease (GERD) and Eosinophilic esophagitis (EE), and other conditions for which an amino acid-based diet is requi

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Neocate Junior

Nutricia North

America

WIC-eligible

Nutritional

X

An elemental WIC-eligible Nutritional containing 100% free amino acids. Complete nutritional support for children with

For children over one year of age with with cow and soy milk allergy, multiple food protein intolerance, food allergy-related Gastroesophageal Reflux Disease

Metabolic Pharmacy

special order

14.1oz

(400gm) can



Product Name


Yes


Type Issuance


gastrointestinal impairment due to cow and soy protein allergies or sensitivity or other medical conditions affecting the gastrointestinal tract.

(GERD) and Eosinophilic esophagitis (EE), and other conditions for which an amino acid-based diet

Neocate Junior - Prebiotics

Nutricia North

America

WIC-eligible

Nutritional

X

An elemental WIC-eligible Nutritional containing 100% free amino acids and prebiotic fiber. Complete nutritional support for children with gastrointestinal impairment due to cow and soy protein allergies or sensitivity or other medical conditions affecting the gastrointestinal tract

For children over one year of age with with cow and soy milk allergy, multiple food protein intolerance, food allergy-related Gastroesophageal Reflux Disease (GERD) and Eosinophilic esophagitis (EE), and other conditions for which an amino acid-based diet

Metabolic Pharmacy

special order

Powder 14.1oz

(400gm) can



Product Name


Yes


Type Issuance


Neocate Nutra

Nutricia North

America

WIC-eligible

Nutritional

X

Hypoallergenic, amino acid-based semi-solid WIC-eligible Nutritional that contains essential vitamins and minerals.

For infants over 6 months of age with cow or soy milk allergy, multiple WIC-eligible Nutritional protein intolerance or gastrointestinal conditions

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Neocate Splash

Nutricia North

America

WIC-eligible

Nutritional

X

Pediatric amino acid-based ready-to-feed liquid for children over 1 year in age. Nutritionally complete, including vitamins, minerals, and trace elements. Available in multiple flavors.

For children over one year of age with cow and soy milk allergy, multiple food protein intolerance, food allergy-related Gastroesophageal Reflux Disease (GERD) and Eosinophilic esophagitis (EE), and other conditions for which an amino acid-based diet is r

Metabolic Pharmacy

special order

8oz (237mL) - 27containers/case



Product Name


Yes


Type Issuance


Neocate Syneo

Nutricia North

America

Special Infant

Formula X

Hypoallergenic amino-acid based infant formula for the dietary management of infants with cow milk allergy, multiple food allergies, and related GI conditions. Contains Syndeo, a patented synbiotic (prebiotic and probiotic).

For use in infants - under medical supervision.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Nepro Abbott Nutrition

WIC-eligible

Nutritional

X

Therapeutic nutrition for people on dialysis.

For dialyzed dialysis patients with chronic renal failure (stage 5 of CKD).

Metabolic Pharmacy

special order

Ready to Feed

8oz (237mL)

can- 24cans/ca

se

Novasource Renal


WIC-eligible

Nutritional

X

Nutritionally complete, calorically-dense liquid formula fortified with vitamins and minerals commonly lost in dialysis; used for oral and/or

For dialyzed patients with acute or chronic renal failure; Generally designed for adults and children at least 10 years of age; provides a reduced electrolyte content to help

Adult/Older Child

Supplements


Ready to Feed

8oz (237mL) can - 24cans/case



Product Name


Yes


Type Issuance


tube feeding; lactose-free, gluten-free, low-residue, kosher.

prevent imbalances.

Nutramigen

Mead Johnson

Nutritionals

Special Infant

Formula X

Hypoallergenic formula; contains extensively hydrolyzed proteins; includes DHA and ARA.

For infants who have allergies to the intact proteins in cow's milk and soy formulas.

Metabolic Retail 13oz can 32oz bottle

Nutramigen Toddler (with Enflora LGG)

Mead Johnson

Nutritionals

Special Infant

Formula X

Hydrolyzed infant formula with probiotics.

For older infants and toddlers aged 9 to 36 months with Cow's Milk Allergy.

Lactose-Free Retail

12.6oz (357gram)

can

Nutramigen with Enflora LGG

Mead Johnson

Nutritionals

Special Infant

Formula X

Hypoallergenic, extensively hydrolyzed protein so it is uncommonly recognized as an allergen by the body's immune system. The probiotic LGG has been shown to promote a healthy GI and immune system

For the dietary management of infants with cow's milk protein allergy. Infants who are allergic to cow's milk protein may have immune system imbalance, a harmful gut microflora, and a compromised gut barrier.

Metabolic Retail 12.6oz

(357gram) can

2oz nursette - 48ea/case

; 8oz plastic

bottle - 6 bottles/pa

ck; 32oz plastic bottles



Product Name


Yes


Type Issuance


by supporting a balanced immune response, colonizing the

Nutren 1.0 Nestle


WIC-eligible

Nutritional

X

Nutritionally complete with 20% of fat source coming from MCT oil.

Generally for adults and children at least 13 years of age; ideal for short or long-term tube feeding for those with normal protein and calorie requirements.

Adult/Older Child

Supplements


250mL carton -

24ea/case

Nutren 1.0 with Fiber


WIC-eligible

Nutritional

X

Nutritionally complete with a blend of soluble and insoluble fiber (15.2 g fiber/1000 mL) and 20% of the fat source coming from MCT oil.

Generally for adults and children at least 13 years of age; ideal for short- or long-term tube feeding for patients with normal protein and calorie requirements. Fiber helps in management of

Adult/Older Child

Supplements


250mL carton -

24ea/case



Product Name


Yes


Type Issuance


diarrhea and/or constipation.

Nutren 1.5 Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, calorically dense and 20% of the fat source coming from MCT oil.

Generally for adults and children at least 13 years of age; ideal for short- or long-term tube feeding for patients with increased caloric requirements and/or a fluid restriction.

Adult/Older Child

Supplements


250mL carton -

24ea/case

Nutren 2.0 Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, very high calorie and 50% of the fat source coming from MCT oil.

Generally for adults and children at least 13 years of age; ideal for short- or long-term tube feeding for patients with very high caloric requirements or severe fluid restriction.

Adult/Older Child

Supplements


250mL carton -

24ea/case



Product Name


Yes


Type Issuance


Nutren Junior


WIC-eligible

Nutritional

X

Nutritionally complete, isotonic, whole protein liquid diet for complete or supplemental nutrition support in pediatric patients; use as oral and/or tube feeding; lactose-free, gluten-free, kosher, low-residue.

Designed for children ages 1-10,with stable and functioning gastrointestinal tract. Can be used with cancer; pre- and post-surgery; pediatric failure to thrive; neurologic disease or impairment; HIV/AIDS; multiple fractures; anorexia/weight loss; malnutrition

Adult/Older Child

Supplements


250mL carton -

24ea/case

Nutren Junior with Fiber


WIC-eligible

Nutritional

X

Nutritionally complete, fiber-containing, whole protein liquid diet for complete or supplemental nutrition support for oral and/or tube feeding in pediatric patients; lactose-free, gluten-free, kosher, low-residue.

Designed for children ages 1-10, with stable and functioning gastrointestinal tract. Can be used with cancer; pre-and post-surgery; pediatric failure-to-thrive; neurological disease or impairment; HIV/AIDS; multiple fractures; anorexia/weight loss; malnut

Adult/Older Child

Supplements


250mL carton -

24ea/case



Product Name


Yes


Type Issuance


Nutren Pulmonary


WIC-eligible

Nutritional

X

Nutritionally complete, low carbohydrate formula with a high-fat profile that includes MCT and canola oil to improve tolerance. Calorically-dense to meet elevated energy needs in a low volume for oral and/or tube feeding use; lactose-free, gluten-free, lo

Generally designed for adults and children at least 10 years of age with respiratory disease. Designed to reduce CO2 production. High MCT content to minimize fat intolerance; elevated phosphorus content to replenish low serum phosphorus levels.

Adult/Older Child

Supplements


250mL carton -

24ea/case

Nutricia Liquigen

Nutricia North

America

WIC-eligible

Nutritional

X

An emulsified Medium Chain Triglyceride (MCT) oil.

Recommended for long-chain fatty acid oxidation disorders and conditions managed by the ketogenic diet.

Metabolic Pharmacy

special order

8.5oz (250mL)

bottle - 12 bottles/ca

se

NutriHep Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, calorically dense liquid formerly for Hepatic patients. Lactose-free, gluten-free,

Generally designed for adults and children at least 10 years of age for the nutritional management of liver injury which can be caused by

Adult/Older Child

Supplements


250mL carton -

24ea/case



Product Name


Yes


Type Issuance


low-residue, and kosher. For tube feeding and/or oral supplement.

viral infection, ischemia, metabolic abnormalities, or damage from hepatotoxic substances.

OA 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Isoleucine-, Methionine-, Threonine- and Valine-free iron-fortified dietary powder.

Inborn error of metabolism: For the dietary management of infants and toddlers with propionic and methylmalonic acidemias under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1lb

(454gm) can

OA 2

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

Isoleucine-, Methionine-, Threonine- and Valine-free iron fortified dietary powder.

Inborn error of metabolism: For the dietary management of children and adults with propionic and methylmalonic acidemias under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1 lb

(454gm) can



Product Name


Yes


Type Issuance


Osmolite (1 Cal, 1.2 Cal, and 1.5 Cal)

Abbott Nutrition

WIC-eligible

Nutritional

X Isotonic nutrition.

For patients with caloric requirements of less than 2000 Cal per day or for patients with increased protein requirements.

Metabolic Pharmacy

special order

8oz (237mL)

container -

24ea/case

Oxepa Abbott Nutrition

WIC-eligible

Nutritional

X

Therapeutic nutrition for modulating inflammation in sepsis, ALI, ARDS.

For critically ill, mechanicall-ventilated patients with SIRS, ALI or ARDS.

Adult/Older Child

Supplements


8oz can -

24cans/case

PediaSure (Grow and Gain)

Abbott Nutrition

WIC-eligible

Nutritional

X

Suitable for lactose intolerance, gluten-free liguid food for oral and tube feeding.

For children 1 to 10 years of age who are undernourished due to illness or a medical condition that warrants the prescription of the product.

Adult/Older Child

Supplements

Retail 8oz - 6pack

PediaSure (Grow and Gain) with Fiber

Abbott Nutrition

WIC-eligible

Nutritional

X

A milk-based, fiber-containing, gluten-free, lactose-free isotonic enteral formula for tube or oral feeding.

For children 1 to 10 years of age. Note: Use under medical supervision. Not intended for infants under 1 year of age unless specified by a physician. May be used as the sole source of nutrition. See product

Adult/Older Child

Supplements

Retail

8oz bottle - 6pack



Product Name


Yes


Type Issuance


literature or manufacturer representative for de

PediaSure 1.5 Cal

Abbott Nutrition

WIC-eligible

Nutritional

X

Higher caloric density product designed for pediatric patients who require higher caloric concentrated feedings, such as for children with malnutrition, children who have fluid restrictions, or children who have poor tolerance to large volume feeds.

Not intended for infants under 1 year of age unless specified by a physician. Not for parenteral use. Not for children with galactosemia.

Adult/Older Child

Supplements


8oz (237mL)

can - 24cans/ca

se



Product Name


Yes


Type Issuance


PediaSure 1.5 Cal with Fiber

Abbott Nutrition

WIC-eligible

Nutritional

X

Higher caloric density product designed for pediatric patients who require higher caloric concentrated feedings, such as for children with malnutrition, children who have fluid restrictions, or children who have poor tolerance to large volume feeds.

Not intended for infants under 1 year of age unless specified by a physician. Not for parenteral use. Not for children with galactosemia.

Adult/Older Child

Supplements


8oz (237mL)

can - 24cans/ca

se

PediaSure Enteral Formula

Abbott Nutrition

WIC-eligible

Nutritional

X

A milk-based, gluten-free and lactose-free formula for tube or oral feeding.

For tube feeding children 1 to 13 years of age. May be used as the sole source of nutrition. See product literature or manufacturer representative for details. Note: Not for children with galactosemia. Use under medical

Milk-Based,

Lactose-Free


8oz (237mL)

can - 24cans/ca

se



Product Name


Yes


Type Issuance


supervision. Not intended for infan

PediaSure Enteral Formula with fiber

Abbott Nutrition

WIC-eligible

Nutritional

X

A milk-based, gluten-free and lactose-free formula with fiber; contains a patented blend of soluble and insoluble fibers and fructooligosaccharides (FOS).

For children 1 to 13 years of age. It is designed for tube feeding but is also appropriate for oral feeding. Note: Not for children with galactosemia. Use under medical supervision. Not intended for infants under 1 year of age unless specified by a physic

Metabolic Pharmacy

special order

8oz (237mL)

can - 24cans/ca

se

PediaSure Peptide 1.0 Cal

Abbott Nutrition

WIC-eligible

Nutritional

X

Therapeutic Semi-Elemental Nutrition for Children for tube or oral feeding.

For tube or oral feeding as sole source or supplemental nutrition. Designed for children ages 1-13 with malabsorption, maldigestion or impaired GI function resulting

Adult/Older Child

Supplements


8oz (237mL)

can - 24cans/ca

se



Product Name


Yes


Type Issuance


from: inflammatory bowel disease (ulcerative colitis, crohn's), cystic fibrosis, celiac d

PediaSure Peptide 1.5 Cal

Abbott Nutrition

WIC-eligible

Nutritional

X

Therapeutic peptide-based nutrition for children. For oral or tube feeding.

For tube or oral feeding as sole source or supplemental nutrition. Designed for children ages 1-13 with malabsorption, maldigestion or impaired GI function resulting from: inflammatory bowel disease (ulcerative colitis, crohn's), cystic fibrosis, celiac d

Adult/Older Child

Supplements


8oz (237mL)

can - 24cans/ca

se



Product Name


Yes


Type Issuance


Pediasure Sidekicks

Abbott Nutrition

WIC-eligible

Nutritional

X

Provides complete nutrition for children ages 2-13 with 150 calories per 8 fluid ounce serving compared to 240 calories for standard PediaSure.

May meet the dietary needs of individuals with neurological impairments such as cerebral palsy or growth retarding syndromes who would medically benefit from a lower calorie product that contains 100 percent of the Dietary Reference Intake levels recommen

Adult/Older Child

Supplements

Retail 8oz - 6pack

Pepdite Junior

Nutricia North

America

WIC-eligible

Nutritional

X

A semi-elemental, non-dairy WIC-eligible Nutritional containing low molecular weight peptides and free amino acids. Complete nutritional support for children with gastrointestinal impairment where a

For patients with GI tract impairment, malabsorption, whole protein intolerance, other medical conditions where an elemental diet is indicated.

Metabolic Pharmacy

special order

51gram packets -

15packets/case



Product Name


Yes


Type Issuance


hydrolyzed, non-dairy formula is indicated.

Peptamen Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, isotonic, liquid, peptide-based elemental diet; provides complete or supplemental nutritional support in easily absorbed form from partially hydrolyzed whey protein for tube feeding; lactose-free, gluten-free, and low- residue.

For adults and children generally over 10 who have impaired gastrointestinal function; also short bowel syndrome, inflammatory bowel disease, malabsorption syndromes, pancreatic insufficiency, chronic diarrhea, radiation enteritis, and delayed gastric emp

Metabolic Pharmacy

special order

250mL container

- 24containers/case

Peptamen with Prebio1


WIC-eligible

Nutritional

X

Nutritionally complete, 100% hydrolyzed whey protein. Lactose-free, gluten-free. For tube feeding and/or oral supplement.

Complete elemental diet for adults and children at least 10 years of age with impaired gastrointestinal function with the added benefits of soluble fiber.

Metabolic Pharmacy

special order

250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Peptamen 1.5


WIC-eligible

Nutritional

X

Nutritionally complete, calorically dense, liquid peptide-based elemental diet, provides complete or supplemental nutritional support in a readily absorbable form from partially hydrolyzed whey protein for tube feeding; lactose -free, gluten -free, low- residue

For adults and children generally over 10 who have impaired gastrointestinal function with normal or elevated caloric requirements. Peptide-based to improve absorption, designed for those with malabsorption complicated by fluid restriction, elevated calor

Metabolic Pharmacy

special order

250mL container

- 24containers/case

Peptamen 1.5 with Prebio1


WIC-eligible

Nutritional

X

Complete nutrition, calorically dense, peptide based tube feeding formula with soluble fiber added to help support digestive health.

Calorically dense, complete elemental diet with soluble fiber for adults and children at least 10 years of age with impaired gastrointestinal function that have normal or elevated caloric requirements and

Adult/Older Child

Supplements


250mL container

- 24containers/case



Product Name


Yes


Type Issuance


require the added benefits of soluble fiber.

Peptamen AF


WIC-eligible

Nutritional

X

Nutritionally complete elemental formula with partially hydrolyzed whey protein and soluble fiber. It is isotonic, high calorie and protein, lactose-free, gluten-free, and may be used for oral and/or tube feeding. It is not for individuals with galactosemia

Designed for adults with medical conditions such as impaired gastrointestinal function, adult respiratory distress syndrome, organ transplant, cancer or sepsis. It is not for individuals with galactosemia.

Metabolic Pharmacy

special order

250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Peptamen Intense HP


WIC-eligible

Nutritional

X

Complete nutrition, peptide based tube feeding formula intended to meet the calorie and protein needs of acutely ill patients with obesity.

Complete elemental nutrition for adults and children at least 10 years of age that are acutely ill and require special caloric and protein intake.

Adult/Older Child

Supplements


250mL container

- 24containers/case

Peptamen Junior


WIC-eligible

Nutritional

X

Nutritionally complete, isotonic, peptide-based elemental diet partially hydrolyzed whey protein. Provides complete or supplemental nutritional support; for tube feeding use; lactose-free, gluten-free, and low residue.

Provides a customized protein, lipid, vitamin, and mineral profile for children ages 1 to 10 with impaired gastrointestinal function; also for inflammatory bowel disease, short bowel syndrome, cystic fibrosis, chronic diarrhea, malabsorption, cerebral pal

Metabolic Pharmacy

special order

250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Peptamen Junior with Prebio1


WIC-eligible

Nutritional

X

Nutritionally complete, elemental liquid diet; may also be used as a dual feeding with TPN or as a transition diet from TPN.

For the nutritional management of children ages 1 to 10 with chronic diarrhea/malabsorption, growth failure, short-bowel syndrome, bowel transplants, cerebral palsy, Crohn's disease, HIV/AIDS and cystic fibrosis, as well as other conditions causing impair

Metabolic Pharmacy

special order

250mL container

- 24containers/case

Peptamen Junior 1.5


WIC-eligible

Nutritional

X

Nutritionally complete peptide-based elemental nutrition for children ages 1 to 13. Lactose-fee and gluten-free.

For children 1 to 13 years of age who require 100% enzymatically hydrolyzed whey protein. Can be used in children for a variety of medical conditions, including chronic diarrhea, short bowel syndrome and cystic fibrosis.

Metabolic Pharmacy

special order

250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Peptamen Junior Fiber


WIC-eligible

Nutritional

X

Elemental formula with a blend of Prebio1 and insoluble fiber.

For the dietary management of gastrointestinal-compromised children 1 to 10 years of age. Can provide support for children with short bowel syndrome, cerebral palsy, cystic fibrosis, Crohn's disease, HIV/AIDS, malabsorption, chronic diarrhea, delayed gast

Metabolic Pharmacy

special order

250mL container

- 24containers/case

Peptamen Junior HP

Nestle Healthcare Nutrition

WIC-eligible

Nutritional

X

Enzymatically hydrolyzed 100 percent whey, nutritionally complete, peptide-based formula with impaired gastrointestinal function. Suitable for lactose intolerance but not for galactosemia or cows' milk allergy.

For use in children ages 1 to 13 years.

Adult/Older Child

Supplements


250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Perative Abbott Nutrition

WIC-eligible

Nutritional

X

Therpeutic, peptide based nutrition for metabolic stress.

For use in the nutritional management of metabolically stressed patients such as those with multiple fractures, wounds, burns, decubitus ulcers, surgery, hypermetabolism and/or risk of sepsis.

Metabolic Pharmacy

special order

8oz (237mL)

can - 24cans/ca

se

Periflex Advance

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free powdered drink mix that contains a balanced mixture of other essential and non-essential amino acids, carbohydrate, fat and micronutrients. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in older children and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

16oz

(454gm) can



Product Name


Yes


Type Issuance


Periflex Early Year Formula

Nutricia North

America

Special Infant

Formula X

Phenylalanine-free but contains balanced mixture of all other essential and non-essential amino acids, carbohydrate, fat, vitamins, minerals and trace elements. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in infants.

Metabolic Pharmacy

special order

14.1oz (400gm) can

Periflex Junior

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free powdered drink mix that contains a balanced mixture of other essential and non-essential amino acids, carbohydrate, fat and micronutrients. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in toddlers and young children.

Metabolic Pharmacy

special order

14.1oz (400gm) can



Product Name


Yes


Type Issuance


PFD 2

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

Protein- and Amino acid-free product. This product does contain taurine, a non-protein-building amino acid.

For the dietary management of children and adults with inborn errors of amino acid metabolism or with special nutritional needs under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

16oz

(454gm) can

PFD Toddler

Mead Johnson

Nutritionals

Special Infant

Formula X

Protein- and Amino acid-free product. This product does contain taurine, a non-protein-building amino acid.

For the dietary management of toddlers with inborn errors of amino acid metabolism under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

16oz

(454gm) can

Phenactin AA Plus

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

For the dietary management of individuals with phenylketonuria (PKU).

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in children over 1 and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

8.5oz (250mL) cartons -

30cartons/case



Product Name


Yes


Type Issuance


Phenex-1 Abbott Nutrition

Special Infant

Formula X

Phenylalanine-free formula for infants.

Inborn errors of metabolism: Nutrition support for infants and toddlers with phenylketonuria (PKU) and hyperphenyl-alanimenia (hyperphe).

Metabolic Pharmacy

special order

14.1oz

(400gm) can

Phenex-2 Abbott Nutrition

WIC-eligible

Nutritional

X

Phenylalanine-free formula for children and adults.

Inborn errors of metabolism: Nutrition support of children and adults with PKU or hyperphe.

Metabolic Pharmacy

special order

14.1oz

(400gm) can

PhenylAde Amino Acid Bars

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; can be used for oral feeding; some contain phenylalanine while others phenylalanine-free.

Inborn errors of metabolism: Phenylketonuria Diagnosis Code 270.1 -Can be used by children, adults and pregnant women -Not for infants under one year old.

Metabolic Pharmacy

special order

47gram bar -

12bars/case



Product Name


Yes


Type Issuance


PhenylAde Essential Drink Mixes

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; improved nutrient profile, contains flax & fiber; can be used for oral and/or tube feeding; fortified with vitamins, minerals essential and non essential amino acids, does not contain phenylalanine.

Inborn errors of metabolism: Phenylketonuria Diagnosis Code 270.1 -Can be used by children, adults and pregnant women -Not for infants under one year old -Not for parenteral use. Must be used under medical supervision.

Metabolic Pharmacy

special order

1lb (454gm)

can; 40gram -

16packets

PhenylAde MTE Amino Acid Blend

Nutricia North

America

WIC-eligible

Nutritional

X

Metabolic formula; nutritionally incomplete; can be used for oral and/or tube feeding; does not contain phenylalanine.

Inborn errors of metabolism: Phenylketonuria Diagnosis Code 270.1 -Can be used by children, adults and pregnant women -Not for infants under one year old -Not for parenteral use.

Metabolic Pharmacy

special order

1lb (454gm)

can; 12.8gram pouches -

30pouches/box



Product Name


Yes


Type Issuance


PhenylAde40 Drink Mixes

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free Metabolic formula; nutritionally incomplete; high in protein, low in fat and calories, can be used for oral and/or tube feeding; fortified with essential and non-essential amino acids.

Inborn errors of metabolism: Phenylketonuria Diagnosis Code 270.1 - Can be used by children, adults and pregnant women - Not for infants under one year old - Not for parenteral use. Must be used under medical supervision.

Metabolic Pharmacy

special order

25gram pouches -

20 puches/box

PhenylAde60 Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free Metabolic formula; nutritionally incomplete; high in protein, low in calories and low in fat, can be used for oral and/or tube feeding; fortified with vitamins, minerals, essential and non-essential amino acids.

Inborn errors of metabolism: Phenylketonuria Diagnosis Code 270.1 - Can be used by children, adults and pregnant women - Not for infants under one year old - Not for parenteral use. Must be used under medical supervision.

Metabolic Pharmacy

special order

1lb (454gram)

can; 16.7gram pouch -

30puches/box



Product Name


Yes


Type Issuance


Phenyl-Free 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Phenylalanine-free, iron-fortified dietary powder.

Inborn errors of metabolism: For the dietary management of infants and toddlers with PKU (phenylketonuria) under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1 lb

(454gm) can

Phenyl-Free 2

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X Phenylalanine-free dietary powder.

Inborn errors of metabolism: For the dietary management of children and adults with PKU (phenylketonuria) under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1 lb

(454gm) can

Phenyl-Free 2 HP

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

Phenylalanine-free dietary powder; high in protein.

Inborn errors of metabolism: For the dietary management of children and adults with PKU (phenylketonuria), also appropriate for women with maternal PKU. Use under the direct

Metabolic Pharmacy

special order

1 lb (454gm)

can



Product Name


Yes


Type Issuance


and continuing supervision of a doctor.

Phlexy-10 Drink Mix

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free powdered drink mix that contains a balanced mixture of all other essential and non-essential amino acids and carbohydrate. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in children over the age of 1 year and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

14oz

(400gram) can

Phlexy-10 Tablets

Nutricia North

America

WIC-eligible

Nutritional

X

Phenylalanine-free but otherwise balanced mixture of essential and non-essential amino acids in a cellulose capsule. Not suitable as sole source of

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in children (need to be able to swallow capsules) and adults, including pregnant women and women of

Metabolic Pharmacy

special order

75

tablets/bottle



Product Name


Yes


Type Issuance


nutrition. child-bearing age.

PKU Cooler 10

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Ready to drink phenylalanine free protein substitute, available in flavored and neutral tasting options, containing essential and non-essential amino acids, carbohydrate, vitamins, trace elements and the omega-3 fatty acid DHA; provides 10g protein per se

For use in the dietary management of Phenylketonuria for people 3 years of age and older.

Metabolic Pharmacy

special order

87mL pouch -

30pouches/carton

PKU Cooler 15

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Ready to drink phenylalanine free protein substitute, available in flavored and neutral tasting

For use in the dietary management of Phenylketonuria for people 3 years of age and older.

Metabolic Pharmacy

special order

130mL pouch -

30pouches/carton



Product Name


Yes


Type Issuance


options, containing essential and non-essential amino acids, carbohydrate, vitamins, trace elements and the omega-3 fatty acid DHA; provides 15g protein per serving

PKU Cooler 20

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Ready to drink phenylalanine free protein substitute, available in flavored and neutral tasting options, containing essential and non-essential amino acids, carbohydrate, vitamins, trace elements and the omega-3 fatty acid DHA; provides 20g protein per serving

Provide Phenylalanine-free protein for patients 8 years of age and older.

Metabolic Pharmacy

special order

174mL pouch -

30pouches/carton



Product Name


Yes


Type Issuance


PKU Express20

Vitaflo USA LLC

WIC-eligible

Nutritional

X A phenylalanine free protein substitute.

For the dietary management of Phenylketonuria (PKU). Suitable from 3 years of age.

Metabolic Food


34gram packet -

30packets/carton

PKU Gel Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered phenylalanine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins and trace elements; can be blended with water into a smooth gel or drink.

For use in the dietary management of Phenylketonuria for people 1 year of age and older.

Metabolic Pharmacy

special order

24gram packets -

30packets/case

PKU Lophlex LQ

Nutricia North

America

WIC-eligible

Nutritional

X

A phenylalanine-free, ready to drink WIC-eligible Nutritional containing amino acids, vitamins, trace elements and some minerals.

For the dietary management of phenylketonuria (PKU) in individuals 4 years and older, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

4.2oz (125mL)

pouches - 30pouches/carton



Product Name


Yes


Type Issuance


PKU Lophlex Powder

Nutricia North

America

WIC-eligible

Nutritional

X

Low-volume, phenylalanine-free, amino acid-based powdered drink mix with vitamins and minerals.

Inborn errors of metabolism: For the dietary management of phenylketonuria in children over the age of 4 and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

27.8gram sachets -

30sachets/box

PKU Periflex Early Years


Formula X

Phenylalanine free infant formula

Ages 0-12 months with diagnosed Phenylketonuria.

Metabolic Pharmacy

special order

14.1oz

(400gram) can

PKU Trio Vitaflo USA LLC

WIC-eligible

Nutritional

X

Phenylalanine free WIC-eligible Nutritional.

Inborn errors of metabolism: intended for use in dietary management of Phenylketonuria (PKU) from 1 year of age and during pregnancy.

Metabolic Pharmacy

special order

400gram can



Product Name


Yes


Type Issuance


PKU-Express (15 and 20)

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Powdered phenylalanine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins and trace elements; can be blended with water into a low-volume drink.

Provide phenylalanine-free protein for patients 8 years or older.

Metabolic Pharmacy

special order

25grams or 34grams -

30packets/carton

Polycal Nutricia North

America

WIC-eligible

Nutritional

X

Powdered carbohydrate energy source. Contains maltodextrin as the sole ingredient.

For the dietary management of adults and children over 1 year of age with disease related malnutrition and conditions requiring a high energy, low fluid diet.

Metabolic Pharmacy

special order

400gram can

Portagen

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

Milk-based powder with medium chain triglycerides (MCT).

For children and adults with defects in the breakdown, absorption and transport of fat in the body.

Metabolic Pharmacy

special order

14.46 oz can



Product Name


Yes


Type Issuance


Pregestimil

Mead Johnson

Nutritionals

Special Infant

Formula X

An iron-fortified, lactose-free, sucrose (table sugar)-free, hypoallergenic infant formula with 55% of the fat from medium-chain triglycerides (MCT) oil; includes DHA and ARA.

For infants who experience fat malabsorption and who may be sensitive to intact proteins.

Metabolic Pharmacy

special order

1lb (16oz) can

Pregestimil 20 and 24 Cal/fl oz

Mead Johnson

Nutritionals

Special Infant

Formula X

An iron-fortified, lactose-free, sucrose (table-sugar)-free, hypoallergenic infant formula with 55% of the fat from medium-chain triglycerides (MCT) oil; includes DHA and ARA.

For infants who experience fat malabsorption and who may be sensitive to intact proteins.

Metabolic Pharmacy

special order

2oz nursettes -

48 nursettes/

case



Product Name


Yes


Type Issuance


Product 3232A

Mead Johnson

Nutritionals

Special Infant

Formula X

A protein hydrolysate formula base that is to be used with added carbohydrate. It contains tapioca starch.

Inborn errors of metabolism: For use in the dietary management of infants and children with disaccharidase deficiencies or other disorders of carbohydrate metabolism under the direct and continuing supervision of a doctor.

Metabolic Pharmacy

special order

1lb (16oz) can

Promactin AA Plus

Cambrooke

Therapeutics

WIC-eligible

Nutritional

X

For the dietary management of individuals with methylmalonic acidemia (MA) and propionic acidemia (PA).

Inborn errors of metabolism: For the dietary management of proven methylmalonic acidemia and propionic acidemia in children over 1 and adults, including pregnant women and women of child-bearing age.

Metabolic Pharmacy

special order

8.5oz (250mL)

containers - 30

containers/case



Product Name


Yes


Type Issuance


ProMod Liquid Protein

Abbott Nutrition

WIC-eligible

Nutritional

X Concentrated liquid protein.

For people with increased protein needs including wounds, protein-energy malnutrition (PEM), involuntary weight loss (IWL), pre-and post-surgery, anorexia, stress, trauma, cancer and burns.

Metabolic Pharmacy

special order

1 quart (32oz) bottle

Promote Abbott Nutrition

WIC-eligible

Nutritional

X

High-protein, nutritionally complete liquid food.

For patients who may benefit from an increased protein intake. A lactose-free/gluten-free liquid; it will not contribute to lactose-associated diarrhea.

Adult/Older Child

Supplements


8oz (237oz)

can - 24cans/ca

se

Promote with Fiber

Abbott Nutrition

WIC-eligible

Nutritional

X

Complete, balanced, very-high-protein, and fiber-fortified liquid formula.

For patients who need a higher proportion of calories from protein, for those with low caloric and/or wound healing needs and those at risk for protein-energy malnutrition or pressure ulcers.

Adult/Older Child

Supplements


8oz (237oz)

can - 24cans/ca

se



Product Name


Yes


Type Issuance


Pro-Phree Abbott Nutrition

Special Infant


Nutritional

X Protein-free formula.

Nutrition support of infants and toddlers requiring reduced protein intake or increased energy, minerals & vitamins.

Metabolic Pharmacy

special order

14.1 oz (400

grams) cans

Propimex-1

Abbott Nutrition

WIC-eligible

Nutritional

X

Methionine- and valine-free, low in isoleucine and threonine.

Inborn errors of metabolism: For nutrition support of infants and toddlers with propionic or methylmalonic acidemia.

Metabolic Pharmacy

special order

14.1oz

(400gram) can

Propimex-2

Abbott Nutrition

WIC-eligible

Nutritional

X

Methionine- and valine-free, low in isoleucine and threonine.

Inborn errors of metabolism: For nutrition support of infants and toddlers with propionic or methylmalonic acidemia.

Metabolic Pharmacy

special order

14.1oz

(400gram) can

ProViMin Abbott Nutrition

Special Infant


Nutritional

X Protein, vitamins and minerals.

Inborn errors of metabolism: Nutrition support for disorders of: abeta and hypo betalipoproteinemia, cholestasis, chylothorax, chylous ascites, fatty acid oxidation defects (mitochondrial),

Metabolic Pharmacy

special order

5.3oz

(150gram) can



Product Name


Yes


Type Issuance


glutaric aciduria type II, hyperlipoproteinemia

Pulmocare Abbott Nutrition

WIC-eligible

Nutritional

X

Therapeutic nutrition for people with COPD.

High-calorie, low-carbohydrate formula to help reduce carbon dioxide production, which may be helpful for paitents with COPD, cystic fibrosis, or respiratory failure.

Metabolic Pharmacy

special order

8oz (237mL)

can - 24cans/ca

se

Puramino

Mead Johnson

Nutritionals

Special Infant

Formula X

Hypoallergenic, amino acid-based formula for infants and toddlers with severe cow's milk protein and multiple food allergies.

For the dietary management of infants and toddlers with severe cow's milk protein and multiple food allergies.

Metabolic Pharmacy

special order

14.1oz

(400gram) can

PurAmino Toddler

Mead Johnson

Nutritionals

WIC-eligible

Nutritional

X

100 percent amino acid formula with DHA.

For toddlers aged 1 year and older with severe cow's milk allergies and mutiple food allergies.

Metabolic Pharmacy

special order

14.1oz (400gram)

can



Product Name


Yes


Type Issuance


Renalcal Nestle


WIC-eligible

Nutritional

X

Ready-to-use, nutritionally incomplete calorically dense low protein formula with a low electrolyte profile for short term use; lactose-free, gluten-free, low residue and kosher. Uses are tube feeding and/or oral supplement.

Provides nutritional support for patients with acute renal failure. Generally recommended for adults and children at least 10 years of age. This formula contains no added electrolytes or fat soluble vitamins.

Adult/Older Child

Supplements


250mL container

- 24containers/case

Renastart Vitaflo USA LLC

WIC-eligible

Nutritional

X

A nutritionally complete, powdered formula with low levels of protein, calcium, chloride, potassium, phosphorus and vitamin A, containing whole protein, amino acids, carbohydrate, fat, vitamins, minerals, trace

May be used for complete nutritional support or supplementary feeding in the dietary management of renal failure in individuals 1 year of age and older.

Metabolic Pharmacy

special order

14.11oz

(400gram) can



Product Name


Yes


Type Issuance


elements and the long-chain polyunsaturated

Replete Nestle


WIC-eligible

Nutritional

X

Nutritionally complete, high-protein formula for healing support with 20% of the fat source coming from MCT oil.

Formulated to meet the nutritional requirements of wound healing and protein repletion. Specifically formulated for use in patients recovering from surgery, burns, or pressure ulcers. Generally designed for adults and children at least 13 years of age.

Adult/Older Child

Supplements


250mL container

- 24containers/case



Product Name


Yes


Type Issuance


Replete Fiber


WIC-eligible

Nutritional

X

Nutritionally complete, high protein, with a blend of soluble and insoluble fiber (15.2 g fiber/1000 mL) and 20% of the fat source coming from MCT oil.

Formulated to meet nutritional requirements of wound healing. Fiber helps in management of diarrhea and/or constipation. For those recovering from surgery, burns, or pressure ulcers. Generally designed for adults and children at least 13 years of age.

Adult/Older Child

Supplements


250mL container

- 24containers/case

Resource 2.0


WIC-eligible

Nutritional

X

Calorically dense, high-nitrogen, low-sodium, complete liquid formula for adults. Low residue, lactose-free, gluten-free, kosher.

For patients on medication pass programs, wound prevention and treatment programs, fluid restricted/volume sensitive patients (congestive heart failure, liver disease with ascites, respiratory disease, pulmonary edema), shortened feeding schedules, elevat

Adult/Older Child

Supplements


32oz carton;

8oz cartons -

27cartons/case



Product Name


Yes


Type Issuance


Ross Carbohydrate Free (RCF)

Abbott Nutrition

Special Infant

Formula X Carbohydrate-

free formula.

For use in patients with carbohydrate malabsorption, disaccharidase deficiencies, glucose transport defect, seizure disorders requiring a ketogenic diet.

Metabolic Pharmacy

special order

13oz (384mL)

can - 12cans/c

ase

ScandiShake

AxcanPharma

WIC-eligible

Nutritional

X

High calorie gluten-free high-fat high-carbohydrate powdered mixture without supplemental vitamins and minerals. Certified kosher. Lactose Free and Sweetened with Aspartame formulations. Note: ScandiShake is not a meal replacement and should not be considered as a sole source of nutrition

For the dietary management of an adult or child with a warranted medical condition.

Adult/Older Child

Supplements


85gram sachets -

6sachets/box



Product Name


Yes


Type Issuance


Similac Special Care 24

Abbott Nutrition

Special Infant

Formula X

A ready-to-feed, commercially sterile, premature infant formula, suitable for use as a human milk fortifier.

For premature infants.

Milk-Based


2oz nursette - 48nursettes/case

Similac Advance

Abbott Nutrition

Infant Formula X

Infant formula with iron; milk-based, supplemented with DHA and ARA. Supplemented with prebiotics, antioxidants, and nucleotides.

For infants 0 - 12 months.

Milk-Based Retail

13oz concentrate can

12.4oz can

1qt (32oz) bottle; 8oz bottle-six

pack

Similac Alimentum

Abbott Nutrition

Special Infant

Formula X

A protein hydrolysate formula with iron for oral or tube feedings.

A nutritionally complete hypoallergenic formula for infants and a supplemental beverage for children with severe food allergies, sensitivity to intact protein, protein maldigestion or fat

Metabolic Pharmacy

special order

1lb

(454gram) can

1 quart (32oz) bottle



Product Name


Yes


Type Issuance


malabsorption.

Similac for Diarrhea

Abbott Nutrition

Special Infant

Formula X

A soy formula with iron for diarrhea for oral or tube feedings. Caution: Should not be fed to infants or toddlers with constipation.

A short-term (7-10 days or as directed by a doctor) feeding for the dietary management of diarrhea in infants older than 6 months and toddlers.

Metabolic


1quart (946mL) bottle

Similac for Spit-Up

Abbott Nutrition

Infant Formula X

Milk-based, lactose free infant formula. Contains rice starch.

For lactose sensitivity and when milk-based formula is medically recommended.

Milk-Based,

Lactose-Free

Retail 12oz (340gram) can

1quart (32oz) bottle



Product Name


Yes


Type Issuance


Similac Go and Grow (milk based) - unflavored and vanilla

Abbott Nutrition

Infant Formula X

Older infant and toddler formula with iron; milk-based, supplemented with DHA and ARA. (9-12 months=Infant Formula, 12+months=WIC-eligible Nutritional). Formerly Similac 2 Advance.

Toddlers 12 - 24 months

Milk-Based Retail 1.5lb

powder

Similac Human Milk Fortifier

Abbott Nutrition

Special Infant

Formula & WIC-eligible Nutritio

nal

X

Nutritionally incomplete supplement to be added to preterm human milk (human milk fortifier.)

For premature or low-birthweight infants.

Metabolic


0.9gram packet - 50packets/carton

Similac NeoSure

Abbott Nutrition

Special Infant

Formula X

Higher calorie, higher nutrient base formula. May be used for oral or tube feeding.

For premature infants. Metabolic Retail 13.1oz can

1quart (946mL) bottle



Product Name


Yes


Type Issuance


Similac PM 60/40

Abbott Nutrition

Special Infant

Formula X

A low-iron infant formula for oral or tube feedings.

For infants predisposed to or being treated for hypocalcemia due to hyperphosphatamia, or those with impaired renal function who would benefit from lowered mineral intake. Additional iron should be supplied form other sources.

Metabolic


14.1oz (400gram) can

Similac Sensitive

Abbott Nutrition

Infant Formula X

Lactose-free, milk-based formula.

For lactose sensitivity and when milk-based formula is medically recommended.

Milk-Based,

Lactose-Free

Retail 12oz (340gram) can

1quart (32oz) bottle



Product Name


Yes


Type Issuance


Similac Soy Isomil*

Abbott Nutrition

Infant Formula X

A soy-based, iron-fortified infant formula, supplemented with DHA and ARA.

For infants with feeding problems such as allergies or sensitivity to cow's-milk protein; for patients with disorders for which lactose should be avoided, including lactase deficiency, lactose intolerance, and galactosemia (Powder preferred).

Soy-Based,

Lactose-Free

Retail 12.4oz powder can

1quart bottle

Similac Special Care 24

Abbott Nutrition

Special Infant

Formula X

A 24 Cal/fl oz, low-iron premature infant formula; contains DHA and ARA. Additional iron may be supplied from other sources as necessary.

For growing, low-birth-weight infants. Very low-birth-weight infants are particularly susceptible to gastrointestinal complications; therefore, feeding should be initiated cautiously.

Metabolic


2oz nursettes -48 nursettes/case



Product Name


Yes


Type Issuance



Abbott Nutrition

Infant Formula X

Milk-based, powdered nutritionally complete infant formula with 100% partially hydrolyzed whey protein and 98% less lactose than other Similac standard milk-based infant formulas. Contains DHA, prebiotics and lutein.

Easy to digest, lactose reduced formula for infants.

Milk-Based Retail

12oz (340gram) can

SOD Anamix Early Years


Formula X

Comes in powdered form in 14.1 oz (400 grams) cans providing 1892 calories. When reconstituted according to directions, produces 90 oz of fluid

For infants ages 0-12 months with diagnosed Sulfite Oxydase Deficiency

Metabolic


400gram can



Product Name


Yes


Type Issuance


SolCarb Solace Nutrition

WIC-eligible Nutritio

nal

X

Soluble form of powdered carbohydrate. Can be added to tube feedings, liquids, or moist foods.

For indications such as inborn errors of metabolism, gastrointestinal volume restriction, and limited renal solute load in individuals from one year of age.

Metabolic


1lb (454gram) can

SOS (15, 20, and 25)

Vitaflo USA LLC

WIC-eligible

Nutritional

X

Age specific range of neutral-tasting carbohydrate powder drink mixes; can be blended with water into a low-volume drink.

For use as an emergency regimen in the dietary management of inborn errors of metabolism. S.O.S. 15 is recommended from 1 to 2 years of age.S.O.S. 20 is recommended from 2 to 10 years of age.S.O.S. 25 is recommended from 1

Metabolic Pharmacy

special order

31gram sachet, 42gram sachet, 52gram sachet - 30sachets/carton



Product Name


Yes


Type Issuance


Super SolubleDuocal

Nutricia North

America


nal

X

A powdered WIC-eligible Nutritional providing fat and carbohydrate for increased caloric intake; not suitable as sole source of nutrition.

Inborn errors of metabolism: For patients with disorders of protein and amino acid metabolism, protein restricted diets, electrolyte restricted diets, high energy diets, failure to thrive.

Adult/Older Child Supplem

ents


14.oz (400 gram) can

Suplena Abbott Nutrition


nal

X

Therapeutic nutrition for people with chronic kidney disease (Stages 3&4).

For people with chronic kidney disease (stages 3 and 4) to help mainain their nutritional status while adhering to their renal diets.

Metabolic


8oz (237mL)

can - 24cans/c

ase

Tolerex

Nestle HealthCar

e Nutrition


nal

X

Nutritionally complete, very low-fat elemental diet for adults containing 100% free amino acids. Low residue, lactose-free,

For use in patients with impaired digestion and absorption, specialized nutrient needs e.g. food allergies.

Metabolic


2.82oz packets - 60packets/case



Product Name


Yes


Type Issuance


gluten-free, kosher.

TRY Lophlex LQ

Nutricia North

America


nal

X

Nutritionally incomplete, tyrosine and phenylaline free.

Inborn errors of metabolism: intended for use in dietary management of Tyrosinemia (TRY).

Metabolic


4.2oz (125mL) pouches - 30pouches/carton

Two Cal HN

Abbott Nutrition


nal

X

Nutritionally complete, high-calorie, high-nitrogen liquid formula for oral or tube feeding.

For severely fluid-restricted patients or those with limited volume tolerance.

Metabolic


8oz (237mL) can - 24cans/case

Tylactin 15 RTD

Cambrooke

Therapeutics


nal

X

Contains Tylactin, a proprietary, advanced formulation of glycomacropeptide and essential amino acids without added tyrosine and phenylalanine.

For ages 1 and up for the dietary management of tyrosinemia.

Metabolic


8.5oz (250mL) cartons - 30cartons/case



Product Name


Yes


Type Issuance


TYR Anamix Early Years

Nutricia X

Comes in powdered form in 14.1 oz ( 400 grams ) cans providing 1892 calories. When reconstituted according to directions, produces 90 oz of fluid.

For ages 0-12 months with diagnosed Tyrosinemia.

Pharmacy

special order

14oz (400gram) can

TYR Anamix Next

Nutricia North

America


nal

X

For the dietary management of individuals with proven Tyrosinemia (TYR); a phenylalanine and tyrosine free, mild flavored powdered product. Nutritionally incomplete.

Inborn errors of metabolism: For the dietary management of Tyrosinemia in children over the age of 1 year.

Metabolic





Product Name


Yes


Type Issuance


TYR Cooler (10, 15, and 20)

Vitaflo USA LLC


nal

X

Ready to drink tyrosine and phenylalanine free protein substitute, available in orange flavor, containing essential and non-essential amino acids, carbohydrate, vitamins, trace elements and DHA & EPA.

For use in the dietary management of Tyrosinemia for people 3 years of age and older.

Metabolic


87mL, 130mL, 174mL pouches - 30 pouches/case

TYR Cooler 20

Vitaflo USA LLC


nal

X

Phenyalanine and tyrosine free protein substitute for the dietary management of tyrosinemia (TRY). Nutritionally incomplete.

For the dietary management of individuals (suitable from three years of age) with inborn errors of metabolism. Should be used under strict medical supervision.

Metabolic




Product Name


Yes


Type Issuance


TYR Express (15 and 20) Powder

Vitaflo USA LLC


nal

X

Powdered tyrosine and phenylalanine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins and trace elements; can be blended with water into a low-volume drink.

For use in the dietary management of Tyrosinemia for people 3 years of age and older.

Metabolic


25gram or 34gram packets; 30 packets/carton

TYR Gel Vitaflo USA LLC


nal

X

Powdered tyrosine and phenylalanine free protein substitute containing essential and non-essential amino acids, carbohydrate, vitamins and trace elements; can

For use in the dietary management of Tyrosinemia for people 1 year of age and older.

Metabolic


24gram packets - 30packets/case



Product Name


Yes


Type Issuance


be blended with water into a smooth gel or drink.

Tyrex-1 Abbott Nutrition

Special Infant

Formula & WIC-eligible Nutritio

nal

X

Phenylalanine-and tyrosine-free formula.

Inborn errors of metabolism: Nutrition support of infants and toddlers with tyrosinemia types I,II,III.

Metabolic



Tyrex-2 Abbott Nutrition


nal

X

Phenylalanine-and tyrosine-free formula.

Inborn errors of metabolism: Nutrition support of infants and toddlers with tyrosinemia types I,II,III.

Metabolic





Product Name


Yes


Type Issuance


TYROS 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Phenylalanine- and Tyrosine-free iron fortified dietary powder.

Inborn error of metabolism: For the dietary management of infants and toddlers with Tyrosinemia Type I and Type II under the direct and continuing supervision of a doctor.

Metabolic


1lb (454gram) can

TYROS 2

Mead Johnson

Nutritionals


nal

X

Phenylalanine- and tyrosine-free dietary powder.

Inborn errors of metabolism: For the dietary management of children and adults with inborn errors of Tyrosine metabolism including Tyrosinemia Type II under the direct and continuing supervision of a doctor.

Metabolic


1lb (454gram) can



Product Name


Yes


Type Issuance


UCD Anamix Jr. (Unflavored and Vanilla)

Nutricia North

America


nal

X

Contains essential amino acids and branched chain amino acids (BCAA) to help maintain positive nitrogen balance and promote optimal protein synthesis. A nutrionally incomplete product, it must be supplemented with protein and other nutrients as medically

Inborn errors of metabolism: For the dietary management of Urea Cycle Disorder (UCD), Hyperammonemia, Hyperornithinemia, Homocitrullinemia Syndrome and Gyrate Atrophy. For children one year of age and older.

Metabolic


14oz (400gram) can

UCD Trio Vitaflo USA LLC


nal

X

Essential amino acid WIC-eligible Nutritional.

Inborn errors of metabolism: intended for use in dietary management of Urea Cycle

Metabolic


400gram can



Product Name


Yes


Type Issuance


Disorder (UCD) from 1 year of age and during pregnancy.

Valine (50 & 1000) Amino Acid Supplement

Vitaflo USA LLC


nal

X

Powdered valine amino acid supplement on a carbohydrate base.

To be used in conjunction with a protein substitute for people with Maple Syrup Urine Disease 1 year of age and older.

Metabolic


4grams - 30sachets

/carton

Vilactin AA Plus

Cambrooke

Therapeutics


nal

X

For the dietary management of individuals with maple syurp urine disease (MSUD).

Inborn errors of metabolism: For the dietary management of proven maple syrup urine disease in children over 1 and adults, including pregnant women and women of child-bearing age.

Metabolic


8.5oz (250mL) containers - 30containers/case



Product Name


Yes


Type Issuance


Vital Peptide 1.5

Abbott Nutrition


nal

X

Calorie dense, peptide-based formula. Lipid source 55% medium chain triglycerides

Malabsorption, maldigestion, and other GI conditions. Designed for ages 14+. Provides complete nutrition for those 14 to 18 years old.


ents


8oz (237mL) containers- 24 containers/case

Vital High Protein

Abbott Nutrition


nal

X

Therapeutic, elemental, lowfat nutrition.

For patients with chronically impaired gastrointestinal function (maldigestion, malabsorption).


ents


8oz (237mL) containers - 24 containers/case

Vivonex Pediatric

Nestle HealthCar

e Nutrition


nal

X

Nutritionally complete elemental formula for children ages 1-10. Used as a tube feeding or consumed orally. Low residue, lactose-free, gluten-free, kosher.

For use in patients with transitional feeding following TPN, short bowel syndrome, malabsorption syndrome, select trauma/surgery, Crohn's disease, GI enterocutaneous fistula, intractable

Metabolic


1.7oz packets -

36packets/case



Product Name


Yes


Type Issuance


diarrhea, GI disorder related to AIDS.

Vivonex Plus

Nestle HealthCar

e Nutrition


nal

X

High-nitrogen, low-fat, elemental diet for total enteral nutrition for adults. Low residue, lactose-free, gluten-free, kosher.

For use in patients with transitional feeding following TPN, bowel resection, irradiated bowel malabsorption syndrome, select trauma/surgery, early postoperative feeding, Crohn's disease, GI enterocutaneous fistula, pancreatic disorders.

Metabolic


2.8oz packets -

36packets/case

Vivonex Ready to Feed

Nestle HealthCar

e Nutrition


nal

X

High-nitrogen, low-fat elemental diet for total enteral nutrition for adults. Low residue, lactose-free, gluten-free,

For use in patients with bowel resection, irradiated bowel, malabsorption syndrome, select trauma/surgery, Crohn's disease, GI enterocutaneous

Metabolic


250mL cartons - 24carton

s/case



Product Name


Yes


Type Issuance


kosher. fistula, pancreatic disorders, early postoperative feeding, transitional feeding following TPN.

Vivonex T.E.N.

Nestle HealthCar

e Nutrition


nal

X

Nutritionally complete low-fat, elemental diet for total enteral nutrition for adults. Low residue, lactose-free, gluten-free, kosher.

For use in patients with bowel resection, irradiated bowel, malabsorption syndrome, select trauma/surgery, Crohn's disease, GI enterocutaneous fistula, pancreatic disorders, limited gut function.

Metabolic


2.84oz packets - 60packet

s/case

WND 1

Mead Johnson

Nutritionals

Special Infant

Formula X

Non-essential amino acid-free iron fortified dietary powder.

Inborn error of metabolism: For the dietary management of infants and toddlers with inborn errors of

Metabolic


1lb (454gram)

can



Product Name


Yes


Type Issuance


the urea cycle under the direct and continuing supervision of a doctor.

WND 2

Mead Johnson

Nutritionals


nal

X

Non-essential amino acid free dietary powder.

Inborn errors of metabolism: For the dietary management of children and adults with inborn errors of the urea cycle under the direct and continuing supervision of a doctor.

Metabolic


1lb (454gram)

can

Xleu Maxamum

Nutricia North

America


nal

X

Leucine-free powdered drink mix that contains a balanced mixture of all other essential and non-essential amino acids, carbohydrate and micronutrients

Inborn errors of metabolism: For the dietary management of proven isovaleric acidemia and other disorders of leucine metabolism in children over 8 years of age and adults.

Metabolic


1lb (454gram)

can



Product Name


Yes


Type Issuance


. Not suitable as sole source of nutrition.

XLys, XTrp Maxamum

Nutricia North

America


nal

X

Lysine- and tryptophan--free powdered drink mix but contains a balanced mixture of all other essential and non-essential amino acids, carbohydrate and micronutrients. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven glutaric academia Type I in older children and adults, including pregnant women and women of child-bearing age.

Metabolic


1lb (454gram)

can



Product Name


Yes


Type Issuance


XMet Analog

Nutricia North

America

Special Infant

Formula X

Methionine-free but contains balanced mixture of all other essential and non-essential amino acids, carbohydrate, fat, and vitamins, minerals, and trace elements. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven vitamin B6 non-responsive homocystinuria or hypermethioninemia in infants.

Metabolic


400gram can

XMTVI Maxamum

Nutricia North

America


nal

X

Methionine-, threonine-, valine-free and isoleucine-low powdered drink mix that contains a balanced mixture of all other essential and non-essential

Inborn errors of metabolism: For the dietary management of proven propionic or methylmalonic acidemia in older children and adults, including pregnant women and women of child-bearing age.

Metabolic


1lb (454gram)

can



Product Name


Yes


Type Issuance


amino acids, carbohydrate and micronutrients. Not suitable as sole source of nutrition.

Xphe Maxamum

Nutricia North

America


nal

X

Phenylalanine-free powdered drink mix that contains a balanced mixture of all other essential and non-essential amino acids, carbohydrate and micronutrients. Not suitable as sole source of nutrition.

Inborn errors of metabolism: For the dietary management of proven phenylketonuria in older children and adults, including pregnant women and women of child-bearing age.

Metabolic


1lb (454gram)

can



Product Name


Yes


Type Issuance


#0120A L-Arginine

Nutricia North

America

WIC-eligible

Nutritional

X

Single amino acid WIC-eligible Nutritional.

For the dietary management of inborn errors of metabolism that provide necessary nutrients to people with inherited metabolic disorders of metabolism such as phenylketonuria, maple syrup urine disease and glutaric aciduria Type I. May be used for children

Metabolic Pharmacy

special order

50gram bottle

#0130G Glycine

Nutricia North

America

WIC-eligible

Nutritional

X



Metabolic Pharmacy

special order

Powder 50gram bottle



Product Name


Yes


Type Issuance


#0140I L-Isoleucine

Nutricia North

America

WIC-eligible

Nutritional

X



Metabolic Pharmacy

special order

50gram bottle

#0150L L-Leucine

Nutricia North

America

WIC-eligible

Nutritional

X



Metabolic Pharmacy

special order

50gram bottle



Product Name


Yes


Type Issuance


#0160T L-Tyrosine

Nutricia North

America

WIC-eligible

Nutritional

X



Metabolic Pharmacy

special order

50gram bottle

#0170V L-Valine

Nutricia North

America

WIC-eligible

Nutritional

X


For the dietary management of inborn errors of metabolism that provide necessary nutrients to people with inherited metabolic disorders of metabolism such as phenylketonuria, maple syrup urine disease and glutaric aciduria Type I.

Metabolic Pharmacy

special order

50gram bottle

2% ONESource Optimal Nutrition Drink

One Source

Nutrition, LLC

WIC-eligible

Nutritional

X

Gluten-free, lactose-free, kosher, oral nutrition drink.

For children from one year age and adults.

Adult/Older Child

Supplements


8oz box - 27ea/case

* = Non-contract formula limited to specific fragile needs circumstances.



Index 19 kcal/oz Contract Formulas, 4-4, 4-6, 4-

10, 4-11, 4-12, 4-39 AHCCCS Referral Letter, 4-29 Conditionally Special Formula, 4-5, 4-6, 4-

10, 4-15 Contract Formula, 4-4, 4-6, 4-10, 4-11, 4-

12, 4-13, 4-16 corrected age, 4-18, 4-20 Documentation, 4-6, 4-7, 4-8, 4-10, 4-11,

4-16 Formula Descriptions, 4-40 gestational age, 4-20 immunocompromised infants, 4-20 Liquid Formula, 4-20 low birth weight, 4-5, 4-20, 4-39, 4-42, 4-

43, 4-60 Low Iron Formula, 4-23 Medical documentation, 4-8, 4-11, 4-13 New Food Package Form, 4-26 Non-Contract Formula, 4-4, 4-6, 4-12, 4-67 oral nutritional supplements, 4-14, 4-30 pharmacy special order, 4-13, 4-45, 4-51 powdered infant formula, 4-20, 4-67, 4-75,

4-84 Premature Infant, 4-18 prescriptive authority, 4-6, 4-7, 4-8, 4-9, 4-

10, 4-11, 4-13, 4-20, 4-21

refrigeration, 4-19, 4-20 restricted water supply, 4-19 Special Formula, 4-5, 4-6, 4-10, 4-13, 4-14,

4-15, 4-30, 4-48, 4-53, 4-57, 4-58, 4-60, 4-61, 4-62, 4-63, 4-66, 4-67, 4-70, 4-73, 4-74, 4-76, 4-77, 4-80, 4-85, 4-86, 4-88, 4-90, 4-91, 4-94, 4-103, 4-104, 4-107, 4-111, 4-112, 4-113, 4-114, 4-118, 4-119, 4-120, 4-121, 4-122, 4-126, 4-127, 4-129, 4-130, 4-131, 4-132, 4-133

Standard Contract Formulas, 4-4, 4-6, 4-10, 4-11, 4-12, 4-16, 4-19

WIC-Eligible Nutritionals, 4-5, 4-6, 4-10, 4-15, 4-47, 4-48, 4-49, 4-50, 4-51, 4-52, 4-53, 4-54, 4-55, 4-56, 4-57, 4-58, 4-63, 4-64, 4-65, 4-66, 4-68, 4-69, 4-70, 4-71, 4-72, 4-73, 4-74, 4-75, 4-76, 4-77, 4-78, 4-79, 4-80, 4-81, 4-82, 4-83, 4-84, 4-85, 4-86, 4-87, 4-88, 4-89, 4-90, 4-91, 4-92, 4-93, 4-94, 4-95, 4-96, 4-97, 4-98, 4-99, 4-100, 4-101, 4-102, 4-103, 4-104, 4-105, 4-106, 4-107, 4-108, 4-109, 4-110, 4-111, 4-112, 4-113, 4-114, 4-115, 4-116, 4-117, 4-118, 4-119, 4-121, 4-123, 4-124, 4-125, 4-126, 4-127, 4-128, 4-129, 4-130, 4-131, 4-132, 4-133, 4-134, 4-135

Documents

Chapter Four Food Package – Formula - Arizona · PDF fileChapter Four Food Package ... 4 -6 Medical ... enteral nutrition support for individuals with a qualifying condition,