Texas WIC Formulary and Medical Reasons for Issuance - JUNE 2014

Transcription

1 Acerflex Isoleucine, leucine and valinefree Maple syrup urine disease (MSUD) in children over the age of 1 year : 454g can medical food; not intended Manufacturer Nutricia as a sole source of nutrition; not intended for infants under 1 Pineapple Metabolic year of age. System will not allow formula to be issued <9 months of age. Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Alimentum 20cal/oz, casein hydrolysate, 1) Intolerance, sensitivity or allergy to cow's milk, soy, and/or intact protein : 16oz can hypoallergenic infant formula with DHA/ARA added; ironfortified, 2) Malabsorption Manufacturer Abbott gluten-free, lactose- 3) GERD, free; 33% of fat is MCT oil. contains sucrose and 4) Gastroesophageal reflux (GER) with one or more of the following: aspiration or risk of aspiration, : 32oz container modified tapioca starch. respiratory disease (bronchopulmonary dysplasia, reactive airway disease, chronic lung disease, asthma, or pneumonia), poor weight gain or weight loss, esophagitis, or using reflux medications. 6 containers/case Powdered Alimentum differs Protein Hydrolysate from in that it contains corn derivatives. 5) Food protein-induced enterocolitis syndrome (FPIES) Level 1 Exempt may be issued for intolerance to powder, if the form improves compliance, or better accommodates the infants condition. BCAD 1 Isoleucine, leucine and valinefree iron-fortified formula; Maple syrup urine disease (MSUD) in infants or toddlers : 16oz can Manufacturer Mead Johnson contains increased levels of B- vitamins for cofactor production. Appropriate Metabolic amounts of leucine, isoleucine, and valine must be supplied by Level S/1 Exempt/Medical Food other foods. Not intended as a Requires State Agency approval and metabolic prescription form. sole source of nutrition; 16.2g protein equivalents/100g powder. BCAD 2 Isoleucine, leucine and valinefree; amino acid modified, Maple syrup urine disease (MSUD) in children or adults : 16oz can Manufacturer Mead Johnson branched-chain amino acid-free, medical food with iron. Appropriate amounts of leucine, isoleucine, and valine must be Metabolic supplied by other foods. Glutenfree, Can only be issued to women and children. Level S/1 Medical Food lactose-free, galactose-free; Requires State Agency approval and metabolic prescription form. not intended as a sole source of nutrition; 24g protein equivalents/100g powder. Texas WIC 1

2 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Benecalorie 220 cal/oz; 330cal per 1.5oz container; lactose-free, glutenfree, 1) Medical condition that increases calorie needs* : 1.5oz container Manufacturer Nestle Kosher, cholesterol-free; 7g of milk protein as calcium 2) Oral motor feeding problems, volume intolerance, and/or inadequate oral intake 24 containers/case caseinate per 1.5oz serving; not hypoallergenic; liquid modular Approver note: Limited to 2 cases per month; maximum quantity allows issuance of this product Modular intended to be added to food or beverage. and up to 1/2 package of another formula. Level 4 Medical Food System will not allow this product to be issued < 6 months of age. Requires State Agency approval. Boost 31cal/oz, nutritionally complete, Kosher, gluten-free, 1) Medical condition that increases calorie needs* : 8oz container Manufacturer Nestle lactose-free liquid supplement; similar to Ensure and Nutren. 2) Oral motor feeding problems 24 containers/case 3) Tube feeding Increased Calorie Supplement Normally used for adults. If prescribed for a child or for any reason other than that listed above, Chocolate Level 2 Medical Food consult with local agency RD or State Agency staff. Strawberry Boost High Protein 30cal/oz, nutritionally : 8oz container complete, Kosher, high-protein, Medical conditions that increase protein requirements, such as those recovering from illness including Manufacturer Nestle low residue, gluten-free, lactosefree cancers, wounds, and surgery 24 containers/case liquid supplement; similar to Ensure High Protein. Increased Calorie Supplement Level 2 Medical Food Can only be issued to women and children. Boost Plus 46cal/oz, nutritionally 1) Medical condition that increases calorie needs and/or fluid restriction* : 8oz container complete, high-calorie, Kosher, Manufacturer Nestle low-residue, gluten-free, lactosefree 2) Oral motor feeding problems 24 containers/case oral supplement; similar to 3) Tube feeding Ensure Plus. Increased Calorie Supplement Normally used for adults. If prescribed for a child or for any reason other than that listed above, Chocolate Level 2 Medical Food consult with local agency RD or State Agency staff. Strawberry Can only be issued to women and children. Texas WIC 2

3 Manufacturer Boost Pudding Nestle Texas WIC ulary and Medical Reasons for Issuance - JUNE cal/5 oz, nutritionally 1) Chewing or swallowing problems (dysphagia) : 5oz cup complete, Kosher, low-residue, gluten-free, lactose-free 2) Medical condition that increases calorie needs* 4 cups/carton supplement in pudding form; 3) Fluid restrictions similar to Ensure Pudding. Increased Calorie Supplement Chocolate Level 2 Medical Food System will not allow formula to be issued <9 months of age. Butterscotch Manufacturer Boost Very High Calorie Nestle cal/oz; nutritionally complete, Kosher, gluten-free, lactose-free supplement; suitable for celiac disease. 1) Medical conditions that increase calorie needs* 2) Inadequate growth (at risk for Failure-to-Thrive) 3) Failure-to-Thrive with wt/ht <10th percentile and/or downward crossing of 2 major percentiles (weight falls more than 2 major percentiles) : 8oz container 27 containers/case 4) Oral motor feeding problems, oral aversion, or inability to consume solid foods Increased Calorie Supplement 5) Prematurity Level 2 Medical Food Typically used when calorie needs are higher than what can be achieved with 30 cal/oz products. Can only be issued to women and children. Bright Beginnings Soy Pediatric Drink 30cal/oz, nutritionally complete, Kosher, gluten-free, Cow's milk allergy and intolerance and/or one or more of the following: : 8oz can Manufacturer PBM Products lactose-free, cow's milk proteinfree 1) Medical conditions that increase calorie needs* 24 cans/case supplement for oral or tube 2) Inadequate growth (at risk for FTT) feeding; added DHA and prebiotics; contains 3g fiber/8oz 3) FTT with wt/lth <10 and/or downward crossing of 2 major percentiles (wt falls more than 2 major can. percentiles) Increased Calorie Supplement 4) Tube feeding 5) Oral motor feeding problems, oral aversion, or inability to consume solid foods Level 2 Medical Food 6) Galactosemia Normally used for children. If prescribed for an infant or for any reason other than that listed above, consult with local agency RD or State Agency staff. System will not allow formula to be issued <9 months of age. Calcilo XD 20cal/oz, low-calcium, vitamin 1) Osteopetrosis : 13.2oz can D-free, infant formula; Kosher, Manufacturer Abbott gluten-free, lactose-free, 2) William's syndrome nutritionally complete for all 3) For all other reasons, contact State nutrients except calcium, Special Medical Conditions phosphorus and vitamin D. If for metabolic reason, requires State Agency approval and metabolic prescription form. Level 4 Exempt Requires State Agency approval. Texas WIC 3

4 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Compleat 32cal/oz, blenderized, glutenfree, lactose-free, nutritionally Medical condition requiring tube feeding : 250mL container Manufacturer Nestle balanced supplement made 24 containers/case from natural foods; 1.5g fiber/250ml container. Normally used for adults. If prescribed for a child or for any reason other than that listed above, Increased Calorie Supplement consult with local agency RD or State Agency staff. Level 2 Medical Food Can only be issued to women and children. Compleat Pediatric 30cal/oz, blenderized, nutritionally balanced, glutenfree, Medical condition requiring tube feeding : 250mL container Manufacturer Nestle lactose-free, formulated 24 containers/case from natural foods with fiber; 1.7g fiber/250ml container. Normally used for children. If prescribed for an infant or for any reason other than that listed Increased Calorie Supplement above, consult with local agency RD or State Agency staff. Level 2 Medical Food System will not allow formula to be issued <9 months of age. Compleat Pediatric Reduced Calorie cal/oz; nutritionally 1) Medical condition requiring or resulting in decreased calorie needs complete, made from real food : 250mL container Manufacturer Nestle with 3.4 g/l soluble fiber and 2) Tube feeding 24 containers/case 3.4 g/l of insoluble fiber; pediatric tube feeding Special Medical Conditions supplement - not for oral consumption. Can only be issued to women and children. Level 2 Medical Food Complex Essential MSD Isoleucine, leucine, and valinefree, nutritionally incomplete; Maple Syrup Urine Disease : 1lb can Manufacturer Nutricia for oral or tube feeding; 380cal, 4 cans/case 3.9g fiber, and 25g protein equivalent per 100g powder; not Metabolic for infants under 1 year of age. Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Texas WIC 4

5 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Complex Junior MSD Isoleucine, leucine, and valinefree; for oral and tube feeding; Maple Syrup Urine Disease : 400g can Manufacturer Nutricia 496cal and 13g of protein 4 cans/case equivalent per 100g pwd. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Complex MSD Amino Acid Blend Isoleucine, leucine, and valinefree, nutritionally incomplete; Maple Syrup Urine Disease : 1lb can Manufacturer Nutricia for oral or tube feeding; 323cal and 81g protein equivalent per 4 cans/case 100g of pwd; not for infants Metabolic under 1 year of age. Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Cyclinex 1 Non-essential amino acid-free 1) HHH Syndrome (ornithine translocase deficiency- hyperornithinemia, hyperammonemia, medical food with iron; nutrient homocitrullinemia) : 14.1oz can Manufacturer Abbott profile designed for infants and 2) Defects in urea cycle enzyme toddlers; gluten-free and lactosefree. 3) Gyrate atrophy of the choroid and retina Metabolic Note: For infants or children Level S/1 Exempt/Medical Food Requires State Agency approval and metabolic prescription form. Cyclinex 2 Non-essential amino acid-free 1) HHH Syndrome (ornithine translocase deficiency- hyperornithinemia, hyperammonemia, medical food with iron; designed homecirtrullinuria) : 14.1oz can Manufacturer Abbott for children and adults; glutenfree and lactose-free. 2) Defects in urea cycle enzyme 3) Gyrate atrophy of the choroid and retina Level S/1 Metabolic Medical Food Can only be issued to women and children. Requires State Agency approval and metabolic prescription form. Texas WIC 5

6 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 DiabetiSource AC 36cal/oz, Kosher, gluten-free, 1) Diabetes Mellitus : 250mL container lactose-free, nutritionally Manufacturer Nestle 2) Glucose intolerance balanced supplement made 24 containers/case from natural foods; does not contain sugar alcohols; 3.8g 3) Stress-induced hyperglycemia Increased Calorie Supplement fiber/250ml container. 4) Diabetes with wounds Level 4 Medical Food Can only be issued to women and children. Requires State Agency Approval Duocal 4.9cal/g, 42cal/level Tbsp, highcalorie, carbohydrate and fat 1) Protein, electrolyte, and/or fluid restriction : 400g can Manufacturer Nutricia North America supplement; does not contain 2) Medical conditions that increase calorie needs* protein, gluten, sucrose, fructose or lactose; contains 35% MCT; 3) Disorders of protein and amino acid metabolism Modular not intended as a sole source of 4) Malabsorptive states nutrition; suitable for oral and Level 4 Medical Food tube feedings. 1Tbsp = 8.5g, 1C Note: 80 scoops/can; 48 Tbsp/can = 117g, 1 scoop = 25cal, 1 scoop = 5g. Requires State Agency approval EleCare DHA/ARA 20cal/oz for infants; 30cal/oz 1) Severe malabsorption : 14.1oz can for children; nutritionally Manufacturer Abbott complete hypoallergenic amino 2) GI impairment acid-based formula with iron 3) Food allergies, e.g., allergy to cow's milk, soy, and/or intact protein Elemental * Note: A protein hydrolysate (Nutramigen, Alimentum, or Pregestimil) should be tried before issuing unless medically contraindicated. Level 3 Exempt 4) Medical condition requiring an elemental formula such as: short bowel syndrome, necrotizing enterocolitis, eosinophilic esophagitis, etc. PurAmino. EleCare Jr 30 cal/oz is the standard 1) Severe malabsorption : 14.1oz can dilution for children over 1 year Manufacturer Abbott of age; nutritionally complete 2) GI impairment hypoallergenic amino acid-based 3) Severe food allergies, multiple protein intolerance Unflavored formula with iron; for oral or 4) Medical condition requiring an elemental formula such as: short bowel syndrome, necrotizing Elemental tube feeding; does not contain milk or soy protein, fructose, enterocolitis, eosinophilic esophagitis, etc. Level 3 Exempt galactose, lactose, or gluten; contains 33% MCT oil; similar to Neocate Jr. Can only be issued to women and children. and DHA/ARA; for oral or tube feeding; does not contain milk or soy protein, fructose, galactose, lactose, or gluten; contains 33% MCT oil; similar to Neocate DHA/ARA and Texas WIC 6

7 See guidelines in next panel Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 EnfaCare 22 cal/oz, iron fortified, Kosher, high protein, vitamin, Premature or low birth weight infants meeting birth weight guidelines as indicated below. Premature infants : 12.8oz can Manufacturer Mead Johnson and mineral milk-based formula weighing more than 5lbs 8oz at birth - may issue for 1 month with hospital prescription. with added DHA/ARA, designed for preterm and/or 3lb 5oz (1500gm) to 5lb 8oz (<2500gm) issue up to 9 months chronological age low birth weight infants; glutenfree; 20% of fat is MCT oil; : 32oz can Premature/LBW < 3lb 5oz (<1500gm) issue up to 12 months chronological age similar to NeoSure and Good If requested outside of these parameters or for other reasons, contact Local RD or the State Agency Level 1 Exempt Start Nourish. for approval. may be issued for intolerance to powder, if the form improves compliance, or better accommodates the infants condition. Enfamil 24 24cal/oz, iron-fortified, For infants who have exceptional calorie needs*, volume restriction, and/or oral motor feeding problems : 2oz bottle Kosher, milk-based, infant Manufacturer Mead Johnson who cannot be accommodated by liquid concentrate or powder plus intolerance to contract formula. formula. 48 bottles/case Level 1 Special Medical Conditions Level 4 Exempt Requires State Agency approval 1 month Enfamil AR 20 cal/oz, iron-fortified, Kosher, gluten-free, 20:80 whey:casein ratio, milk based Manufacturer Mead Johnson infant formula with rice starch, DHA/ARA; thickening occurs, when it comes in contact with stomach acid; prebiotics added; similar to Similac for Spit-Up. Milk-Based Standard Non-Exempt 3 months Enfamil Human Milk Fortifier or Acidified Liquid (EHMF) 1 month ** Refer to issuance guidelines on last page of formulary. Documented intolerance to contract formula (Similac Advance and Similac for Spit Up) WITH: 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, intestinal disorder (other than allergy or malabsorption), GERD, and syndromes 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying available contract formulas After 3 months retrial on a contract formula (Similac Spit-Up preferred) unless medically contraindicated. *Acidified Liquid: Do not add EHMF to breast milk in a ratio greater than 1 vial/25ml. Requires State Agency approval. : 12.9oz can : 32oz can Specifically designed to be used 1) To fortify human breast milk for premature/low birth weight babies : 0.71g packet as a supplement to add to Manufacturer Mead Johnson mother's milk collected after 2 2) Contains milk and soy; to be used to enrich human breastmilk for premature LBW infants only 100 packets/carton weeks postpartum; kosher and, gluten-free; contains milk and Additional Calories Desired Preterm Human Milk HMF 2 cartons/case soy; similar to Similac HMF; not Premature/LBW 2 cal/ fl oz 50 ml 1 packet /vial nutritionally complete; 70% : 5mL vial Level 4 Exempt MCT oil. 4 cal/ fl oz 25 ml 1 packet /vial 100 vials/carton 2 cartons/case Texas WIC 7

8 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Enfamil Premature 24 w/ Iron 24cal/oz, Kosher, high-protein For premature or very low birth weight infants and mineral formula, whey : 2oz bottle Manufacturer Mead Johnson protein (60:40) dominant ironfortified infant formula with infants weighing over 2500g (5.5lb) consuming only Enfamil Premature, intake of some nutrients (e.g. fat When more than 12oz (355mL) of 24 calories/fl oz formula is used per day, which may occur in larger 6 bottles/carton DHA/ARA added; 40% of fat soluble vitamins) may be excessive. 48 bottles/case Premature/LBW is MCT oil; gluten-free; similar to Similac Special Care 24 w/ Level 4 Exempt Iron. Requires State Agency approval. 1 month Enfamil Premature High Protein 24 w/ Iron 24cal/oz, Kosher, high-protein For premature or very low birth weight infants and mineral formula, whey : 2oz bottle Manufacturer Mead Johnson protein (60:40) dominant ironfortified infant formula with When more than 12oz (355mL) of 24 calories/fl oz formula is used per day, which may occur in larger 6 bottles/carton DHA/ARA added; 40% of fat infants weighing over 2500g (5.5lb) consuming only Enfamil Premature, intake of some nutrients (e.g. fat 48 bottles/case Premature/LBW is MCT oil; gluten-free; 3.5g soluble vitamins) may be excessive. protein per 100cal. Level 4 Exempt Requires State Agency approval. 1 month Enfamil Premature 30 30cal/oz, high protein and mineral infant formula (3g For premature or very low birth weight infants : 2oz bottle protein/100cal), carbohydrate Manufacturer Mead Johnson blend: 60% corn syrup solids, When more than 12oz (355mL) of 30 calories/fl oz formula is used per day, which may occur in larger 6 bottles/carton 40% lactose; DHA/ARA added; infants weighing over 2500g (5.5lb) consuming only Enfamil Premature, intake of some nutrients (e.g. fat 40% of fat is MCT oil; glutenfree; similar to Similac Special soluble vitamins) may be excessive. 48 bottles/case Premature/LBW Care 30w/ Iron. Level 4 Exempt Requires State Agency approval. 1 month Texas WIC 8

9 Manufacturer Level 1 Manufacturer Level 1 Enfamil Infant Mead Johnson, CON, Milk-Based Standard Non-Exempt Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Documented intolerance to contract formula (Similac Advance and Similac Sensitive or Similac Total Comfort) WITH: 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, intestinal disorder (other than allergy or malabsorption), GERD, and syndromes 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying available contract formulas : 12.5oz can CON: 13oz can 12 cans/case : 32oz can 3 months After 3 months retrial on a contract formula unless medically contraindicated. Enfamil Newborn Mead Johnson Milk-Based Standard Non-Exempt 20 cal/oz, iron-fortified, Kosher, 60:40 whey:casein ratio, milk-based, gluten-free infant formula with DHA/ARA added; contains prebiotic GOS and polydextrose; similar to Similac Advance. ** Refer to issuance guidelines on last page of formulary. 20 cal/oz, nutritionally complete infant formula. 80:20 whey:casein ratio; Kosher, gluten-free; contains DHA/ARA, prebiotic GOS and polydextrose; contains 400 IU of Vit. D in 27 fl oz. Documented intolerance to contract formula (Similac Advance and Similac Sensitive or Similac Total Comfort) WITH: 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, intestinal disorder (other than allergy or malabsorption), GERD, and syndromes 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying available contract formulas : 12.5oz can 3 months After 3 months retrial on a contract formula unless medically contraindicated. Enfaport DHA/ARA 30cal/oz, iron-fortified, milkbased infant formula; gluten- 1) Chylothorax : 8oz container Manufacturer Mead Johnson free, lactose-free with 2) For infants who do not efficiently digest or absorb conventional fat and long chain fatty acid oxidation 24 containers/case DHA/ARA; nutritionally disorders, e.g., decreased pancreatic lipase, decreased bile salts, defective mucosal fat absorption, and/or complete, 84% of fat as MCT; defective lymphatic anomalies, hyperlipoproteinemia Type 1, or long chain 3-hydroxyacyl-CoA Special Medical Conditions sole source of nutrition up to 6 dehydrogenase deficiency (LCHAD). Level 3 Exempt months, major source of 3) Conditions requiring high MCT oil nutrition through 12 months of age. Texas WIC 9

10 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Ensure 31cal/oz, nutritionally complete, Kosher, gluten-free, 1) Medical conditions that increase calorie needs* : 8oz container Manufacturer Abbott lactose-free, low-residue 2) Oral motor feeding problems 24 containers/case supplement for oral or tube 3) Tube feeding feeding; contains prebiotic shortchain, Chocolate, Increased Calorie Supplement fructooligosaccharides Coffee Latte, Strawberry, Level 2 Medical Food (scfos); 3g fiber/8oz container; Normally used for adults. If prescribed for a child or for any reason other than that listed above, similar to Boost. consult with local agency RD or State Agency staff. Butter Pecan Ensure Enlive! 31cal/oz, clear liquid, fat-free, 1) Fat malabsorption low-residue; lactose-free, glutenfree; : 6.7oz container Manufacturer Abbott contains milk ingredients; 2) Fat-restricted diets 27 containers/case not intended as a sole source of 3) For pre- and post-surgeries, bowel-prep nutrition; not for tube feeding; Apple Increased Calorie Supplement 9g whey protein/8.1oz 4) Nutrition support for people with cancer, heart disease, pancreatitis, and hyperlipidemia Mixed Berry Level 3 Medical Food container. 5) Alternative to creamy shake-like supplements Can only be issued to women and children. Ensure High Calcium 28cal/oz, nutritionally complete 1) Persons who are at risk for fractures, need extra protein, calcium, vitamin D, and other nutrients supplement, Kosher, glutenfree, : 8oz container Manufacturer Abbott lactose-free, low-residue; 2) Persons recovering from surgery 24 containers/case 500mg calcium/8oz container. Increased Calorie Supplement Chocolate Level 2 Medical Food Can only be issued to women and children. Ensure High Protein 29cal/oz, high-protein, Kosher, 1) Medical condition that restricts or precludes the use of conventional foods : 8oz container Manufacturer Abbott gluten-free, lactose-free, lowresidue oral supplement; 21.3% 2) Good source of nutrition for persons who have or are at risk for pressure ulcers 24 containers/case calories are from protein; Increased Calorie Supplement nutritionally complete; 12g soy protein/8oz container; similar to Chocolate Level 2 Medical Food Boost High Protein. Can only be issued to women and children. Wild Berry Texas WIC 10

11 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Ensure Plus 45cal/oz, nutritionally 1) Medical condition that increases calorie needs and/or fluid restriction* : 8oz container complete, Kosher, high calorie, Manufacturer Abbott 2) Oral motor feeding problems 24 containers/case low-residue, gluten-free, lactosefree, oral supplement; contains 3) Tube feeding, Chocolate, Butter prebiotic short-chain Pecan, Strawberries & fructooligosaccharides (scfos); Increased Calorie Supplement Normally used for adults. If prescribed for a child or for any reason other than that listed above, 3g fiber/8oz container; similar Cream, Coffee Latte consult with local agency RD or State Agency staff. Level 2 Medical Food to Boost Plus. Can only be issued to women and children. : 32oz container 6 containers/case, Chocolate Ensure Pudding 170cal/4 oz, nutritionally 1) Chewing or swallowing problems : 4oz cup complete, Kosher, gluten-free, Manufacturer Abbott lactose-free, supplement in 2) Need for increased calories* 4 cups/carton pudding form; contains 3) Fluid restricted diets prebiotic short-chain Increased Calorie Supplement fructooligosaccharides (scfos); Milk Chocolate Level 2 Medical Food similar to Boost Pudding. System will not allow formula to be issued <9 months of age. Butterscotch EO28 Splash 30cal/oz, nutritionally 1) Severe malabsorption (eosinophilic esophagitis, GERD, SBS) complete, lactose, gluten, whey, : 8oz container Manufacturer Nutricia soy and milk protein-free 2) Severe food allergies, multiple protein intolerance 27 containers/case elemental formula containing 100% free amino acids; for oral 3) GI impairment Orange-Pineapple Elemental or tube feeding; 35% of fat is MCT oil; not intended for 4) Medical condition requiring a hypoallergenic elemental formula Tropical Fruit Level 3 Medical Food infants under 1 year of age. Normally used for children over age 1. Grape System will not allow formula to be issued <9 months of age. FiberSource HN 36cal/oz, nutritionally For persons with abnormal bowel function, extended inactivity, neurologic impairment, or developmental : 250mL container complete, high-nitrogen, 100% Manufacturer Nestle disability requiring additional protein soy protein supplement with 24 containers/case fiber for oral or tube feeding; contains 20% MCT oil; 2.5g Increased Calorie Supplement fiber/250ml container. Can only be issued to women and children. Level 4 Medical Food Requires State Agency approval. Texas WIC 11

12 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 GA Lysine and tryptophan-free, iron-glutarifortified formula; contains aciduria (acidemia) type I in infants or children : 16oz can Manufacturer Mead Johnson increased B-vitamins for cofactor production; sucrose added; gluten-free, lactose-free, Metabolic galactose-free; 15.1g protein Level S/1 Exempt/Medical Food equivalents/100g powder. Requires State Agency approval and metabolic prescription form. Manufacturer Level 1 Gentlease Mead Johnson, Milk-Based Standard Non-Exempt 3 months GlutarAde Amino Acid Blend GA-1 20 cal/oz, iron-fortified, Kosher, gluten-free, nutritionally complete infant formula with reduced lactose (20%), partially hydrolyzed 60:40 whey:casein ratio, nonfat cow milk protein, and whey protein concentrate with DHA/ARA. ** Refer to issuance guidelines on last page of formulary. Documented intolerance to contract formula (Similac Advance and Similac Sensitive or Similac Total Comfort) WITH: 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, intestinal disorder (other than allergy or malabsorption), GERD, and syndromes 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying available contract formulas After 3 months retrial on a contract formula (Similac Total Comfort preferred) unless medically contraindicated. Glutaric aciduria (acidemia) Type I in children and adults : 12.4oz can : 32oz can Low in tryptophan, no lysine, : 1lb can Manufacturer Nutricia nutritionally incomplete; for oral or tube feeding; not for infants 4 cans/case under one year old. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. GlutarAde Jr GA-1 Drink Mix Low in tryptophan, no lysine, Glutaric aciduria (acidemia) Type I in children, adults, and pregnant women : 400g can nutritionally incomplete; for oral Manufacturer Nutricia or tube feeding.; not for infants 4 cans/case under one year old. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Texas WIC 12

13 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Glutarex 1 Amino acid modified medical Glutaric aciduria (acidemia) type I in infants or children : 14.1oz can food with iron; lysine and Manufacturer Abbott tryptophan-free; nutrient profile designed for infants and toddlers; gluten-free and lactosefree. Metabolic Level S/1 Exempt Requires State Agency approval and metabolic prescription form. Glutarex 2 Amino acid modified medical Glutaric aciduria (acidemia) type I in children and adults : 14.1oz can food with iron; lysine and Manufacturer Abbott tryptophan-free; nutrient profile designed for children and adults; gluten-free and lactose-free. Metabolic Level S/1 Medical Food Can only be issued to women and children. Requires State Agency approval and metabolic prescription form. Glytrol 30cal/oz, iron-fortified, Diabetes mellitus, abnormal glucose tolerance, or hyperglycemia Kosher, gluten-free, lactose-free, : 250mL container Manufacturer Nestle sucrose-free carbohydrate blend 24 containers/case to support glycemic control. Increased Calorie Supplement; Special Medical Conditions Can only be issued to women and children. Level 4 Medical Food Requires State Agency approval. 20 cal/oz, nutritionally Good Start Gentle Documented intolerance to contract formula (Similac Advance and Similac Sensitive or Similac Total complete infant formula with : 12.7oz can Comfort) WITH: partially hydrolyzed 100% whey 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, Manufacturer Nestle protein; contains DHA/ARA and prebiotic GOS. intestinal disorder (other than allergy or malabsorption), GERD, and syndromes, CON, 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart Con: 12.1oz ctnr Milk-Based Standard 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care 12 containers/case Level 1 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying Non-Exempt ** Refer to issuance available contract formulas : 33.8oz guidelines on last page of 3 months formulary. After 3 months retrial on a contract formula unless medically contraindicated. 4-4 packs/case Texas WIC 13

14 Level 1 Level 4 Exempt See guidelines under reasons for issuance section Premature/LBW Premature/LBW Exempt 1 month Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Good Start Nourish 22 cal/oz, iron-fortified, high Premature or low birth weight infants meeting birth weight guidelines as indicated below. Premature infants : 12.6 oz can protein, vitamin, and mineral Manufacturer Nestle weighing more than 5lbs 8oz at birth - may issue for 1 month with hospital prescription. milk-based formula with DHA/ARA for pre-term and, 3lb 5oz (1500gm) to 5lb 8oz (<2500gm) issue up to 9 months chronological age low birth weight infants; < 3lb 5oz (<1500gm) issue up to 12 months chronological age Premature/LBW contains 100% partially hydrolyzed, whey protein. : 3 oz bottles If requested outside of these parameters or for other reasons, contact Local RD or the State Agency for approval. may be issued for intolerance to powder, if the form improves compliance, or better accommodates the infants condition. Requires State Agency approval. 8 bottles/carton 48 bottles/case 24cal/oz, iron-fortified, Good Start Premature 24 For premature or low birth weight infants : 3oz bottle nutritionally complete, high Manufacturer Nestle protein and mineral infant 8 bottles/case formula with partially hydrolyzed whey protein; caseinfree; DHA/ARA added; similar to Enfamil Premature 24 and Similac Special Care 24. At the present time, the manufacturer does not have weight or intake guidelines. Consult with Primary Healthcare Provider (PCP) when the infant reaches a weight of 8 pounds or consumes oz in 24 hours. Level 4 Exempt Requires State Agency approval. 1 month 24cal/oz, high protein and Good Start Premature High Protein 24 For premature or low birth weight infants : 3oz bottle mineral infant formula with Manufacturer Nestle partially hydrolyzed whey 8 bottles/carton protein; casein-free; At the present time, the manufacturer does not have weight or intake guidelines. Consult with Primary 48 bottles/case Healthcare Provider (PCP) when the infant reaches a weight of 8 pounds or consumes oz in 24 hours. carbohydrate blend: 50% maltodextrin, 50% lactose; DHA/ARA added; 3.6g protein/100cal similar to Enfamil Premature 24 and Similac Special Care 24. Texas WIC 14

15 Manufacturer Good Start Soothe Nestle Milk-Based Standard Texas WIC ulary and Medical Reasons for Issuance - JUNE cal/oz, nutritionally complete infant formula with partially hydrolyzed 100% whey protein; 70% corn maltodextrin and 30% lactose; contains probiotic, L. reuteri. Documented intolerance to contract formula (Similac Advance and Similac Sensitive or Similac Total Comfort) WITH: 1. Chronic or acute medical diagnosis/condition such as: neurological, heart/cardiovascular, respiratory, intestinal disorder (other than allergy or malabsorption), GERD, and syndromes 2. Weight loss, failure to gain weight, or Failure to Thrive that is evidenced by growth chart information (weight/length 10th percentile), drop in 2 major percentiles on the growth chart 3. Recent hospitalization, recent recovery from or current serious illness (flu, RSV, pneumonia, etc.), recent or pending surgery, and/or recent placement in foster care : 12.4oz can Level 1 Non-Exempt 3 months 4. Severe intolerance symptoms such as vomiting, diarrhea, and blood in the stool that persists after trying available contract formulas After 3 months retrial on a contract formula (Similac Total Comfort preferred) unless medically contraindicated. Good Start Soy 20 cal/oz, iron-fortified, Current contract standard soy-based formula : 12.9oz can Kosher, nutritionally complete Manufacturer Nestle milk-free, lactose-free infant 1. Over age 1 with cow's milk allergy or intolerance formula with partially, CON, hydrolyzed soy protein; 2. Galactosemia CON: 12.1oz container DHA/ARA added. Soy-Based Standard 3. Vegan diet 12 containers/case Contract Non-Exempt No RX when <1 year of age. Level 1 when >1 year of age : 33.8oz container ** Refer to issuance guidelines on last page of formulary. 4-4 packs/case Graduates Gentle 20cal/oz, nutritionally complete Over age 1 with medical need for 20 cal/oz formula. toddler formula; contains : 22oz container Manufacturer Nestle DHA/ARA, prebiotic Possible reasons include: prematurity, developmental delay, oral-motor feeding problems. 6 containers /case galactoolgossaccharides (GOS), partially hydrolyzed 100% whey Milk-Based Standard protein with additional calcium and iron. Level 1 Non-Exempt Can only be issued to women and children. Graduates Protect 20cal/oz, nutritionally complete Over age 1 with medical need for 20 cal/oz formula: toddler formula; contains : 22oz container Manufacturer Nestle DHA/ARA, probiotic bifidus Possible reasons include: prematurity, developmental delay, oral-motor feeding problems. 6 containers/case lactis (BL), partially hydrolyzed 100% whey protein with Milk-Based Standard additional calcium and iron. Level 1 Non-Exempt Can only be issued to women and children. Texas WIC 15

16 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Graduates Soy 20cal/oz, soy-based toddler Over age 1 year with medical need for 20 cal/oz soy-based toddler formula: : 24oz can formula; Kosher; partially Manufacturer Nestle hydrolyzed soy protein and 1) Possible reasons include: prematurity, developmental delay, oral-motor feeding problems, AND/OR: DHA/ARA added; contains 2) Allergy or sensitivity to cow's milk, galactosemia, or vegan diet more calcium, phosphorus, and Soy-Based Standard iron per 100 cal than Good Start Current contract toddler soy-based formula. Soy. Contract Non-Exempt Can only be issued to women and children. Hepatic Aid II 35cal/oz, essential and nonessential amino acid supplement Chronic liver disease : 3oz/packet Manufacturer Hormel Health Labs high in branched chain amino 24 packets/case acids, carbohydrates and fats; contains no added phenylalanine Chocolate or aspartic acid; for oral or tube Special Medical Conditions feedings. Can only be issued to women and children. Eggnog Level 4 Exempt Requires State Agency approval. Custard HCY 1 Methionine-free medical food Homocystinuria in infants or children with cysteine and iron; increased : 16oz can Manufacturer Mead Johnson B vitamins for cofactor production; not intended as a sole source of nutrition; glutenfree, Metabolic lactose-free, galactose-free; 16.2g protein equivalents/100g Level S/1 Exempt; Medical Food powder. Requires State Agency approval and metabolic prescription form. HCY 2 Methionine-free medical food Homocystinuria in children or adults : 16oz can with iron; care must be taken to Manufacturer Mead Johnson provide enough methionine from other foods to support growth. Not intended as a sole Metabolic source of nutrition; gluten-free, Can only be issued to women and children. Level S/1 Medical Food lactose-free, galactose-free; 22g Requires State Agency approval and metabolic prescription form. protein equivalents/100g powder. Texas WIC 16

17 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 HOM 2 L-amino acids free of methionine, enriched with Homocystinuria (vitamin B-6 non-responsive) due to cystathionine synthase deficiency : 500g can Manufacturer Nutricia vitamins and minerals; does not 2 cans/case contain fat. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Hominex 1 Amino acid modified medical Homocystinuria (vitamin B-6 non-responsive) in infants or toddlers : 14.1oz can Manufacturer Abbott food with iron; methionine-free; nutrient profile designed for infants and toddlers; gluten-free and lactose-free. Metabolic Level S/1 Exempt/Medical Food Requires State Agency approval and metabolic prescription form. Hominex 2 Amino acid modified medical Homocystinuria (vitamin B-6 non-responsive) in children or adults : 14.1oz can food with iron; methionine-free; Manufacturer Abbott nutrient profile designed for children and adults; gluten-free Metabolic and lactose-free. Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. I Valex 1 Amino acid modified medical food with iron; leucine-free; Isovaleric acidemia or other disorders of leucine catabolism in infants or toddlers : 14.1oz can Manufacturer Abbott nutrient profile designed for infants and toddlers; gluten-free and lactose-free. Metabolic Level S/1 Exempt/Medical Food Requires State Agency approval and metabolic prescription form. Texas WIC 17

18 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 I Valex 2 Amino acid modified medical food with iron; leucine-free; Isovaleric acidemia or other disorders of leucine catabolism in children or adults : 14.1oz can Manufacturer Abbott nutrient profile designed for children and adults; gluten-free and lactose-free. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. IMPACT 30cal/oz, gluten-free, lactosefree, low-residue enteral formula 2) Post-surgery 1) Trauma Manufacturer Nestle for critically ill adults. 3) Burns or wounds 4) Mechanically ventilated 5) Critically ill Increased Calorie Supplement Level 4 Medical Food Can only be issued to women and children. Requires State Agency approval. 1) Trauma IMPACT w/fiber 2) Post-surgery Manufacturer Nestle 3) Burns or wounds 4) Mechanically ventilated 5) Critically ill Increased Calorie Supplement 30 cal/oz, gluten-free, lactosefree enteral formula w/fiber for critically ill adults; 2.5 g fiber/ 250mL container. : 250mL container 24 containers/case : 250mL container 24 containers/case Level 4 Medical Food Can only be issued to women and children. Requires State Agency approval. IMPACT cal/oz, nutritional complete, 1) Trauma, post-surgery, burns, wounds, mechanically ventilated, critically ill high-calorie, high-protein, low : 250mL container Manufacturer Nestle residue, gluten-free, lactose-free, 2) Increased caloric needs low-residue elemental diet; not 24 containers/case for galactosemia; 50% of fat is 3) Volume restriction Increased Calorie Supplement MCT oil; for critically ill adults. Level 4 Medical Food Can only be issued to women and children. Requires State Agency approval. Texas WIC 18

19 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Isosource cal/oz, Kosher, gluten-free, 1) Fluid restriction lactose-free, high-calorie, highnitrogen, : 250mL container Manufacturer Nestle complete liquid 2) Higher caloric and protein needs 24 containers/case formula; contains 2g fiber/250ml container; for oral Increased Calorie Supplement or tube feedings. Can only be issued to women and children. Level 4 Medical Food Requires State Agency approval. 36cal/oz, Kosher, gluten-free, Isosource HN 1) Malnutrition : 250mL container lactose-free, high-protein, highnitrogen, complete liquid Manufacturer Nestle 2) Increased protein requirements 24 containers/case formula with fiber; 13.4g soy protein/250ml container; intended for tube feedings only. Increased Calorie Supplement Can only be issued to women and children. Level 4 Medical Food Requires State Agency approval. Jevity 1 Cal 31cal/oz, nutritionally complete, high-protein, glutenfree, 1) Tube feeding : 8oz can Manufacturer Abbott lactose-free, isotonic 2) Wound healing 24 cans/case nutritional supplement with fiber to support lean body mass; Increased Calorie Supplement 3.4g fiber/8oz serving. Can only be issued to women and children. Level 4 Medical Food Requires State Agency approval. Ketocal 3:1 Nutritionally complete, high-fat, Non-metabolic reason: : 300g can low-carbohydrate medical food; Manufacturer Nutricia for oral or tube feeding; 3 to 1 Intractable epilepsy in children over 1 year of age fat to carbohydrate and protein If requested for infants, approval is level 4 ratio. Level S/1 Special Medical Conditions; Metabolic Medical Food Metabolic reasons are listed below. Requires State Agency approval and metabolic prescription form. 1) Pyruvate dehydrogenase deficiency (PDH) 2) Glucose transporter type-1 deficiency Texas WIC 19

20 Manufacturer Nutricia Special Medical Conditions; Metabolic Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Nutritionally complete, high-fat, Non-metabolic reason: low-carbohydrate medical food; : 300g can for oral or tube feeding; 4 to 1 Intractable epilepsy in children over 1 year of age fat to carbohydrate and protein ratio. If requested for infants, approval is level 4 Level S/1 Medical Food 1) Pyruvate dehydrogenase deficiency (PDH) Ketocal 4:1 2) Glucose transporter type-1 deficiency Metabolic Metabolic reasons are listed below. Requires State Agency approval and metabolic prescription form. Ketocal 4:1 Liquid Nutritionally complete, high-fat, Non-metabolic reason: : 8oz container low-carbohydrate medical food; Manufacturer Nutricia for oral or tube feeding; 4 to 1 Intractable epilepsy in children over 1 year of age 27 containers/case fat to carbohydrate and protein Metabolic reasons are listed below. Requires State Agency approval and metabolic prescription ratio; contains 2.65g fiber per form. 8oz container; contains Special Medical Conditions; 1) Pyruvate dehydrogenase deficiency (PDH) DHA/ARA; contains sucralose. Metabolic Level S/1 Medical Food 2) Glucose transporter type-1 deficiency Can only be issued to women and children. Ketonex 1 Branched-chain amino acid-free Branched-chain ketoaciduria (maple syrup urine disease) in infants or toddlers : 14.1oz can medical food with iron; nutrient Manufacturer Abbott profile designed for infants and toddlers; gluten-free and lactosefree. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Ketonex 2 Branched-chain amino acid-free Branched-chain ketoaciduria (maple syrup urine disease) in children or adults medical food with iron; nutrient : 14.1oz can Manufacturer Abbott profile designed for children and adults; gluten-free and lactosefree. Metabolic Can only be issued to women and children. Level S/1 Medical Food Requires State Agency approval and metabolic prescription form. Texas WIC 20

21 Kid Essentials 1.5 Manufacturer Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Kid Essentials 30cal/oz, nutritionally 1) Medical conditions that increase calorie needs* : 8.25oz container complete, Kosher, gluten-free, Manufacturer Nestle 2) Inadequate growth (at risk for FTT) lactose-free, low-residue 4 containers/case supplement for oral or tube 3) FTT with wt/lth <10 and/or downward crossing of 2 major percentiles (wt falls more than 2 major feeding; contains MCT oil; full percentiles) Increased Calorie Supplement name is Boost Kid Essentials. 4) Tube feeding 5) Oral motor feeding problems, oral aversion, or inability to consume solid foods Chocolate Level 2 6) Prematurity Normally used for children. If prescribed for an infant or for any reason other than that listed above, consult with local agency RD or State Agency staff. System will not allow formula to be issued <9 months of age. Nestle 1) Medical conditions that increase calorie needs* : 8oz container 2) Inadequate growth (at risk for FTT) 27 containers/case 3) FTT with wt/lth <10 and/or downward crossing of 2 major percentiles (wt falls more than 2 major percentiles) 4) Tube feeding Chocolate 5) Oral motor feeding problems, oral aversion, or inability to consume solid foods Strawberry 6) Prematurity Typically used when calorie needs are higher than what can be achieved with 30cal/oz products. Level 2 Medical Food Normally used for children. If prescribed for an infant or for any reason other than that listed above, consult with local agency RD or State Agency staff. System will not allow formula to be issued <9 months of age. Kid Essentials 1.5 w/fiber 45cal/oz, nutritionally Increased fiber needs and/or one or more of the following: : 8oz container complete, Kosher, gluten-free, Manufacturer Nestle 1) Medical conditions that increase calorie needs* lactose-free with fiber 27 containers/case Increased Calorie Supplement supplementation for oral or tube 2) Inadequate growth (at risk for FTT) feeding; contains MCT oil; 2.1g 3) FTT with wt/lth <10 and/or downward crossing of 2 major percentiles (wt falls more than 2 major fiber/8oz container. percentiles) Chocolate 4) Tube feeding Strawberry 5) Oral motor feeding problems, oral aversion, or inability to consume solid foods Level 2 Medical Food Increased Calorie Supplement Medical Food 45cal/oz, nutritionally complete, Kosher, gluten-free, lactose-free, low-residue supplement for oral or tube feeding; contains MCT oil. 6) Prematurity Typically used when calorie needs are higher than what can be achieved with 30cal/oz products. Normally used for children. If prescribed for an infant or for any reason other than that listed above, consult with local agency RD or State Agency staff. System will not allow formula to be issued <9 months of age. Texas WIC 21

22 Texas WIC ulary and Medical Reasons for Issuance - JUNE 2014 Lipistart Nutritionally complete; low-fat, 1) Fat malabsorption high in medium chain : 400g can Manufacturer Vitaflo triglycerides (MCT) and low in 2) Long chain fatty acid oxidation disorders long chain triglycerides (LCT); contains DHA/ARA and L- 3) Disorders requiring high MCT, low LCT formula Special Medical Conditions carnitine and taurine; suitable 4) Hyperlipoproteinemia type 1 for children from 12 months of age and older. 1 scoop = 6g powder; standard dilution = 1 scoop to 30mL of water. Level 4 Medical Food 5) Chylothorax Normally used for children. If prescribed for an infant or for any reason other than that listed above, consult with local agency RD or State Agency staff. Requires State Agency approval. LMD A leucine-free, iron-fortified product; contains increased B- Disorders of leucine metabolism (including isovaleric acidemia) in infants, children or adults : 16oz can Manufacturer Mead Johnson vitamins for cofactor production; sucrose added; gluten-free, lactose-free, Metabolic galactose-free; 16.2g protein Level S/1 Exempt/Medical Food equivalents/100g powder. Requires State Agency approval and metabolic prescription form. Lophlex LQ 20 Phenylalanine-free medical food; Phenylketonuria in children older than 4 years fat-free; not intended as a sole : 125mL pouch Manufacturer Nutricia source of nutrition; contains a 30 pouches/case balanced mixture of all other essential and non-essential Berry Metabolic amino acids, carbohydrate, vitamins, minerals and trace Can only be issued to women and children. Tropical Level S/1 Medical Food elements; 20g protein Requires State Agency approval and metabolic prescription form. equivalents/125ml pouch. MCT Oil 8.3cal/g, 7.7cal/mL, Kosher, 1) Fat malabsorption : 32oz bottle gluten-free, lactose-free, 100% Manufacturer Nestle MCT oil. 2) Defective lymphatic transport of fat 6 bottles/case 3) Conditions with decreased pancreatic lipase and/or decreased bile salts Modular Level 4 Medical Food Requires State Agency approval. Texas WIC 22