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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 214 (CI) Fortini (4 oz. RTF) 4.00 Increased Calorie Infant Formula: 30 cal/oz, high calorie, contains milk and soy, prebiotic fiber and DHA/ARA, for oral and tube feeding.

Allergens by Nature: Milk and Soy Weight/length or BMI <10% and/or downward crossing of 2 major percentiles along with one or more of the following diagnoses: 1. Faltering weight or inadequate weight gain 2. Failure to Thrive (FTT) or malnutrition 3. Increased calorie needs 4. Tube feeding* 5. Oral motor feeding issues/aversions* 6. Developmental delays (sensory & motor)* 7. Prematurity (<37 weeks)/LBW *Authorization is not dependent on growth meeting parameters outlined above when diagnosis is present. See Note on page 24 for additional information. Limitations: Can only issue to infants and children through 23 months old. Cannot continue more than 90 days - prescriptions written for more than 3 months will not be honored.

Requirements: Monthly weights must be obtained Nutricia 30 bottles/case 216 (CI) GA-1 Anamix Early Years (14.1 oz. Powder) 80.00 Special Medical Conditions - Metabolic: lysine-free, low tryptophan, nutritionally incomplete; 12.5 g of protein equivalent per 100 g powder.

Mixing Instructions: To make a standard dilution (21 kcal/fl oz), add 1 unpacked level scoop (5 g) of powder to each fluid ounce of water.

Allergens by Nature: Milk, Coconut and Soy Glutaric aciduria type 1 (GA-1) Limitations: Can only issue to infants and children

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case 172 Glucerna (8 oz. RTF)

8.00 Increased Calorie Supplement: 28 cal/oz, nutritionally complete. 10g protein and 180 calories per container.

Similar to Boost Glucose Control

Allergens by Nature: Milk and Soy

1. Gestational Diabetes 2. Diabetes Mellitus Limitations: Can only issue to women. Abbott 24 containers/case homemade vanilla rich chocolate creamy strawberry 226 (CI) Glutarade Essential (16 oz Powder) 80.00 Special Medical Conditions - Metabolic: lysine-free, low tryptophan, nutritionally incomplete.

Mixing Instructions: Add 40 g (approx. 1/4 cup, level and unpacked) to approx. 7 fl oz (210 mL) of cold water

Allergens by Nature: Soy 1. Glutaric aciduria type 1 (GA-1) 2. Pyridoxine-dependent epilepsy (PDE) or other epilepsy and recurrent seizure. Limitations: Can only issue to children 12 months through 5 years and women.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case 22 (CI) Glutarex-1 (14.1 oz. Powder) 96.00 Special Medical Conditions - Metabolic: Lysine- and tryptophan-free, with DHA/ARA; nutritionally incomplete; lactose-free.

1 Tbsp powder = 8 g; preparation and dilution only as directed by a physician

RFO is calculated based on mixing to 20cal/oz

Allergens by Nature: Coconut and Soy Glutaric aciduria type I (GA-1) Limitations: Can only issue to infants and children.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Abbott 6 cans/case unflavored