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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 147 (CI) PediaSure Peptide 1.5 (8 oz. RTF) 8.00 Hydrolyzed/Peptide Increased Calorie Supplement: 45 cal/oz, lactose-free; nutritionally complete; hydrolyzed formula with hydrolyzed whey protein and 50% of fat as MCT oil; for oral or tube feeding.

Similar to Peptamen Junior 1.5

Allergens by Nature: Milk and Soy Need for peptide formula AND 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. Condition that impairs digestion/absorption 8. Food Allergies (cow’s milk, soy, corn) *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 children 12 months to 5 years old. Abbott 24 containers/case vanilla 204 (CI) Pediasure Sidekicks High Protein (8 oz. RTF) 8.00 Increased Calorie Supplement: 22.5 cal/oz, lactose-free; nutritionally complete; contains 3 g prebiotic fiber and 10 g milk protein per bottle.

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 children 12 months to 5 years old. Abbott 24 containers/case vanilla chocolate 99 (CI) Peptamen Junior (8.45 oz. RTF) 8.45 Hydrolyzed/Peptide Increased Calorie Supplement: 30 cal/oz, lactose-free, gluten- free, peptide-based, 100% hydrolyzed whey protein, nutritionally complete; 60% of fat is MCT oil.

Similar to PediaSure Peptide 1.0

Allergens by Nature: Milk and Soy Need for peptide formula AND 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. Condition that impairs digestion/absorption 8. Food Allergies (cow’s milk, soy, corn) *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 children 12 months to 5 years old. Nestle 24 containers/case unflavored vanilla