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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 102 (CI) Similac PM 60/40 (14.1 oz. Powder) 102.00 Special Medical Conditions - Hypocalcemia: 20 cal/oz, (60:40) whey:casein ratio, lower in iron and other minerals and electrolytes; nutritionally complete; additional iron should be supplied from other sources.

Mixing Instructions: Add 1 unpacked level scoop (8.7 g) to 2 fl oz of water

Allergens by Nature: Coconut, Soy and Milk 1. Hypocalcemia 2. Hyperphosphatemia 3. CRF/EASD 4. Hyperkalemia Limitations: Can only issue to infants and children through 23 months old. Abbott 6 cans/case unflavored 130 (CI) Tolerex (2.82 oz.) 8.00 Elemental: 30 cal/oz, nutritionally complete elemental formula made of 100% free amino acids; Lactose-free, gluten-free, low-residue.

Dilution: mix 1 packet (2.82oz) with 1 cup water.

Allergens by Nature: N/A 1. Severely impaired GI function: 2. Severe protein and fat malabsorption, specialized nutrient needs Limitations: Can only issue to children 2 to 5 years old and women. Nestle 60 packets/case 222 (CI) TYR Anamix Early Years (14.1 oz. Powder) 80.00 Special Medical Conditions - Metabolic: tyrosine and phenylalanine-free with DHA/ARA; nutritionally incomplete; 13.5 g of protein equivalent per 100 g.

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: Soy, Coconut and Milk. Tyrosinemia (TYR) 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 244 (CI) TYR Anamix Next (14.1 oz. Powder) 78.00 Special Medical Conditions - Metabolic: 34.7 cal/9 g scoop; Phenylalanine and tyrosine free with DHA & multi-fiber blend 29% soluble and 71% insoluble); nutritionally incomplete.

Dilution: Add 18 g (2 scoops) powder to 3.5 fl oz water, final product 0.6 kcal/mL

Allergens by Nature: Coconut and Soy. Tyrosinemia (TYR) Limitations: Can only issue to children 12 months to 5 years old and women.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case 245 (CI) UCD Anamix Junior (14.1 oz. Powder) 47.00 Special Medical Conditions - Metabolic: 0.6 g protein (19.2 calories) in 5 g powder; essential amino acids and branched chain amino acids for positive nitrogen balance, non-protein calories, calcium, vitamin D, and zinc; nutritionally incomplete.

Dilution: Add 30 g (approx 6 scoops) powder to 3.5 fl oz water, final product 0.9 kcal/mL (approx protein equivalent 3.6 g)

Allergens by Nature: Coconut 1. Urea Cycle Disorders (UCD) 2. Hyperammonemia, Hyperornithinemia, Homocitrullinemia (HHH) syndrome 3. Gyrate atrophy Limitations: Can only issue to children 12 months to 5 years old and women.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case unflavored vanilla *Note for Increased Calorie Supplements: When specific diagnoses, including tube feeding, oral motor feeding issues/aversions, and/or developmental delays (sensory & motor) are present, BMI or weight/length is not required to fall <10% or have downward crossing of 2 major percentiles. Diagnosis of the condition alone is sufficient for WIC authorization. However, it is important for the child to have regular growth checks and evaluations to determine if the prescribed formula is meeting without exceeding the child’s nutritional needs.