Approved Formulas in the New York State WIC Program

Formulary

Effective July 2016 - Revised

New York State WIC Contract - Infant Formula
Contract Infant Formulas Size and formulation Approved for:
Enfamil A.R. 12.9 oz. powder, 6 pack -8oz. RTU I / C
Enfamil Gentlease 12.4 oz. powder, 32 oz. RTU I / C
Enfamil Infant 13 oz. concentrate, 12.5 oz. powder, 32 oz. RTU I / C
Gerber Good Start Soy
12.1 oz. concentrate, 12.9 oz powder, 4 pack - 8.45 oz RTU I / C

EXEMPT FORMULAS/WIC-ELIGIBLE NUTRITIONALS FOR INFANTS, CHILDREN & WOMEN
Hypoallergenic Formulas Size and formulation Approved for:
EleCareFor Infants 14.1 oz. powder I / C
Nutramigen 13 oz. concentrate, 32 oz. RTU I / C
Nutramigen with EnfloraLGG 12.6 oz. powder I / C
Neocate Infant with DHA and ARA 14.1 oz. powder I / C
Similac Alimentum 12.1 oz. powder, 32 oz. RTU I / C
Formulas for Premature Infants Size and formulation Approved for:
Enfamil EnfaCare (22 Calories/fl oz.) 12.8 oz. powder, 6 pack -8oz. RTU I only
Similac Neosure (22 Calories/fl oz.) 13.1 oz. powder, 32 oz. RTU I only
Specialized Formulas Size and formulation Approved for:
Pregestimil 16 oz. powder I / C
Enfaport 6 pack - 6oz. RTU I only
Similac PM 60/40 14.1 oz. powder I / C
Calorie and Nutrient Dense Products Size and formulation Approved for:
Boost/Boost High Protein 6 pack -8 oz. RTU W only
Boost Kid Essentials 4 pack -8.25 oz. RTU C only
Ensure 6 pack -8 oz. RTU W only
Ensure Plus 6 pack -8 oz. RTU W only
PediaSure/PediaSure with Fiber 6 pack -8 oz. RTU C only
PediaSure Enteral/PediaSure Enteral with Fiber 8 oz. RTU C only
Modular Products Issued by State Level Approval Only Approved for:
MCT oil 32 oz. RTU I / C / W
Phenex-1 14.1 oz.powder I / C
Phenex-2 14.1 oz.powder C / W
Phenyl-Free 1 16 oz.powder I / C
Phenyl-Free 2 16 oz.powder C / W

Please note:

  • Medical documentation is required for:
    • exempt formula, WIC-Eligible Nutritionals, and/or
    • greater amounts of contract formula for infants 6 months or older unable to tolerate solid infant foods
  • Medical documentation includes an appropriate qualifying medical condition/medical reason for the formula, quantity (ounces/day), duration of formula and food restrictions/referral.

The need for Ready-To-Use (RTU) formula will be addressed by the WIC Program.

Legend

  • I = infant < 1 year
  • C = child 1 to ≤ 5 years
  • W = woman