New York State WIC Approved Formulas

Effective October 2013

New York State WIC Contract - Infant Formula

Contract Infant Formulas Size and formulation ** Approved for:
Enfamil A.R. 12.9 oz. pwdr., 32 oz. RTU I / C
Enfamil Gentlease 12.4 oz pwdr., 32 oz. RTU I / C
Enfamil PREMIUM INFANT 13 oz. conc., 12.5 oz. pwdr., 32 oz. RTU I / C
Enfamil ProSobee 13 oz. conc., 12.9 oz. pwdr., 32 oz. RTU I / C

Exempt Formulas for Infants and Children - Medical Documentation Required *

Hypoallergenic Formulas Size and formulation ** Approved for:
EleCare for Infants 14.1 oz. pwdr. I / C
Nutramigen 13 oz. conc., 32 oz. RTU I / C
Nutramigen with Enflora LGG 12.6 oz. pwdr. I / C
Neocate Infant with DHA and ARA 14 oz. pwdr. I / C
Similac Expert Care Alimentum 16 oz. pwdr., 32 oz. RTU I / C
Formulas for Premature Infants    
Enfamil EnfaCare (22 Calories/fl oz.) 12.8 oz., 32 oz. RTU I only
Similac Expert Care Neosure (22 Calories/fl oz.) 13.1 oz. pwdr., 32 oz. RTU I only
Specialized Formulas    
Pregestimil 16 oz. pwdr. I / C
Enfaport 8 oz. RTU I
Similac PM 60/40 14.1 oz. pwdr. I / C

Exempt Formulas for Women & Children - Medical Documentation Required *

Calorie and Nutrient Dense Formulas Size and formulation ** Approved for:
Boost/Boost High Protein 6 pack -8 oz. RTU W
Boost Kid Essentials 4 pack -8.25 oz. RTU C
Ensure 6 pack -8 oz. RTU W
Ensure Plus 6 pack -8 oz. RTU W
PediaSure/PediaSure with Fiber 6 pack -8 oz. RTU C only
PediaSure Enteral/PediaSure Enteral with Fiber 8 oz. RTU C only

Medical Documentation Required *

Modular Products Size and formulation ** Approved for:
MCT oil 32 oz. RTU I / C / W
Phenex-1 14.1 oz. pwdr. I / C
Phenex-2 14.1 oz. pwdr. C / W
Phenyl-Free1 16 oz. pwdr. I / C
Phenyl-Free 2 16 oz. pwdr. C / W
Polycose 12.3 oz. pwdr. I / C / W
Portagen 16 oz. pwdr. C / W

Footnotes

  • * Medical documentation required - Please provide the appropriate diagnosis or medical reason for the formula, ICD-9 code, quantity (ounces/day), duration of formula and food restrictions.
  • ** The need for ready-to-use formula will be addressed by the WIC Program.

Legend

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