common formula package maximums - dph.georgia.gov

Common Formula Package Maximums

Revised September 2021 of 14

Fully Formula Fed (FFF) Infant Max Infant Age† at First Day to Use Date*

Child Max** Woman Max**

0-3 m 4-5 m 6-12 m w/food

6-12 m No food

Max Ounces Per Day Powder

Concentrate Ready to Feed

29 oz 27.4 oz 28.1 oz

32 oz 29.8 oz 30.4 oz

23.2 oz 21 oz

21.4 oz

32 oz 29.8 oz 30.4 oz

30.3 oz 30.3 oz

Max Ounces Per Month Powder

Concentrate Ready to Feed

870 oz 823 oz 832 oz

960 oz 896 oz 913 oz

696 oz 630 oz 643 oz

960 oz 896 oz 913 oz

910 oz 910 oz

Full Nutritional Benefit 806 oz 884 oz 624 oz 884 oz

* Fully formula fed infants always receive the maximum amount of formula allowed for age. This amount must be no less than the full nutritional benefit and no greater than the maximum amount for age.

** Amount needed per day will be issued based on the amount requested on the Medical Documentation Form 1, but not to exceed the maximum allowed.

† Infant age is rounded up to the next month on the 16th day of each month. For example, an infant that is 3 months and 16 days will receive formula in amounts for the 4 months issuance category.

Formula Company Form Package

Size Reconstitute

Amount Containers/

Case Flavors

Fully Formula Fed (FFF) Infant Max Container Amount for Infant Age at First

Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Alimentum – See Similac Alimentum

Alfamino Infant State Order Only

Nestlé Powder 14.1 oz (400 g)

96 oz 6 cans N/A 9 10 7 10 9 ---

Alfamino Junior State Order Only

Nestlé Powder 14.1 oz (400 g)

62 oz 6 cans Unflavored --- --- --- --- 14 ---

Benecalorie K

See Supplemental Formula Conversion Table for Amount of Formula Replaced

State Order Only

Nestlé RTF 1.5oz 1.5oz 24 cups Unflavored --- --- --- 606 606

Beneprotein K (1 scoop = 1 packet) See Supplemental Formula Conversion Table for Amount of Formula Replaced

State Order Only

Nestlé Powder

8 oz (227 g)

NSD 6 cans Unflavored --- --- --- --- 18 18

7 g NSD 75 packets Unflavored --- --- --- --- 583 583

Boost

Nestle RTF 8 oz 8 oz 27 briks Chocolate Strawberry

Vanilla --- --- --- --- 113 113

Boost Kid Essentials (Retail version) K

Nestlé RTF 8.25 oz 8.25 oz 16 prisms

(4-4 packs) Vanilla --- --- --- --- 110 ---

Boost Kid Essentials 1.0 K

Nestlé RTF 8 oz 8 oz 27 briks Chocolate Strawberry

Vanilla --- --- --- --- 113 ---




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Boost Kid Essentials 1.5 K Nestlé RTF 8 oz 8 oz 27 briks Chocolate Strawberry

Vanilla --- --- --- --- 113 ---

Boost Kid Essentials 1.5 w/fiber K

State Order Only Nestlé RTF 8 oz 8 oz 27 briks Vanilla --- --- --- --- 113 ---

Boost Breeze H K

State Order Only

Nestlé RTF 8 oz 8 oz 27 cartons

Orange Peach

Wild Berry Variety

--- --- --- --- 113 113

Boost Nutritional Pudding K

State Order Only Nestlé RTF

150 mL

5 oz 4 cans Chocolate Very

Vanilla --- --- --- --- 182 182

Boost Plus K

State Order Only

Nestlé RTF 8 oz 8 oz 27 cartons Chocolate Strawberry

Vanilla --- --- --- --- 113 113

Bright Beginnings Soy Pediatric Drink K State Order Only

PBM Products

RTF 8 oz 8 oz 24 cans Vanilla --- --- --- --- 113 ---

Calcilo XD State Order Only **Dropship

Abbott Powder 375 g 96 oz 6 cans N/A 9 10 7 10 9 ---

Carnation Breakfast Essentials K Nestlé RTF 237 mL 8 oz 24 cartons

Chocolate Strawberry

Vanilla --- --- --- --- 113 113

Compleat State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cartons Unflavored --- --- --- --- 107 107

Compleat Pediatric

Nestlé RTF 250 mL 8.45 oz 24 cartons Unflavored --- --- --- --- 107 ---

Compleat Pediatric Organic Blends State Order Only

Nestlé RTF 300 mL 10.1 oz 24 cartons

Plant-Based Blend

Chicken-Garden Blend

--- --- --- --- 90 ---

Compleat Pediatric Peptide 1.5 State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 ---

Compleat Pediatric Reduced Calorie State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 ---

Complete Amino Acid Mix See Supplemental Formula Conversion Table for Amount of Formula Replaced

State Order Only **Drop Ship

Nutricia Powder 7 oz

(200 g) NSD 6 cans N/A --- --- --- --- --- ---

Cyclinex-1 H

State Order Only Abbott Powder

14.1 oz (400 g)

NSD 6 cans Unflavored 9 10 7 10 10 10




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Cyclinex-2 H


14.1 oz (400 g)

NSD 6 cans Unflavored 9 10 7 10 10 10

Duocal See Supplemental Formula Conversion Table for Amount of Formula Replaced

State Order Only

Nutricia Powder 400 g

(14 oz) NSD

Order Single cans

Unflavored --- --- --- --- --- ---

Encala

Envara Health

Powder 276 g NSD 1 pouch Unflavored --- --- --- --- 4 6

EleCare for Infants H

(DHA/ARA)

Abbott Powder 400 g

(14.1 oz) 95 oz 6 cans N/A 9 10 7 10 9 ---

EleCare Jr. H

Abbott Powder 400 g

(14.1 oz) 62 oz 6 cans

Banana Chocolate Unflavored

Vanilla

--- --- --- --- 14 ---

Enfamil 24 K

(Not available by State Order)

Mead Johnson

RTF 2 oz 2 oz 6 – pack nursettes

N/A 414 456 318 456 450 ---

Enfamil Infant K, H (Not available by State Order)

Mead Johnson

Powder 12.5 oz (354 g)

90 oz 6 cans N/A 9 10 7 10 10 ---

Conc. 13 oz 26 oz 12 cans N/A 31 34 24 34 35 ---

RTF 32 oz 32 oz 6 bottles N/A 26 28 20 28 28 ---

Enfamil ProSobee K (Not available by State Order)

Mead Johnson


93 oz 6 cans N/A 9 10 7 10 9 ---

Conc. 13 oz 26 oz 12 cans N/A 31 34 24 34 35 ---


Enfamil Gentlease K, H

(Not available by State Order)

Mead Johnson


90 oz 6 cans N/A 9 10 7 10 10 ---

Enfamil AR *NOT FP III RTF Discontinued December 2019 (Not available by State Order)

Mead Johnson


91 oz Single can N/A 9 10 7 10 10 ---

Enfamil NeuroPro EnfaCare (formerly Enfamil EnfaCare)

State Order Only (2 oz RTF) **Drop Ship (2 oz)

Mead Johnson

Powder

12.8 oz 82 oz 6 cans N/A 10 11 8 11 11 ---

13.6 oz 87 oz 6 cans N/A 10 11 8 11 11 ---

RTF

2 oz

2 oz 48 nursettes N/A 416 456 321 456 455 ---




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Enfamil Human Milk Fortifier Order prescribed amount only (Not exceeding the maximum)


Mead Johnson

Liquid 5 ml vial

NSD

100 units per carton; ships

only as 2 cartons

(200)/case

N/A MBF 1029

MBF 1135

MBF 823

MBF 1135

--- ---

Powder 0.71 g packet

Enfamil Premature 20, 24, 30 State Order Only (20 and 30 cal) **Drop Ship

Mead Johnson

RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---

EnfaGrow Premium Toddler Transitions (Not available by State Order)

Mead Johnson

Powder 20 oz 141 oz 4 cans N/A --- --- 4 6 6 ---

EnfaGrow Toddler Transitions Gentlease (Not available by State Order)

Mead Johnson

Powder 20 oz 141 oz 4 cans N/A --- --- 4 6 6 ---

Enfaport State Order Only

Mead Johnson

RTF 6 oz 6 oz 24 cans N/A 138 152 107 152 151 ---

Ensure Original Nutrition Shake

Abbott Nutrition

RTF 8 oz 8 oz 24 bottles Variety --- --- --- --- 113 113

Ensure Clear K

State Order Only Abbott

Nutrition

RTF 10 oz 10 oz 12 bottles Blueberry/

Pomegranate Mixed Fruit

--- --- --- --- 91 91

RTF 8 oz 8 oz 24 cartons Apple

Mixed Berry --- --- --- --- 113 113

Ensure Harvest State Order Only

Abbott Nutrition

RTF 8 oz 8 oz 24 bottles N/A --- --- --- --- 113 113

Ensure High Protein State Order Only

Abbott Nutrition

RTF 8 oz 8 oz 24 bottles Chocolate

Vanilla --- --- --- --- 113 113

Ensure Plus State Order Only

Abbott Nutrition

RTF 8 oz 8 oz 24 bottles Butter Pecan

Chocolate Strawberry Vanilla

--- --- --- --- 113 113

EO28 Splash (See Neocate Splash)

--- --- --- --- --- --- --- --- --- --- --- ---

Gerber Extensive HA 999 Food Package Required

Gerber Powder 14.1 oz (400 g)

96 oz 6 cans N/A 9 10 7 10 9 ---

Glutarex-1 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Glutarex-2 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Glycosade (Suitable from 5 years of age)

Vitaflo Powder 12.1 oz (60 g)

NSD 30 packets N/A --- --- --- --- --- 113




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Glytrol K

(Formerly Nutren Glytrol)

State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107

Hominex-1 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Hominex-2 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

I-Valex-1H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

I-Valex-2 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Kate Farms Pediatric Standard 1.2 State Order Only

Kate Farms RTF 250 ml 8.45 oz 12 cartons Vanilla --- --- --- --- 107 107

Kate Farms Pediatric Peptide 1.0 State Order Only


Kate Farms Pediatric Peptide 1.5 State Order Only


KetoCal 3:1 (Recommended child 1-8 yrs)

State Order Only


(300 g) 70 oz 6 cans N/A 12 13 9 13 13 13

KetoCal 4:1 State Order Only **Drop Ship (Unflavored RTF)

Nutricia

Powder 11 oz

(300 gr) 105 oz

(20 cal/oz) 6 cans Vanilla 8 9 6 9 --- ---

Powder 11 oz

(300 g) 70 oz

(30 cal/oz) 6 cans Vanilla --- --- --- --- 13 13

RTF 8 oz 8 oz 27 boxes Vanilla

Unflavored 104 114 80 114 113 113

Ketonex-1 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Ketonex-2 H


14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

KetoPeptide State Order Only (Suitable from 4 years of age)

Functional Formularies

RTF 8 oz

(227 g) 8 oz. 24 pouches N/A --- --- --- --- 113 113

KetoVie 4:1 K


Cambrooke Therapeutics

RTF 250 mL 8.5 oz 30 cartons Vanilla

Chocolate --- --- --- --- 107 107

KetoVie 3:1 K



RTF 250 mL 8.5 oz 30 cartons Unflavored --- --- --- --- 107 107

KetoVie Peptide 4:1 K



RTF 250 mL 8.5 oz 30 cartons Unflavored --- --- --- --- 107 107




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Lipistart (Recommended child 1+)

State Order Only Vitaflo Powder

14.1 oz (400 g)

80 oz Order single

cans N/A 9 10 7 10 11 11

Liquigen (Modular)

See Supplemental Formula Conversion Table #2 for Amount of Formula Replaced

Nutricia RTF 8.5 oz 8.5 oz 4 bottles N/A --- --- --- --- --- ---

Maxamum XPhe (Not recommended child <9)

State Order Only

Nutricia Powder 16 oz NSD 6 cans

Orange

Unflavored 8 8 6 8 9 9

Microlipids (Modular) K

See Supplemental Formula Conversion Table for Amount of Formula Replaced State Order Only

Nestlé Nutrition

RTF 3 oz

(89ml) NSD 48 bottles N/A --- --- --- --- --- ---

MCT Oil (Modular) K

See Supplemental Formula Conversion Table #2 for Amount of Formula Replaced State Order Only

Nestlé Nutrition

RTF 32 oz NSD Order

single bottles

N/A --- --- --- --- --- ---

Neocate Infant DHA/ARA Nutricia Powder 14.1 oz (400 g)

97 oz 4 cans N/A 9 (0-1m) 8 (2-3m)

10 (4 mo) 9 (5 mo) 7

10 (6 mo) 9 (7-12 mo)

9 ---

Neocate Junior (unflavored) Nutricia Powder 14 oz

(400 g) 64 oz 4 cans Unflavored --- --- --- --- 14 ---

Neocate Junior (flavored) Nutricia Powder 14 oz

(400 g) 60 oz 4 cans

Chocolate Tropical

--- --- --- --- 15 ---

Neocate Junior w/Prebiotics State Order Only


(400 g) 64 oz

Order Single cans

Unflavored Vanilla

Strawberry --- --- --- --- 14 ---

Neocate Nutra K H (Order Rxed amount only - Not exceeding the max)


Nutricia Powder 14 oz 36 oz Order Single

Cans Unflavored --- --- 19 26 25 ---

Neocate Splash State Order Only (Flavored varieties formerly EO28 Splash)

Nutricia RTF 8 oz 8 oz 27 drink box

Unflavored, Grape,

Orange- Pineapple,

Tropical Fruit

--- --- --- --- 113 ---

Neocate Syneo Infant State Order Only

Nutricia Powder 14.1 oz 95 oz 4 cans N/A 9 10 7 10 9 ---

Nepro with Carb Steady K (H-

Butter Pecan only)

State Order Only

Abbott RTF 8 oz 8 oz 24 cans

Butter Pecan

Homemade Vanilla

Mixed Berry

--- --- --- --- 113 113

Nourish State Order Only (Suitable from 4 years of age)


RTF 12 oz

(341 g) 12 oz 24 pouches N/A --- --- --- --- 75 75




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Nourish Peptide State Order Only (Suitable from 4 years of age)


RTF 12 oz

(341 g) 12 oz 24 pouches N/A --- --- --- --- 75 75

Nutramigen Mead

Johnson

Conc. 13 oz 26 oz 12 cans N/A 31 34 24 34 35 ---

RTF 32 oz 32 oz 6 cans N/A 26 28 20 28 28 ---


Nutramigen w/ Enflora LGG Toddler 999 food package needed

Mead Johnson

Powder 12.6 oz 86 oz 6 cans N/A --- --- 8

>9 mo only

11 >9 mo only

10 ---

Nutramigen w/ Enflora LGG Mead

Johnson Powder 12.6 oz 87 oz Single cans N/A 10 11 8 11 10 ---

Nutren 1.0 K


Nutren 1.0 w/ Fiber K


Nutren 1.5 K

State Order Only Nestlé RTF 250 mL 8.45 oz 6 cans Unflavored --- --- --- --- 107 107

Nutren 2.0 K


Nutren Junior K Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---

Nutren Junior Fiber K

State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---

Nutren Pulmonary K

State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans

Vanilla Unflavored

--- --- --- --- 107 107

NutriHep K

State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 107

Osmolite H K

State Order Only Abbott RTF 8 oz 8 oz 24 cans Unflavored --- --- --- --- 113 113

PediaSure Grow and Gain H K Abbott RTF 8 oz 8 oz 24 bottles

Banana Berry

Chocolate Strawberry

Vanilla

--- --- --- --- 113 ---

PediaSure Grow and Gain with Fiber H K

Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---

PediaSure Enteral 1.0 cal H K Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---

PediaSure Enteral 1.0 cal (fiber) H K


PediaSure Harvest State Order Only

Abbott RTF 8 oz 8 oz 24 bottles N/A --- --- --- --- -113 ---

PediaSure 1.5 Cal H K

Abbott RTF 8 oz 8 oz 24 cans Vanilla --- --- --- --- 113 ---




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

PediaSure 1.5 Cal with Fiber H

K Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---

PediaSure Peptide 1.0 Cal H K Abbott RTF 8 oz 8 oz 24 bottles Strawberry Unflavored

Vanilla --- --- --- --- 113 ---

PediaSure Peptide 1.5 Cal H K State Order Only


PediaSure Reduced Calorie State Order Only


PediaSure Sidekicks State Order Only

Abbott RTF 8 oz 8 oz 24 bottles Chocolate Strawberry

Vanilla --- --- --- --- 113 ---

Peptamen Junior State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans

Chocolate Strawberry Unflavored

Vanilla

--- --- --- --- 107 ---

Peptamen Junior Fiber State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---

Peptamen Junior w/ Prebio State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---

Peptamen Junior 1.5 State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored

Vanilla --- --- --- --- 107 ---

PKU Air20 (Suitable from 3 years of age)

Vitaflo RTF 174 ml 174 ml 30 pouches Citrus twist

Coffee fusion Mango breeze

--- --- --- --- 113 113

PKU Periflex Early Years State Order Only


(14.1 oz) 90 oz 6 cans N/A 9 10 7 10 10 ---

PKU Sphere State Order Only (Suitable from 4 years of age)

Vitaflo Powder 35 g

(1.23 oz) 4 oz 30 packets

Red Berry Vanilla

Chocolate --- --- --- --- 267 267

Periflex Infant State Order Only


(14 oz) 84 oz 6 cans N/A 10 11 8 11 10 ---

Periflex Junior State Order Only


(454 g)

57 oz 6 cans Orange --- --- --- --- 15 ---

60 oz 6 cans Unflavored

PKU Explore5 (Order Rxed amount only - Not exceeding the max)

State Order Only

(Suitable from 6 months of age)

Vitaflo Powder 12.5 gm NSD 30 pouches Unflavored --- --- 464 640 606 ---

PKU Explore10 State Order Only (Suitable from 1 years of age)

Vitaflo Powder 25 gm 3 oz

(80 ml) 30 pouches

Raspberry Orange

--- --- --- --- 303 303




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

PKU Periflex Junior Plus State Order Only

Nutricia Powder 14.1 oz 51 oz 6 cans Plain --- --- --- --- 17 ---

Phenex-1 H

State Order Only

Abbott Powder 14.1 oz (400 g)

NSD 6 cans N/A 9 10 7 10 10 10

Phenex-2 H

State Order Only


NSD 6 cans Unflavored

Vanilla 9 10 7 10 10 10

PhenylAde 60 Drink Mix (Recommended child >1 yo)

State Order Only

Applied Nutrition

Corp.

Powder 16 oz

(454 g) 81 oz 4 cans

Unflavored

8 8 6 8 11 11

Powder 16.7 g 3oz 30 pouches Vanilla 290 320 232 320 303 303

PhenylAde Essential Drink Mix (Recommended child >1 yo) State Order Only

Applied Nutrition

Corp.

Powder 16 oz

(454 g) 79 oz 4 cans

Chocolate Orange Crème

Strawberry 11 12 8 12 11

11

Powder 40 g

7 oz 16 pouches Vanilla 124 137 99 137 130

130

PhenylAde MTE AA Blend State Order Only (Recommended child >1 yr.)

Applied Nutrition

Corp.

Powder 16 oz

(454 g) NSD 4 cans Unflavored 8 8 6 8 9 9

Powder 12.8 g NSD 30 pouches Unflavored 283 312 225 312 318 318

Phenyl-Free 2 HP (Recommended child > 1 yr.)

State Order Only

Mead Johnson

Powder 16 oz NSD 6 cans N/A 8 8 6 8 9 9

Phlexy-10 Drink Mix State Order Only

Nutricia Powder 20 g 3.38 oz 30 packets Black Currant/ Apple

Tropical Surprise

-- -- -- -- 269 269

Polycal See Supplemental Formula Conversion Table for Amount of Formula Replaced

Nutricia Powder 14.1 oz (400 g)

NSD 12 Unflavored --- --- --- --- --- ---

Portagen (Recommended for child > 1 yr.)

State Order Only

Mead Johnson

Powder 14.4 oz 64 oz Single cans N/A 13 15 10 15 14 14

Pregestimil State Order Only (2 oz)

Mead Johnson

Powder 16 oz 112 oz Single cans N/A 8 (0-1m) 7 (2-3m) 8 6 8 8 ---


Pregestimil 24 State Order Only **Drop Ship

Mead Johnson


ProMod Liquid Protein (modular: mix 1 oz (30 ml) with 1-2 oz H2O) See Supplemental Formula Conversion Table for Amount of Formula Replaced

State Order Only

Abbott Liquid 32 oz

(946 mL) 32 oz 6 containers Fruit Punch 26 28 20 28 28 28

Pro-Phree H

(Recommended infants & toddlers)

State Order Only


NSD 6 cans N/A 9 10 7 10 10 ---




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Propimex-1 H

(Recommended for infants & toddlers)

State Order Only


NSD 6 cans N/A 9 10 7 10 10 ---

Propimex-2 H

(Recommended child > 1 yr. & adults)

State Order Only


NSD 6 cans N/A 9 10 7 10 10 10

ProViMin H K


5.3 oz (150 g)

NSD 6 cans N/A 24 26 19 26 27 27

PurAmino (DHA & ARA)

Mead Johnson

Powder 14.1 oz 98 oz Order

Single cans N/A

9 (0-1m) 8 (2-3m)

10 (4 m) 9 (5 m)

7 10 (6 m)

9 (7-12 m) 9 ---

PurAmino Jr. (formerly PurAmino

Toddler) State Order Only **Dropship

Mead Johnson

Powder 14.1 oz 66 oz 4 cans Unflavored

Vanilla --- --- --- --- 13 ---

RCF (Ross CHO Free)H K State Order Only

Abbott Conc. 13 oz 26 oz 12 cans N/A 31 34 24 34 35 ---

RenalCal K

State Order Only Nestle RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 107

Renastart State Order Only **Drop Ship

Vitaflo Powder 14.1 oz (400 g)

67.5 oz Single Cans N/A --- --- --- --- 13 13

Replete Fiber K

(Formerly Nutren Replete Fiber)


ScandiShake State Order Only

Aptalis Powder 3 oz

(85 g) 9 oz 4 pkts

Vanilla Strawberry

--- --- --- --- 101 101

Similac Alimentum (formerly Similac Expert Care Alimentum)

Abbott

Powder 12.1 oz 87 oz 6 cans N/A 10 11 8 11 10 ---


RTF 8 oz 8 oz 24 cans N/A 104 114 80 114 113 ---

Similac NeoSure H K

(formerly Similac Expert Care NeoSure)

Abbott

Powder 13.1 oz 87 oz Single Cans N/A 10 11 8 11 10 ---

RTF 1 qt 32 oz 6 bottles N/A 26 28 20 28 28 ---


Similac Human Milk Fortifier H K Order Rxed amount only (Not exceeding the max) State Order Only

Abbott Powder 0.9 g NSD 50

pack/carton N/A

MBF 1029

MBF 1135

MBF 823

MBF 1135

--- ---

Similac Human Milk Fortifier Hydrolyzed Protein Concentrated Liquid H K Order Rxed amount only (Not exceeding the max) State Order Only

Abbott Powder 0.9 g NSD 50

pack/carton N/A

MBF 1029

MBF 1135

MBF 823

MBF 1135

--- ---




Size Reconstitute

Amount Containers/

Case Flavors


Day to Use

Child Max

Woman Max

0-3 m 4-5 m 6-12 m w/food

6-12 m no food

Similac PM 60/40 H K

Abbott Powder 14.1 oz 102 oz Order

Single cans N/A 8 9

7 (6 mo) 6 (7-11

mo) 9 8 ---

Similac Special Care 20, 24, or 30 H K

State Order Only (Special Care 20 and 30) **Drop Ship (SC 30)

Abbott RTF 2 oz 2 oz

20 sold in 8-packs

24 sold in 4-packs, 30 sold in 48-pack

N/A 416 456 321 456 455 ---

SolCarb See Supplemental Formula Conversion Table #2 for Amount of Formula Replaced State Order Only **Drop Ship

Medica-Nutrition

Powder 16 oz

(454 g) NSD 6 cans

N/A --- --- --- --- --- ---

Suplena with Carb Steady H K

State Order Only Abbott RTF 8 oz 8 oz 24 cans Homemade

Vanilla --- --- --- --- 113 113

Tolerex K

Not recommended for infants 0-12 mo

State Order Only Nestlé Powder

2.82 oz (80 g)

10.15 oz 6 pkt/ cartons Unflavored 85

94 68

94 89 89

Tyrex-1 H (for infants & toddlers)

State Order Only Abbott Powder 14.1 oz NSD 6 cans N/A 9 10 7 10 10 ---

Tyrex-2 H (for children & adults)

State Order Only Abbott Powder 14.1 oz NSD 6 cans N/A 9 10 7 10 10 10

UCD Anamix Junior State Order Only

Nutricia Powder 14.1 oz (400 g)

56 oz 6 cans Unflavored

Vanilla --- --- --- --- 16 ---

Vivonex Pediatric K

State Order Only Nestlé Powder 1.7 oz 8.45 oz 36 packets

6 pkt/cartons Unflavored --- --- --- --- 107 ---

Vivonex RTF State Order Only

Nestlé RTF 250 mL 8.45 oz 24 cartons Unflavored --- --- --- --- 107 107

Formula Form:

Infant Maximum if no standard dilution (NSD) Child/Woman Maximum if no standard dilution

Birth- 3 months Age 4- 5 Months Age 6-11 Months Age 6-11 Months (no food)

Powder 128 oz / 3628 g 141 oz / 3997 g 102 oz / 2891 g 141 oz / 3997 g 144 oz / 4082 g (1 fluid ounce = 29.57 milliliters; 1 pound = 453.6 grams; 1 ounce = 28.35 grams)

Notes: NSD = No Standard Dilution K= Kosher; H= Halal Conc. = Concentrate MBF = Mostly breastfeeding **Drop shipped items may take 4-7 business days to arrive after SWO processing.



SUPPLEMENTAL FORMULA CONVERSION TABLE - MODULARS

Displacement Method

Monthly RX

Amount of Formula Replaced

Concentrate 12 - 13 oz

Powder 12 - 16 oz

Powder 22 - 24 oz

Ready to Feed 32 - 34 oz

Duocal (14.1 oz powder) 1 can contains 48 TBSP/80 scoops/400 grams/2008 Calories

1 can 4 1 1 4

2 cans 8 2 1 7

3 cans 12 3 2 10

4 cans 16 4 2 13

SolCarb (16 oz) 1 can contains 76 TBSP/1740 Calories/454 g

1 can 2 1 1 2

2 cans 4 2 2 4

3 cans 6 3 3 6

4 cans 8 4 4 8

5 cans 10 5 5 10

BeneCalorie (1.5 oz cup) 1 cup contains 330 calories and 7 grams of protein

1-2 container(s) 1 1 1 1

3 containers 2 1 1 2

4-5 packets 3 1 1 3

6 packets 4 2 1 3

7-8 containers 5 2 1 4








19-20 containers 13 3 2 10


22-23 containers 14 4 2 12


25-26 containers 16 4 3 13


28-29 containers 18 5 3 15




Monthly RX



Powder 12 - 16 oz

Powder 22 - 24 oz


Human Milk Fortifier

If combining this with other formula, please call the Nutrition Unit for assistance 404-657-2884

BeneProtein (8 oz can) 1 can contains 810 calories and 194 grams of protein 1 can 2 1 1 1 2 cans 3 1 1 3 3 cans 5 2 1 4 4 cans 6 2 1 5

BeneProtein (7 gm packet) 1 packet contains 25 calories and 6 grams of protein

1-30 packets 1 1 1 1 31- 50 packets 2 1 1 2 51-60 packets 3 1 1 2 61-70 packets 3 1 1 3 71-80 packets 4 1 1 3 81-90 packets 4 2 1 4 91-100 packets 5 2 1 4 101-110 packets 5 2 2 4 111-120 packets 6 3 2 5

MCT Oil (32 fl oz bottle) 1 bottle contains 960 cc/64 TBSP/7392 Calories 1 bottle 3 1 1 3 2 bottles 6 2 1 6

Microlipid (3 oz bottle) 1 bottle contains 88.7 ml/399 Calories/44 gr Fat 1-4 bottles 1 1 1 1 5-8 bottles 2 1 1 2 9-10 bottles 3 1 1 3 11-14 bottles 4 1 1 4 15-18 bottles 5 1 1 5 19-20 bottles 6 2 1 6

Complete Amino Acid Mix

1 can 1 1 1 1

2 cans 2 1 1 2

3 cans 3 1 1 3

4 cans 4 1 1 4

5 cans 5 2 1 5

6 cans 6 2 1 6

7 cans 7 2 1 7

8 cans 8 2 1 8

9 cans 9 3 2 9

ProMod (1 qt bottle) 3680 calories per bottle/32 servings/10 CHO, 7 PRO per serving 1 bottle 8 2 1 6 2 bottles 16 4 2 12 3 bottles 24 6 3 18



Monthly RX



Powder 12 - 16 oz

Powder 22 - 24 oz


L-Arginine

1- 4 bottles 1 1 1 1

5-8 bottles 2 1 1 2

9-12 bottles 3 1 1 3

13-16 bottles 4 2 1 4

17-20 bottles 5 2 1 5

21-24 bottles 6 2 1 6

25-29 bottles 7 2 2 7

MCT Procal (480g tub) 3150 calories per tub/30–2 scoop serving/10 gr MCT, 2 gr PRO, 105 cal per serving

1 tub 6 1 1 6

2 tubs 12 3 2 12

3 tubs 18 5 3 18

MCT Procal (16 gr packet) 10 gr MCT, 2 gr PRO, 105 cal per packet

0-5 packets 1 1 1 1

6-10 packets 2 1 1 2

11-15 packets 3 1 1 2

16-20 packets 4 1 1 3

21-25 packets 5 1 1 4

26-30 packets 6 1 1 5

31-35 packets 7 2 1 6

36-40 packets 8 2 1 7

41-45 packets 9 2 1 7

46-50 packets 10 2 1 8

51-55 packets 11 2 1 9

56-60 packets 12 3 2 10

61-65 packets 13 3 2 11

66-70 packets 14 3 2 12

71-75 packets 15 4 2 12

75-80 packets 16 4 2 13

81-85 packets 17 4 2 14

86-90 packets 18 5 3 15

Polycal (14.1 oz powder) 1 can contains 80 scoops/1536 Calories

1 can 4 1 1 4

2 cans 8 2 1 7

3 cans 12 3 2 10

4 cans 16 4 2 13

Monthly RX Amount of Formula Replaced


Powder 12 - 16 oz

Powder 22 - 24 oz


Liquigen (8.5 oz bottle) 1 bottle contains 250 ml/1125 calories/125 g fat 1 bottle 1 1 1 1 2 bottles 2 1 1 2 3 bottles 4 1 1 3 4-5 bottles 5 1 1 4 7 bottles 6 1 1 6 8 bottles 7 2 1 7

This institution is an equal opportunity provider.

common formula package maximums - dph.georgia.gov

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