common formula package maximums (ffy 2016)...common formula package maximums (ffy 2016) updated july...
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Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 1 of 15
Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use* Child
Max**
Woman
Max** 0-3 m 4-5 m
6-11 m
w/food
6-11 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.
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
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 Kid Essentials,
retail version K
Nestlé RTF 8.25 oz 8.25 oz 16 prisms
(4-4 packs)
Vanilla --- --- --- --- 110 ---
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 2 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Boost Kid Essentials
1.0 K
Nestlé RTF 8 oz 8 oz 27 briks Chocolate
Strawberry Vanilla
--- --- --- --- 113 ---
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
Nestlé RTF 8 oz 8 oz 27 briks Vanilla --- --- --- --- 113 ---
Boost Breeze (formerly
Resource Breeze) H K
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
Bright Beginnings Soy
Pediatric Drink K
State Order Only
PBM Products
RTF 8 oz 8 oz 24 cans Vanilla --- --- --- --- 113 ---
Carnation Breakfast
Essentials K
Nestlé RTF 237 mL 8 oz 24 cartons Chocolate
Strawberry Vanilla
--- --- --- --- 113 113
Compleat (Modified) State Order Only
Nestlé RTF 250 mL 8.45 oz 24 cartons Unflavored --- --- --- --- 107 ---
Compleat Pediatric Nestlé RTF 250 mL 8.45 oz 24 cartons 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
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 3 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Cyclinex-2 H
State Order Only
Abbott Powder 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 --- --- --- --- --- ---
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 Unflavored
Vanilla
--- --- --- --- 14 ---
Enfamil AR *NOT FP III
**Drop Ship (8oz RTF)
Mead Johnson
Powder 12.9 oz 91 oz Single can N/A 9 10 7 10 10 ---
RTF 32 oz 32 oz 6 cans N/A 26 28 20 28 28 ---
RTF 8 oz 8 oz 24 bottles N/A 104 114 80 114 113 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Enfamil EnfaCare
**Drop Ship (2 oz. RTF)
Mead Johnson
Powder 12.8 oz 82 oz 6 cans N/A 10 11 8 11 11 ---
RTF 32 oz 32 oz 6 cans N/A 26 28 20 28 28 ---
RTF 8 oz 8 oz 6 bottles N/A 104 114 80 114 113 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Enfamil Human Milk
Fortifier Acidified
Liquid Order Rxed amount
only (Not exceeding the max)
State Order Only
**Drop Ship
Mead
Johnson
Liquid 5 ml vial NSD* 100 (5ml
vials) per
case – Only ships in 2
case qty.
N/A MBF 1029
MBF
1135 MBF
823 MBF
1135
--- ---
Enfamil Premature 20,
24, 30 State Order Only (30 cal) **Drop Ship
Mead
Johnson
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Enfaport State Order Only
Mead Johnson
RTF 6 oz 6 oz 24 cans N/A 138 152 107 152 151 ---
Ensure Clear K
State Order Only Abbott
Nutrition
RTF 10 oz 10 oz 12 carton Peach Blueberry/
Pomegranate
Mixed Fruit
--- --- --- --- 91 91
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 4 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
EO28 Splash Nutricia RTF 237 mL 8 oz 27 carton Grape
Tropical Fruit
Orange-
Pineapple
--- --- --- --- 113 ---
Gerber Extensive HA
(MDF is required) 999 food package needed
Gerber Powder 14.1 oz
(400 g)
96 oz. 6 cans N/A 9 10 7 10 9 ---
Gerber Good Start Gentle (MDF not required) *NOT FP III
Gerber Powder 12.7 oz 90 oz. 6 cans N/A 9 10 7 10 10 ---
Conc. 12.1 oz
24.2 oz. 12 cartons (3-4 packs)
N/A 34 37 26 37 37 ---
RTF 33.8 oz
(4-8 oz)
33.8 16 (4-4
tetrapacks)
N/A 24 27 19 27 26 ---
Gerber Graduates
Gentle (Discontinued April 2016)
Gerber Powder 22 oz 154 oz 6 cans N/A --- --- 4 >9 mo
only
6 >9 mo
only
5 ---
Gerber Good Start
Premature 24
Gerber RTF 3 oz 3 oz 48 nursettes N/A 277 304 214 304 303 ---
Gerber Good Start Soothe (MDF not required) *NOT FP III
Gerber Powder 12.4 oz 90 oz 6 cans N/A 9 10 7 10 10 ---
Gerber Graduates
Soothe (Discontinued April 2016)
Gerber Powder 22 oz 157 oz 6 cans N/A --- --- 4 >9 mo
only
6 >9 mo
only
5 ---
Gerber Good Start
Soy H K
(MDF not required) *NOT FP III
Gerber Powder 12.9 oz 91 oz 6 cans N/A 9 10 7 10 10 ---
Conc. 12.1 oz 24.2 oz 12 cartons (3-4 packs)
N/A 34 37 26 37 37 ---
RTF 33.8 oz
(4-8 oz)
33.8 16 (4-4
tetrapacks)
N/A 24 27 19 27 26 ---
Gerber Graduates Soy (Discontinued April 2016)
Gerber Powder 24 oz 170 oz 6 containers N/A --- --- 4 >9 mo
only
5 >9 mo
only
5 ---
Glutarex-1 H
State Order Only Abbott Powder 14.1 oz
(400 g) NSD* 6 cans N/A 9 10 7 10 10 10
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 5 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Glutarex-2 H
State Order Only Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
Glytrol K
(Formerly Nutren Glytrol)
State Order Only
Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107
Hominex-1 H
State Order Only Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
Hominex-2 H
State Order Only Abbott Powder 14.1 oz
(400 g) NSD* 6 cans N/A 9 10 7 10 10 10
I-Valex-1H
State Order Only Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
I-Valex-2 H
State Order Only Abbott Powder 14.1 oz
(400 g) NSD* 6 cans N/A 9 10 7 10 10 10
KetoCal 3:1 (Recommended child 1-8 yrs)
State Order Only
Nutricia Powder 11 oz
(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
State Order Only Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
Ketonex-2 H
State Order Only Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
KetoVie State Order Only
**Drop Ship
Cambrooke
Therapeutics
RTF 250 mL 8.5 oz 30 cartons Vanilla
Chocolate
--- --- --- --- 107 107
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
Maxamum XPhe (Not recommended child <9)
State Order Only
Nutricia Powder 16 oz NSD* 6 cans
Orange Unflavored
8 8 6 8 9 9
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 6 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
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 8,8,9 9 7 9
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
Nutricia Powder 14 oz
(400 g)
64 oz Order
Single cans
Unflavored
Vanilla
Strawberry
--- --- --- --- 14 ---
Neocate Splash State Order Only
Nutricia RTF 8 oz 8 oz 27 drink box Unflavored --- --- --- --- 113 ---
Nepro with Carb
Steady K (H-Butter Pecan only)
Abbott RTF 8 oz 8 oz 24 cans Butter Pecan
Homemade Vanilla
Mixed Berry
--- --- --- --- 113 113
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 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
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 ---
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 7 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Nutren 1.0 K
State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107
Nutren 1.0 w/ Fiber K
State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107
Nutren 1.5 K
State Order Only
Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 107
Nutren 2.0 K
State Order Only Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107
Nutren Junior K Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---
Nutren Junior Fiber K 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 H K Abbott RTF 8 oz 8 oz 24 bottles Banana
Berry
Chocolate
Strawberry
Vanilla
--- --- --- --- 113 ---
PediaSure 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
Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---
PediaSure 1.5 Cal H K Abbott RTF 8 oz 8 oz 24 cans Vanilla --- --- --- --- 113 ---
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
Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 8 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Peptamen Junior Nestlé RTF 250 mL 8.45 oz 24 cans Chocolate
Strawberry
Unflavored
Vanilla
--- --- --- --- 107 ---
Peptamen Junior
Fiber
Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---
Peptamen Junior w/
Prebio
Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 ---
Peptamen Junior 1.5 Nestlé RTF 250 mL 8.45 oz 24 cans Unflavored --- --- --- --- 107 ---
PKU Periflex Early
Years State Order Only
Nutricia Powder 400 g (14.1 oz)
90 oz 6 cans N/A 9 10 7 10 10 ---
Periflex Infant State Order Only
Nutricia Powder 400 g
(14 oz)
84 oz 6 cans N/A 10 11 8 11 10 ---
Periflex Junior State Order Only
Nutricia Powder 16 oz (454 g)
57 oz 6 cans Orange --- --- --- --- 15 ---
60 oz 6 cans Unflavored
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 Abbott Powder 14.1 oz
(400 g) 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
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 9 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
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.)
Mead Johnson
Powder 14.4 oz 64 oz Single cans N/A 13 15 10 15 14 14
Pregestimil Mead Johnson
Powder 1 lb 112 oz Single cans N/A 7,7,7,8 8 6 8 8 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Pregestimil 24 **Drop Ship
Mead
Johnson
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
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
Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 ---
Propimex-1 H
(Recommended infants & toddlers)
State Order Only
Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 ---
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 10 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
Propimex-2 H
(Recommended child > 1 yr. & adults)
State Order Only
Abbott Powder 14.1 oz
(400 g)
NSD* 6 cans N/A 9 10 7 10 10 10
ProViMin H K
State Order Only Abbott Powder 5.3 oz
(150 g) NSD* 6 cans N/A 24 26 19 26 27 27
PurAmino
Mead
Johnson
Powder 14.1 oz 98 oz Order
Single cans
N/A 8,8,8,9 9 7 9 9 ---
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 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)
State Order Only
Nestlé RTF 250 mL 8.45 oz 24 cans Vanilla --- --- --- --- 107 107
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 16 oz 115 oz 6 cans N/A 7,7,7,8 8 6 8 7 ---
Powder 12.1 oz 87 oz 6 cans N/A 10 11 8 11 10 ---
RTF 32 oz 32 oz 6 bottles N/A 26 28 20 28 28 ---
RTF 8 oz 8 oz 24 cans N/A 104 114 80 114 113 ---
Similac for
Diarrhea H K
(formerly Similac Expert Care for Diarrhea)
Recommended infants > 6 mo
State Order Only
Abbott RTF
8 oz 8 oz 24 cans N/A 104 114 80 114 113 ---
1 qt 32 oz 6 bottles N/A 26 28 20 28 28 ---
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 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 11 of 15
Formula Company
Form Package
Size
Reconstitute
Amount Containers/
Case Flavors Fully Formula Fed (FFF) Infant Max
Infant Age @ First Day To Use
Child
Max
Woman
Max
0-3 m 4-5 m 6-11 m
w/food
6-11 m
No food
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 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 30)
**Drop Ship (SC 30)
Abbott RTF 2 oz 2 oz 20 and 24
sold in
8-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
Solace Powder 8 oz
(227 g)
NSD* 4 cans
N/A --- --- --- --- --- ---
Suplena with Carb
Steady H K
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
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 12 of 15
Formula
Form:
Infant Maximum (if no standard dilution) 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
Except for Neocate Infant and Jr., Nutricia lists their 400 g products as 14 oz; other companies list their products as 14.1 oz
K= Kosher; H= Halal
**Drop shipped items may take 4-7 business days to arrive after SWO processing.
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 13 of 15
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 (8 oz) 1 can contains 57 TBSP/851 Calories
1 can 1 1 1 1
2 cans 2 1 1 2
3 cans 3 2 2 3
4 cans 4 2 2 4
5 cans 5 3 3 5
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
9 containers 6 2 1 5
10-11 containers 7 2 1 6
12 containers 8 2 2 6
13-14 containers 9 2 2 7
15 containers 10 3 2 8
16-17 containers 11 3 2 9
18 containers 12 3 2 10
19-20 containers 13 3 2 10
21 containers 13 4 2 11
22-23 containers 14 4 2 12
24 containers 15 4 2 12
25-26 containers 16 4 3 13
27 containers 17 4 3 14
28-29 containers 18 5 3 15
30 containers 19 5 3 15
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 14 of 15
Monthly RX Amount of Formula Replaced
Concentrate 12 - 13 oz
Powder 12 - 16 oz
Powder 22 - 24 oz
Ready to Feed 32 - 34 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 3
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
Common Formula Package Maximums (FFY 2016)
Updated July 2016 Page 15 of 15
Monthly RX Amount of Formula Replaced
Concentrate 12 - 13 oz
Powder 12 - 16 oz
Powder 22 - 24 oz
Ready to Feed 32 - 34 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 tub 12 3 2 12
3 tub 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