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State of Alaska WIC Program

Directions:

Please complete the Enteral Nutrition Prescription Request (ENPR) form so that WIC can provide a Non Contract formula for your

patient. This form can be provided to the WIC client or faxed to the WIC office. If measurements were completed during the medical exam please

document the most current information. The prescription must be completed by a Health Care Provider eligible to write prescriptions in Alaska.

Please include your Alaska License number or Medicaid Provider number. If the ENPR form is approved by the Local Agency Registered Dietitian,

WIC will provide the Non Contract formula. If your client is currently participating in the State of Alaska Medicaid or Denali Kid Care program, WIC

will apply to Medicaid for the Non Contract Formula. The Local Agency will assist the WIC family in the application process. If Medicaid approves

the prescription, the formula will be shipped directly to your patient’s home. This process may take more than a month for completion, during which

time WIC will provide the Non Contract formula for your patient.

Important:

Medical documentation is federally required in order to issue special formula and some supplemental food to WIC women, infants and

children who have qualifying condition(s) that require the use of the special formulas listed below. The program does NOT authorize issuance of

therapeutic formulas for:

1). Non specific symptoms such as intolerance, fussiness, gas, spitting up, constipation or colic OR

2). Enhancing nutrient intake or managing body weight without an underlying medical condition.

WIC is a supplemental Food Program. Infants who are not breastfed may require more formula than WIC is able to provide.

WIC S

LASKA

TANDARD

ONTRACT FORMULAS

The following contract formulas

for infants younger than 12 months, except when an increased

DO NOT REQUIRE MEDICAL DOCUMENTATION

formula amount is requested for infants 6-11 months:

Similac Advance (milk based) 20 Cal/oz

Gerber Good Start Soy (soy based) 20 Cal/oz

HERAPEUTIC

ORMULAS AND

EDICAL

OODS THAT

AY BE

ROVIDED WITH

EDICAL

OCUMENTATION

Hydrolyzed Protein

Amino Acid Based

WIC-eligible Nutritionals for Children/Women

Similac Expert Care Alimentum

Neocate Infant

Pediasure and Pediasure with Fiber

Nutramigen with Enflora

Neocate Jr.

Ensure

Premature Infant Post

Elecare

Discharge

Enfacare

Soy for Children

Neosure

Gerber Graduates Soy

Females Velocity

Males Velocity of

STIMATED ENERGY AND

ROTEIN

of Weight Gain

gm/day

Weight Gain

gm/day

EQUIREMENTS

Birth-3 month

3-6 months

Age in Years

RDA Energy

Protein

6-9 months

(kcals/kg)

(g/kg/day)

9-12 months

Infants

Premature

120

2.2

12-18 months

0-6months

108

2.2

18-36 months

6-12 months

1.6

3-4 years

Children

1-3 years

102

1.2

4-5 years

4-6 years

1.1

Full Provisions of WIC Formula and Food for a month

Infants

Children and Women



Eggs 1 dozen

Juice 1 gallon (children approx. 4oz/day)

0-3 months of age: 26 ounces of formula/day

Fruits/Vegetables $8 or $11 Whole grains 1-2 pounds



Cereal 36 ounces

Beans 1 pound

4-5 months of age: 29 ounces formula/day

Cheese 1 lb

Peanut Butter 18 ounces



6-11 months of age: 20 ounces formula/day*

Milk up to 4 gallons

(children have a choice of



24 ounces infant cereal

(children 13-17ounces/day)

beans or peanut butter)

32 four ounce containers baby food fruit/vegetables



Exclusively Breastfeeding Women receive additional WIC foods

*Infants unable to consume baby foods may be eligible for up to 29

Formula for Children and Women is approximately 29 ounces/day

ounces formula per day.

Alaska Wic Nutrition Program Enteral Nutrition Prescription Request Form - Department Of Health & Social Services - 2016 Page 2

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