Indiana Wic Authorized Formulas Page 4

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INDIANA WIC AUTHORIZED FORMULAS
(Print in COLOR for ease in reading)
Exempt
Product
Unit of Measure
or
Yield/
****Women
(*IFF)
Infant Fully Formula
&
Infant BF Mostly (***IBPm)
Concentrate
WIC
Unit
&
Infant BF some
(**IBPs)
Formula Name
A
B
C
D
Eligible
in
Children
RTU
A
B
C
0 to 1/ 1-3/ 4-5/ 6-11
0-3mo / 4-5mo / 6-11mo
(Fd. Pkg. III)
Nutritio
fluid
Powder
nals
ounces
Metabolic Formulas Requiring
MAX
MAX CONTAINERS
MAX CONTAINERS
Medical Documentation
CONTAINERS
Glutarex-1
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
14.1-oz powdered
E
96
I
Abbott Nutrition
Glutarex-2
11
WEN
14.1-oz powdered
82
W-C
Abbott Nutrition
HCY 1
4-7
5-8
4-6
1 can / 3
/ 4
/ 3
8
16-oz powdered
E
113
W-I-C
MeadJohnsonNutritionals
HCY 2
9
WEN
16-oz powdered
93
W-C
MeadJohnsonNutritionals
Hominex-1
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
14.1-oz powdered
E
96
I
Abbott Nutrition
Hominex-2
11
WEN
14.1-oz powdered
82
W-C
Abbott Nutrition
I-Valex-1
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
14.1-oz powdered
E
96
I
Abbott Nutrition
I-Valex-2
11
WEN
14.1-oz powdered
82
W-C
Abbott Nutrition
Ketonex-1
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
14.1-oz powdered
E
96
I
Abbott Nutrition
Ketonex-2
11
WEN
14.1-oz powdered
82
W-C
Abbott Nutrition
Lipistart
9
WEN
93
W-C
Vitaflo
400gm.Powdered[14.11 oz]
LMD
4-7
5-8
4-6
1 can / 3
/ 4
/ 3
8
W-I-C
MeadJohnsonNutritionals
16-oz powdered
E
113
MSUD Anamix Early Years
5-9
6-10
5-7
1
1-4/
1-5/
1-4
9
14.1-oz powdered
E
90
I-C
Nutricia North America
MSUD Maxamum
13
WEN
W
Nutricia North America
16-oz powdered
69
OA 1
4-7
5-8
4-6
1 can / 3
/ 4
/ 3
8
16-oz powdered
E
113
W-I-C
MeadJohnsonNutritionals
OA 2
9
WEN
16-oz powdered
93
W-C
MeadJohnsonNutritionals
Periflex Advance
10
WEN
16-oz powdered
83
W
Nutricia North America
PFD Toddler
7
(formerly PFD 1)
4-7
5-8
4-5
1 can / 3
/ 4
/ 3
16-oz powdered
E
120
W-I-C
MeadJohnsonNutritionals
PFD 2
10
WEN
16-oz powdered
91
W-C
MeadJohnsonNutritionals
Phenex-1
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
14.1-oz powdered
E
96
I
Abbott Nutrition
Phenex 2
11
WEN
14.1 oz powdered
82
W-C
Abbott Nutrition
Phenylade-60 Drink Mix
8
WEN
16-oz powdered
106
W-C
Applied Nutrition
Phenylade Drink Mix
10
WEN
W-C
Applied Nutrition
16-oz powdered
90
PhenyladeEssentialDrinkMix
10
WEN
16-oz powdered
90
W-C
Applied Nutrition
Phenyl Free 1
8
4-7
5-8
4-6
1 can / 3
/ 4
/ 3
16-oz powdered
E
113
I-C
MeadJohnsonNutritionals
Phenyl Free 2
9
WEN
16-oz powdered
93
W-C
MeadJohnsonNutritionals
Phenyl Free 2 HP
10
WEN
16-oz powdered
88
W-C
MeadJohnsonNutritionals
5-9
6-10
5- 7
1
1-4/
1-5/
1-4
9
PKU Periflex Early Years
14.1-oz powdered
E
90
I-C
Nutricia North America
Product 3232A
4-7
5-8
4-6
1 can / 3
/ 4
/ 3
8
16-oz powdered
E
113
W-I-C
MeadJohnsonNutritionals
4
Revised September 2017

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