Common Formula Package Maximums - Georgia Department of ...
Transcript of Common Formula Package Maximums - Georgia Department of ...
Common Formula Package Maximums
Revised May 2021 Page 1 of 15
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 ---
Common Formula Package Maximums
Revised May 2021 Page 2 of 15
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
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
Common Formula Package Maximums
Revised May 2021 Page 3 of 15
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
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 --- --- --- --- --- ---
Encala (State Order Only)
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
Powder 12.9 oz (366 g)
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 ---
RTF 8 oz 8 oz 6 - pack N/A 102 114 78 114 108
32 oz 32 oz 6 bottles N/A 26 28 20 28 28 ---
Enfamil Gentlease K, H
(Not available by State Order)
Mead Johnson
Powder 12.4 oz (352 g)
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
Powder 12.9 oz (366 g)
91 oz Single can N/A 9 10 7 10 10 ---
Common Formula Package Maximums
Revised May 2021 Page 4 of 15
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
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 ---
Enfamil Human Milk Fortifier Order prescribed amount only (Not exceeding the maximum)
State Order Only **Drop Ship
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
Common Formula Package Maximums
Revised May 2021 Page 5 of 15
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
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
State Order Only Abbott Powder
14.1 oz (400 g)
NSD 6 cans N/A 9 10 7 10 10 10
Glutarex-2 H
State Order Only Abbott Powder
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
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
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 RTF 250 ml 8.45 oz 12 cartons Vanilla --- --- --- --- 107 107
Kate Farms Pediatric Peptide 1.5 State Order Only
Kate Farms RTF 250 ml 8.45 oz 12 cartons Vanilla --- --- --- --- 107 107
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
Common Formula Package Maximums
Revised May 2021 Page 6 of 15
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
Ketonex-2 H
State Order Only Abbott Powder
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
State Order Only **Drop Ship
Cambrooke Therapeutics
RTF 250 mL 8.5 oz 30 cartons Vanilla
Chocolate --- --- --- --- 107 107
KetoVie 3:1 K
State Order Only **Drop Ship
Cambrooke Therapeutics
RTF 250 mL 8.5 oz 30 cartons Unflavored --- --- --- --- 107 107
KetoVie Peptide 4:1 K
State Order Only **Drop Ship
Cambrooke Therapeutics
RTF 250 mL 8.5 oz 30 cartons Unflavored --- --- --- --- 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
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
Nutricia Powder 14 oz
(400 g) 64 oz
Order Single cans
Unflavored Vanilla
Strawberry --- --- --- --- 14 ---
Neocate Nutra K H (Order Rxed amount only - Not exceeding the max)
State Order Only **Drop Ship
Nutricia Powder 14 oz 36 oz Order Single
Cans Unflavored --- --- 19 26 25 ---
Common Formula Package Maximums
Revised May 2021 Page 7 of 15
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
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)
Functional Formularies
RTF 12 oz
(341 g) 12 oz 24 pouches N/A --- --- --- --- 75 75
Nourish Peptide State Order Only (Suitable from 4 years of age)
Functional Formularies
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 ---
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 ---
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 6 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
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
Common Formula Package Maximums
Revised May 2021 Page 8 of 15
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
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
Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---
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 ---
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 ---
PediaSure Reduced Calorie State Order Only
Abbott RTF 8 oz 8 oz 24 bottles Vanilla --- --- --- --- 113 ---
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
Nutricia Powder 400 g
(14.1 oz) 90 oz 6 cans N/A 9 10 7 10 10 ---
Common Formula Package Maximums
Revised May 2021 Page 9 of 15
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
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
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 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
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
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
Common Formula Package Maximums
Revised May 2021 Page 10 of 15
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
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 ---
RTF 2 oz 2 oz 48 nursettes N/A 416 456 321 456 455 ---
Pregestimil 24 State Order Only **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 for infants & toddlers)
State Order Only
Abbott Powder 14.1 oz (400 g)
NSD 6 cans N/A 9 10 7 10 10 ---
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 (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)
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 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 ---
Common Formula Package Maximums
Revised May 2021 Page 11 of 15
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
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 ---
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
--- ---
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
Common Formula Package Maximums
Revised May 2021 Page 12 of 15
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.
Common Formula Package Maximums
Revised May 2021 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 (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
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
Revised May 2021 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 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
Common Formula Package Maximums
Revised May 2021 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 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
Concentrate 12 - 13 oz
Powder 12 - 16 oz
Powder 22 - 24 oz
Ready to Feed 32 - 34 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
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