medical required must - gcchd.org · will be changing from a 3-pack to a 4-pack case, so it is...

October 1, 2012 Letter #: 2013-001 TO: All WIC Project Directors MAF FROM: Michele A. Frizzell, RD, MBA, Chief, Bureau of Nutrition Services SUBJECT: Physician and Hospital Packets for Fiscal Year 2013 There are two formulas being added to the Ohio WIC formulary beginning October 1, 2012: Pediasure Peptide 1.5 and Compleat Pediatric Reduced Calorie. Pediasure Peptide 1.5 is a calorically dense formula for children ages 1-13 with malabsorption or other GI issues. It is available in 8 ounces RTF and can be used as an alternative to Peptamin Jr. 1.5. Compleat Pediatric Reduced Calorie is a tube feeding formula for pediatric patients with decreased energy needs, such as developmental disabilities, neurological impairment, or neuromuscular disorders. It is available in 8.45 ounce RTF. Also beginning October 1, a prescription is no longer required to issue coupons for Similac Sensitive and Similac for Spit-Up formulas. Once it is approved, local staff is strongly encouraged to review revised policy Section 311 for more information about documentation standards. There will also be a Health Professional Newsletter issued shortly that will provide local staff with more information regarding these changes. In summary, Similac Sensitive may now be issued if there is documentation on the health history form that the parent/caregiver has reported that the infant has been diagnosed with lactose intolerance by a physician, or the parent/caregiver verbally reports that the infant experiences symptoms of lactose intolerance (diarrhea, fussiness, excessive gas, abdominal bloating) when age appropriate amounts of formula are consumed. Documentation of the medical reasons for issuance of Similac Sensitive formula must be present in the participant’s chart. For Similac for Spit-Up, documentation is also required for the medical reasons the formula is being provided. Appropriate reasons to issue Similac for Spit-Up include: the parent/caregiver reports that the infant has been diagnosed with GERD by a physician, the parent/caregiver reports that the infant experiences symptoms of GERD or other associated feeding disorders, or the parent/care giver reports that the infant is on a prescribed medication for reflux. Please see policy for examples of possible other associated feeding disorders. In addition, health professionals must also assess overfeeding and feeding position as a cause for excessive spit-up first before issuing Similac for Spit-Up. This must be documented in the WIC chart and will be monitored on management evaluations.

A letter is attached for use in notifying area physicians of the continuation of the Ohio WIC formula rebate contract with Abbott Nutrition for Similac brand standard formulas. The revised Ohio WIC Prescribed Formula and Food Request form, both in pdf and electronic fillable versions, and the Ohio WIC Approved Formulas document are also attached. State WIC was unable to address local staff clearance comments regarding the Ohio WIC Prescribed Formula and Food Request form at this time due to time constraints. State WIC plans to address these comments at a future date. The Ohio WIC Prescribed Formula and Food Request form will become available for order in the warehouse in the near future. Until that time, please print and use this most current version of the form. All outdated versions of the Ohio WIC Prescribed Formula and Food Request form should be recycled or destroyed. The physician’s letter attached to this All Projects Letter outlines the minimum documentation required and notifies the physician that WIC health professionals will be contacting them if information is missing. The letter also informs physicians that the request for a special formula may be denied if the request does not meet certain criteria. State WIC would like to remind health professionals to use Table 310A which outlines the acceptable uses for special formulas and should be useful when fielding questions from physicians. In addition, State WIC has recently been made aware of several changes involving Neocate Junior product varieties, Neocate Nutra, and Renastart. Neocate Junior products will undergo a label change, but will have no changes in can size, price, codes, or ingredients. Neocate Nutra will also undergo a label change, as well as a change in ingredients and package size. The corn starch in Neocate Nutra will be replaced with a pregelatinized rice starch. Case or package size will be changing from a 3-pack to a 4-pack case, so it is recommended for health professionals to issue the 4- can package size to any child requiring this product. A document describing the label change descriptions provided by Nutricia is attached. As a reminder, this document is to be used as a resource only and is not to be posted in the clinic. Lastly, Renastart formula is no longer being produced at this time; therefore, it cannot be issued to participants. It will not be removed from the prescription form at this time, but prescribers should already be aware of this issue. If you have any questions, please call the direct line for your Nutrition and Administrative Services (NAS) Consultant, or (614) 644-8571. MAF/KRM /krm Attachments - 5

Dear Physician: The Ohio Department of Health subscribes to the infant feeding recommendations made by the American Academy of Pediatrics, Committee on Nutrition. The Ohio Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) encourages you to join us in promoting and supporting breast milk as the optimal food and the primary feeding choice for the first 12 months of life and beyond for all infants. For those mother and infant dyads that choose not to breastfeed exclusively, iron-fortified formula is available. On October 1, 2012, Ohio WIC will continue to offer Abbott Nutrition’s Similac brand standard formulas. A prescription will no longer be required for local WIC clinics to issue Similac Sensitive or Similac for Spit-Up formulas. However, these formulas still must be issued for appropriate medical reasons, and local WIC staff must follow new documentation standards. Local WIC staff reserve the right to deny the issuance of Similac Sensitive and/or Similac for Spit-Up if the request for these formulas does not meet WIC requirements for issuance. Also effective October 1, 2012, Ohio Women, Infants, and Children program (WIC) is adding Pediasure Peptide 1.5 and Compleat Pediatric Reduced Calorie to the child formulary. Pediasure Peptide 1.5 is a calorically dense formula for children ages 1-13 with malabsorption or other GI issues. It is available in 8 ounces RTF, and can be used as an alternative to Peptamin Jr. 1.5. Compleat Pediatric Reduced Calorie is a tube feeding formula for pediatric patients with decreased energy needs, such as developmental disabilities, neurological impairment, or neuromuscular disorders. It is available in 8.45 ounce RTF. As a reminder, special formulas issued by WIC must be prescribed for their specific nutrient content or for treatment of a medical condition. Prescription requests for special formulas must contain all of the following information:

participant’s name and date of birth; amount of formula to be provided per day (must be a specific volume); intended length of use of the formula (not to exceed six months); applicable ICD9 code and documented medical diagnosis (should relate to the

special formula requested); name of formula; any contraindications for other supplemental foods that WIC provides; signature, credentials, and telephone number of the physician or nurse practitioner;

and date prescribed.

Please ensure that you are using the most current WIC prescription with the effective date of October 1, 2012.

WIC reserves the right to deny a special formula request if the formula:

is not part of the approved WIC formulary, prescription does not include the minimum information outlined in this letter, does not meet WIC requirements for issuance, or is prescribed solely for weight management or nonspecific “intolerance.”

WIC health professionals will work with physicians to obtain any missing data and provide expedient service to participants. The health professionals in the WIC clinics make their decisions on acceptable formulas and foods based on WIC policy and an individualized nutrition assessment. Requested information is used to ensure that the most appropriate formula and supplemental foods are provided. Thank you for your continued support of the WIC program. If you should have any questions, please contact your local WIC office. Sincerely, Michele A. Frizzell Michele A. Frizzell, RD, MBA Chief, Bureau of Nutrition Services MAF/KRM/krm Enclosures- 3

Ohio WIC Prescribed Formula and Food Request - Women, Infants, and Children

Please complete this Ohio WIC Prescribed Formula and Food Request form in full.

REQUIRED FOR APPROVAL:

1. Amount of infant/child/adult formula to be provided per DAY: __________________________________________________________

Special Instructions/Comments: ___________________________________________________________________________________

2. Intended length of use: 1 month 2 months 3 months 4 months 5 months 6 months (maximum)

3. ICD-9 code: _____.___ and Medical diagnosis (please print): _________________________________________________________ (Must support the need for the formula requested.)

For Issuance of Soy Milk or Tofu only, ICD-9 code is not required. Must provide a valid medical diagnosis. For PKU and Metabolic Needs: WIC collaborates with the Ohio Metabolic Formula Program which supplies certain PKU and metabolic formulas prescribed by an Ohio Department

of Health (ODH) approved metabolic service provider. A separate form must be completed. Please contact your WIC office for more information.

4. Prescribed Formulas:

For infants, a trial with either of these formulas is required prior to ordering any of the formulas listed in the box below. Please indicate if the infant has tried either Similac Advance with Early Shield or Similac Soy Isomil formulas: Yes No

Infants and Children

EleCare for Infants Enfamil Nutramigen AA Similac Expert Care NeoSure Enfamil EnfaCare (≤ 12 mo corrected age) Enfamil Pregestimil (≤ 12 mo corrected age)

Enfamil Enfaport Neocate Infant with DHA & ARA Similac PM 60/40 Enfamil Nutramigen w/ Enflora LGG (powder only) Neocate Nutra (≥ 6 mo age)

Enfamil Nutramigen (liq conc & RTF only) Similac Expert Care Alimentum Infant Foods: Indicate which infant foods listed below are contraindicated or require restrictions.

Infant Cereal Fruits (strained textures) Vegetables (strained textures) Do not provide any of the infant WIC foods listed

Children Only

Boost Kid Essentials 1.0 Cal (pharmacy) KetoCal 4:1 Liquid PediaSure with Fiber Enteral Renastart Boost Kid Essentials 1.0 Cal (retail) KetoCal 4:1 Powder PediaSure 1.5 Cal Resource Breeze Boost Kid Essentials 1.5 Cal Monogen PediaSure 1.5 Cal with Fiber Similac Advance with Early Shield Boost Kid Essentials with Fiber 1.5 Cal Neocate Junior PediaSure Peptide (≤ 12 mo corrected age) Bright Beginnings Soy Pediatric Drink Neocate Junior with Prebiotics PediaSure Peptide 1.5 Cal Similac Soy Isomil Compleat Pediatric Nutren Junior Peptamen Junior Super Soluble Duocal Compleat Pediatric Reduced Calorie Nutren Junior with Fiber Peptamen Junior with Fiber Vivonex Pediatric Elecare Junior Unflavored PediaSure Peptamen Junior with Prebio1 Elecare Junior Vanilla PediaSure with Fiber Peptamen Junior 1.5 Cal E028 Splash PediaSure Enteral Portagen

Adult

Boost Ensure Monogen Portagen Resource Breeze Super Soluble Duocal

5. WIC Foods: Participants on Prescribed Formulas may receive the following foods offered by WIC. Please indicate the appropriateness of the following foods to accompany the prescribed formula.

WIC Foods That May Be Provided (12 Months and Older, Adults) Milk Substitutions: (Children Age 2 Years and Older & Adults)

Are there any contraindications or restrictions for any of these foods? Yes, specify:

Whole milk Lactaid® whole milk Cheese Milk Beans, dried peas and legumes Juice Peanut butter (Children Age 1 Years and Older & Adults) Breakfast cereal Whole grains Eggs (bread, brown rice, oatmeal, corn/whole wheat tortillas) Fruits Fish (women only, as applicable) Vegetables

Do not provide any of the above WIC foods Soy Milk (child) Tofu (child) >4lbs Tofu (women)

(Rev. 10/1/12) PPL 180 This institution is an equal opportunity provider. ODH 3989.23

Patient’s name (please print) Date of birth

Weeks born early (if applicable)

Caregiver’s name (please print) Phone

Health Care Provider’s Name (please print)

Phone

Health Care Provider’s Signature

Date

Check this box to give authority to the WIC health professional (RD/LD, RN or DTR) to prescribe the foods listed below based upon the complete nutritional assessment.

Indicate which foods are to be substituted for reduced fat, low fat or skim milk for the following diagnoses: Lactose intolerance, FTT, slow weight gain, low/under weight, or other qualifying conditions.

*Only for patients receiving a prescribed formula who require additional calories

Indicate which foods are to be substituted for whole, reduced fat, low fat or skim milk for the following diagnoses: milk allergy, severe lactose maldigestion, vegetarian/vegan diet or other qualifying conditions.

*Patient does not need to be on a prescribed formula to receive these foods.

Common ICD-9 Codes

This listing is a sample of common ICD-9 codes which support the issuance of a specialty formula for Ohio WIC participants and is not meant to be all inclusive.

Non-specific symptoms or diagnosis (e.g., formula/food intolerance, spitting up, colic, constipation, fussiness, and gas).

Solely for the purpose of enhancing nutrient intake or managing body weight without an underlying qualifying medical condition (e.g., poor appetite, picky eater).

Food or formula intolerance that can be successfully managed with the use of WIC foods or contract formulas.

Parental/patient preference or food dislikes

Infants and Children Acute Gastritis 535.0 Allergic Gastroenteritis And Colitis 558.3 Allergy to Milk Products V15.02

Anemia 281.9 Anaphylactic Shock Due To Milk Products 995.67 Celiac Disease 579.0 Cleft Palate, Cleft Lip 749.00, 749.1 Congenital Heart Disease 746.9 Cystic Fibrosis 277.0 Dermatitis Due To Food Taken Internally 693.1 Developmental Sensory/Motor Delays 783.40 Diabetes 250 Disorders Relating To Extreme Immaturity Of Infant

(<500g, 500-749g, 750-999g, 1000-1249g, 1250-1499g) 765.01, 765.02, 765.03, 765.04, 765.05

Failure to Thrive 783.41 Fetal Alcohol Syndrome 760.1 Gastro Esophageal Reflux Disease (GERD) 530.81 Severe Lactose Intolerance 271.3 Immunodeficiency 279.3

Short Stature 783.43 Underweight 783.22 Unspecified Intestinal Malabsorption 579.9

Breastfeeding, Pregnant, Postpartum Women Allergy to Milk Products V15.02

Anemia 281.9 Cesarean Delivery 763.4 Gestational Diabetes 648.8 Hyperemesis Gravidarum 643.00 Low Maternal Weight Gain 646.8 Maternal Weight Loss During Pregnancy 783.21 Severe Lactose Intolerance 271.3 Multifetal Gestation 651

Examples of non-qualifying conditions that do NOT support WIC issuance of specialty formulas:

Rev 10.1.10 PPL 176; Reissued PPL 178

Ohio WIC Prescribed Formula and Food Request - Women, Infants, and Children

Please complete this Ohio WIC Prescribed Formula and Food Request form in full.

REQUIRED FOR APPROVAL:

1. Amount of infant/child/adult formula to be provided per DAY: __________________________________________________________

Special Instructions/Comments: ___________________________________________________________________________________

2. Intended length of use: 1 month 2 months 3 months 4 months 5 months 6 months (maximum)

3. ICD-9 code: _____.___ and Medical diagnosis (please print): _________________________________________________________ (Must support the need for the formula requested.)

For Issuance of Soy Milk or Tofu only, ICD-9 code is not required. Must provide a valid medical diagnosis. For PKU and Metabolic Needs: WIC collaborates with the Ohio Metabolic Formula Program which supplies certain PKU and metabolic formulas prescribed by an Ohio Department

of Health (ODH) approved metabolic service provider. A separate form must be completed. Please contact your WIC office for more information.

4. Prescribed Formulas:

For infants, a trial with either of these formulas is required prior to ordering any of the formulas listed in the box below. Please indicate if the infant has tried either Similac Advance with Early Shield or Similac Soy Isomil formulas: Yes No

Infants and Children

EleCare for Infants Enfamil Nutramigen AA Similac Expert Care NeoSure Enfamil EnfaCare (≤ 12 mo corrected age) Enfamil Pregestimil (≤ 12 mo corrected age)

Enfamil Enfaport Neocate Infant with DHA & ARA Similac PM 60/40 Enfamil Nutramigen w/ Enflora LGG (powder only) Neocate Nutra (≥ 6 mo age)

Enfamil Nutramigen (liq conc & RTF only) Similac Expert Care Alimentum Infant Foods: Indicate which infant foods listed below are contraindicated or require restrictions.

Infant Cereal Fruits (strained textures) Vegetables (strained textures) Do not provide any of the infant WIC foods listed

Children Only

Boost Kid Essentials 1.0 Cal (pharmacy) KetoCal 4:1 Liquid PediaSure with Fiber Enteral Renastart Boost Kid Essentials 1.0 Cal (retail) KetoCal 4:1 Powder PediaSure 1.5 Cal Resource Breeze Boost Kid Essentials 1.5 Cal Monogen PediaSure 1.5 Cal with Fiber Similac Advance with Early Shield Boost Kid Essentials with Fiber 1.5 Cal Neocate Junior PediaSure Peptide (≤ 12 mo corrected age) Bright Beginnings Soy Pediatric Drink Neocate Junior with Prebiotics PediaSure Peptide 1.5 Cal Similac Soy Isomil Compleat Pediatric Nutren Junior Peptamen Junior Super Soluble Duocal Compleat Pediatric Reduced Calorie Nutren Junior with Fiber Peptamen Junior with Fiber Vivonex Pediatric Elecare Junior Unflavored PediaSure Peptamen Junior with Prebio1 Elecare Junior Vanilla PediaSure with Fiber Peptamen Junior 1.5 Cal E028 Splash PediaSure Enteral Portagen

Adult

Boost Ensure Monogen Portagen Resource Breeze Super Soluble Duocal

5. WIC Foods: Participants on Prescribed Formulas may receive the following foods offered by WIC. Please indicate the appropriateness of the following foods to accompany the prescribed formula.

WIC Foods That May Be Provided (12 Months and Older, Adults) Milk Substitutions: (Children Age 2 Years and Older & Adults)

Are there any contraindications or restrictions for any of these foods? Yes, specify:

Whole milk Lactaid® whole milk Cheese Milk Beans, dried peas and legumes Juice Peanut butter (Children Age 1 Years and Older & Adults) Breakfast cereal Whole grains Eggs (bread, brown rice, oatmeal, corn/whole wheat tortillas) Fruits Fish (women only, as applicable) Vegetables

Do not provide any of the above WIC foods Soy Milk (child) Tofu (child) >4lbs Tofu (women)

(Rev. 10/1/12) PPL 180 This institution is an equal opportunity provider. ODH 3989.23

Patient’s name (please print) Date of birth

Weeks born early (if applicable)

Caregiver’s name (please print) Phone

Health Care Provider’s Name (please print)

Phone

Health Care Provider’s Signature

Date

Check this box to give authority to the WIC health professional (RD/LD, RN or DTR) to prescribe the foods listed below based upon the complete nutritional assessment.

Indicate which foods are to be substituted for reduced fat, low fat or skim milk for the following diagnoses: Lactose intolerance, FTT, slow weight gain, low/under weight, or other qualifying conditions.

*Only for patients receiving a prescribed formula who require additional calories

Indicate which foods are to be substituted for whole, reduced fat, low fat or skim milk for the following diagnoses: milk allergy, severe lactose maldigestion, vegetarian/vegan diet or other qualifying conditions.

*Patient does not need to be on a prescribed formula to receive these foods.

Rev 10.1.10 PPL 176; Reissued PPL 178

Common ICD-9 Codes

This listing is a sample of common ICD-9 codes which support the issuance of a specialty formula for Ohio WIC participants and is not meant to be all inclusive.

Non-specific symptoms or diagnosis (e.g., formula/food intolerance, spitting up, colic,

constipation, fussiness, and gas). Solely for the purpose of enhancing nutrient intake or managing body weight without an

underlying qualifying medical condition (e.g., poor appetite, picky eater). Food or formula intolerance that can be successfully managed with the use of WIC foods

or contract formulas. Parental/patient preference or food dislikes.

Infants and Children Acute Gastritis 535.0 Allergic Gastroenteritis And Colitis 558.3 Allergy to Milk Products V15.02 Anemia 281.9 Anaphylactic Shock Due To Milk Products 995.67 Celiac Disease 579.0 Cleft Palate, Cleft Lip 749.00, 749.1 Congenital Heart Disease 746.9 Cystic Fibrosis 277.0 Dermatitis Due To Food Taken Internally 693.1 Developmental Sensory/Motor Delays 783.40 Diabetes 250 Disorders Relating To Extreme Immaturity Of Infant

(<500g, 500-749g, 750-999g, 1000-1249g, 1250-1499g) 765.01, 765.02, 765.03, 765.04, 765.05

Failure to Thrive 783.41 Fetal Alcohol Syndrome 760.1 Gastro Esophageal Reflux Disease (GERD) 530.81 Severe Lactose Intolerance 271.3 Immunodeficiency 279.3 Short Stature 783.43 Underweight 783.22 Unspecified Intestinal Malabsorption 579.9

Breastfeeding, Pregnant, Postpartum Women Allergy to Milk Products V15.02 Anemia 281.9 Cesarean Delivery 763.4 Gestational Diabetes 648.8 Hyperemesis Gravidarum 643.00 Low Maternal Weight Gain 646.8 Maternal Weight Loss During Pregnancy 783.21 Severe Lactose Intolerance 271.3 Multifetal Gestation 651

Examples of non-qualifying conditions that do NOT support WIC issuance of specialty formulas:

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12.6 oz

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12.3 oz

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13.1 oz

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*According to WIC Federal Regulations, Ready to Feed infant formula may only be provided to infants who meet certain conditions as determined by a WIC health professional. This institution is an equal opportunity provider. Effective 10.1.2012 – 9.30.2013

Milk-based, Modified Vitamin and Mineral Content Infant Formula:

Product Name Indications for Use Powder Concentrate Ready to Feed*

Similac PM 60/40 Milk-based, intact protein formula with reduced levels of several vitamins, minerals and electrolytes for the infant with hypocalcaemia or whose renal, digestive, or cardiovascular functions require reduced minerals.

14.1 oz

Milk-based, High MCT Oil Infant Formula:

Product Name Indications for Use Powder Concentrate Ready to Feed*

Enfamil Enfaport Milk-based, intact protein formula for infants with fat malabsorption such as chylothorax or Long-chain 3 hydroxyacyl CoA Dehydrogense deficiency (LCHAD).

8 oz

Hypoallergenic Infant Formulas: Product Name Indications for Use Powder Concentrate Ready to Feed*

Enfamil Nutramigen with Enflora LGG

Extensively Hydrolyzed Protein, Lactose-Free formula for infants with intact cow’s milk or soy protein sensitivity.

12.6 oz

Enfamil Nutramigen

Extensively Hydrolyzed Protein, Lactose-Free formula for infants with intact cow’s milk or soy protein sensitivity.

13 oz 32 oz (1 QT)

Enfamil Pregestimil

Extensively Hydrolyzed Protein, Lactose-Free formula for infants with intact cow’s milk or soy protein sensitivity. Contains 50% fat as MCT for infants with fat malabsorption.

16 oz

Similac Expert Care Alimentum

Extensively Hydrolyzed Protein, Lactose-Free formula for infants with intact cow’s milk or soy protein sensitivity. Contains 33% fat as MCT for infants with fat malabsorption.

16 oz 32 oz (1 QT)


Hypoallergenic Infant Formulas continued:

EleCare for Infants

Amino acid based formula for infants with sensitivity to extensively hydrolyzed protein, gastrointestinal impairment, or severe food allergies.

14.1 oz

Neocate Infant with DHA & ARA


14 oz

Nutramigen AA


14.1 oz

Hypoallergenic Medical Food: Product Name Indications for Use Powder Concentrate Ready to Feed*

Neocate Nutra

Amino acid based semi-solid medical food for infants >6 months with intact protein intolerance. For oral use only. Not intended for use in a bottle or tube feed. Not suitable as a sole source of nutrition.

14 oz

Child Formulas

Milk-Based, Blenderized Food Pediatric Formulas: Product Name Indications for Use Powder Concentrate Ready to Feed

Compleat Pediatric

For children with an intolerance to standard pediatric formulas requiring tube feeding. Made from real blenderized foods.

8.45 oz

Compleat Pediatric Reduced Calorie For children with an intolerance to standard pediatric formulas requiring tube feeding. Reduced calorie for decreased energy needs.

8.45 oz


Milk-Based, Pediatric Formulas:

Product Name Indications for Use Powder Concentrate Ready to Feed

Boost Kid Essentials 1.0 Cal (retail)

Standard, intact protein, lactose-free, gluten-free formula for children requiring oral supplementation.

8.25

Boost Kid Essentials 1.0 Cal (pharmacy only)

Standard, intact protein, lactose-free, gluten-free formula for children requiring tube feeding, full diet or oral supplementation.

8 oz

PediaSure


8 oz

PediaSure with Fiber


8 oz

PediaSure Enteral


8 oz

PediaSure Enteral with Fiber


8 oz

Nutren Junior


8.45 oz

Nutren Junior with Fiber


8.45 oz

Milk-Based, High Calorie Pediatric Formulas: Product Name Indications for Use Powder Concentrate Ready to Feed

Boost Kid Essentials 1.5 Cal

Nutritionally complete, intact protein, lactose-free, gluten free formula for children requiring higher calorie needs and tube feeding, full diet or oral supplementation.

8 oz


Milk-Based, High Calorie Pediatric Formulas continued:

Boost Kid Essentials 1.5 Cal with Fiber

Nutritionally complete, intact protein, lactose-free, gluten free formula with fiber for children requiring higher calorie needs and tube feeding, full diet or oral supplementation.

8 oz

PediaSure 1.5 Cal

Nutritionally complete, intact protein, lactose-free, gluten-free formula for children requiring higher calorie needs and tube feeding, full diet or oral supplementation.

8 oz

PediaSure 1.5 Cal with Fiber

Nutritionally complete, intact protein, lactose-free, gluten-free formula for children requiring higher calorie needs and tube feeding, full diet or oral supplementation.

8 oz

Soy-Based Pediatric Formula: This product is not to be used as a substitute for soy milk unless medically warranted.


Bright Beginnings Soy Pediatric Drink

Nutritionally complete, intact protein, lactose-free, gluten-free formula for children requiring tube feeding, full diet or oral supplementation.

8 oz

Peptide-Based Pediatric Formulas:


PediaSure Peptide Nutritionally complete, lactose-free formula for children with gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8 oz

Peptamen Junior Nutritionally complete, lactose-free formula for children with gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8.45 oz

Peptamen Junior with Fiber

Nutritionally complete, lactose-free formula for children with gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8.45 oz


Peptide-Based Pediatric Formulas Continued:

Peptamen Junior with Prebio1

Nutritionally complete, lactose-free formula for children with gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8.45 oz

Peptide-Based, High Calorie Pediatric Formulas:


PediaSure Peptide 1.5 Cal

Nutritionally complete, lactose-free formula for children with higher calorie needs and gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8 oz

Peptamen Junior 1.5 Cal Nutritionally complete, lactose-free formula for children with higher calorie needs and gastrointestinal impairment and/or malabsorption requiring tube feeding, full diet, or oral supplementation.

8.45 oz

Hypoallergenic, High MCT Oil Pediatric Formulas:


EleCare Junior Unflavored

Amino acid based (100%), nutritionally complete formula for children with severe food allergies, gastrointestinal impairment, or malabsorption who are allergic to peptide-based (extensively hydrolyzed) formulas.

14.1 oz

EleCare Junior Vanilla


14.1 oz

E028 Splash


8 oz


Hypoallergenic, High MCT Oil Pediatric Formulas Continued:

Neocate Junior Amino acid based (100%), nutritionally complete formula for children with severe food allergies, gastrointestinal impairment, or malabsorption who are allergic to peptide-based (extensively hydrolyzed) formulas.

14 oz

Neocate Junior with Prebiotics


14 oz

Vivonex Pediatric Amino acid based (100%), nutritionally complete formula for children with severe food allergies, gastrointestinal impairment, or malabsorption who are allergic to peptide-based (extensively hydrolyzed) formulas.

1.72 oz

Hypoallergenic Medical Food:


Neocate Nutra

Amino acid based semi-solid medical food for children with intact protein intolerance. For oral use only. Not intended for use in a bottle or tube feed. Not suitable as a sole source of nutrition

14.1 oz

Ketogenic Formula:


KetoCal 4:1 For children with intractable epilepsy, pyruvate dehydrogenase deficiency (PDH) or glucose transporter type-1 deficiency.

11 oz 8oz


Child and Adult Formulas Clear Liquid Formula:


Resource Boost Breeze

Fruit flavored, low fat, lactose and gluten-free formula for children or women with fat malabsorption or intolerance of milkshake-like supplemental beverages. Not nutritionally complete.

8 oz

Milk-based, High MCT Oil Formulas:


Monogen

Lactose-free, gluten-free formula for children and women with fat malabsorption. Contains 90% fat as MCT oil.

14.3 oz

Portagen

Lactose-free, gluten-free formula for children and women with fat malabsorption. Contains 87% fat as MCT oil.

16 oz

Caloric Additive:


Super Soluble Duocal

Energy enhancer; provides 42 calories per tablespoon from carbohydrates and fats only, indicated for children and women with disorders of protein and amino acid metabolism, protein restricted diets, or high energy diets (i.e., FTT).

14 oz

Adult Formulas

Milk-based Adult Formulas: Product Name Indications for Use Powder Concentrate Ready to Feed

Boost Nutritionally complete, lactose and gluten-free formula for women with increased calorie needs.

8 oz

Ensure Nutritionally complete, lactose and gluten-free formula for women with increased calorie needs.

8 oz

New Neocate® Packaging – Great New Look, Same Great Products!

1-800-NEOCATE (636-2283) | www.Neocate.com

Neocate Junior Unflavored

Neocate Nutra

Neocate Junior with Prebiotics(Unflavored)

Neocate Junior Chocolate

Neocate Junior Tropical

August 2012

Dear WIC Official,

Nutricia North America will soon have a new and improved packaging look for Neocate Junior (similar to our new Prebiotics Vanilla) and Neocate Nutra. This new packaging look will be seen in the market starting in September.

Neocate Junior varieties will have no change in can size, price, codes or ingredients. Neocate Junior remains the same great product with the same great benefits!

Benefits of new packaging: • Clearerflavorcommunicationanddifferentiation• Simplereasy-to-readpreparation• NeocateJunior:Bigandboldcupiconindicatesforchildren1yearandolder

Neocate Nutra will have a big and bold bowl and spoon icon to indicates it is a food item for children 6 months and older. Neocate Nutra will have no change in can size, however the codes and case pack will be changing. Neocate Nutra case size will change from a 3 pack to a 4 pack.

PleaseinformyourcolleaguesandWICclinicsofthischangewhenorderingNeocateNutra(seenewNeocateNutracodes below).

Neocate Nutra OLD NEWPack Size: 400 grams x 3 cans 400 grams x 4 cans

Nutricia Product Code: 12910 66739

Nutricia Unit Code: 7497350-29107 7497350-67390

Nutricia Case Code: 7497351-29104 7497351-67397

NDC code: 49735-0129-10 49735-0167-39

Neocate Nutra Ingredient ChangeThe corn starch will be replaced with a pregelatinized rice starch whichishighlyrefinedtoremoveanyriceprotein leavingpurelythestarch component. The change to hypoallergenic rice starch wasnecessitatedbya limitedsupplyofhypoallergeniccornstarch.ThischangewillmaintainthehighestqualityNeocateNutraforyourpatients.

Tohelpyouidentifythenewpackaginguponitsarrival,pleaseseethe new look (to the right).

ClinicallyprovenNeocate–thetrustedfamilyofaminoacid-basednutritionshowntobeeffectiveinthedietarymanagementoffoodallergy-associated conditions such as CMA, MFPI, EoE, SBS,GERDandotherGIconditions.

Ifyouorcaregivershaveanyquestions,pleasecallourCustomerServiceDepartmenttoll-freeat1-800-NEOCATE,MondaythroughFriday,8:30am–7:00pmEST,orvisitwww.Neocate.com.

Sincerely, Neocate’s Specialized Pediatric Team

medical required must - gcchd.org · will be changing from a 3-pack to a 4-pack case, so it is...

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