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Approved Formulas and WIC-Eligible Nutritionals

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WIC and Nutrition Services

Missouri Department of Health and Senior Services
PO Box 570
Jefferson City, MO 65102-0570

Telephone: 573-751-6204 or
(toll-free) 800-392-8209
Fax: 573-526-1470
 

Email
WICinfo@health.mo.gov
Phone
573-751-6204

This is a list of WIC-approved formulas and WIC-eligible nutritionals that may be prescribed to an eligible participant. The WIC-27 Medical Documentation form is required to prescribe many of these items. A health care provider's prescription is not an allowable substitution. A qualifying condition must be present for approval. Health insurance companies, including MO HealthNet, are the primary payers for exempt, WIC-eligible nutritionals and metabolic formulas (i.e., special formulas) for infants and children.

Common acronyms:

  • Ready-to-feed (RTF).
  • Ready-to-use (RTU).
  • Concentrate (Conc.).

Infants

The maximum approval length for all formulas in this category is six months.

Contract formulas 

A WIC-27 is only needed when mixing instructions differ from the product label.

  • Similac Advance (Powder, Conc., RTF).
  • Similac Gentle Comfort (Powder).
  • Similac Sensitive (Powder and RTF).
  • Similac Soy Isomil (Powder, Conc., RTF).

Note: Contract formula will be issued unless a health care provider diagnoses a qualifying condition that warrants a formula in the sections below (i.e., non-contract, exempt, WIC-eligible nutritional and metabolic).

A WIC-27 is required for the following formula categories. The maximum approval length is six months, with the exception of the Metabolic Formulas, which is two months.

Non-contract formulas

Enfamil A.R. (PWD).

Exempt formulas

  • 3232A (Powder). 
  • Alfamino Infant (Powder). 
  • Calcilo XD (Powder).
  • EleCare for Infants DHA/ARA (Powder).
  • EnfaCare NeuroPro (Powder).
  • Enfaport (RTU).
  • Extensive HA.
  • Neocate Infant Formula DHA/ARA (Powder).
  • Nutramigen (RTU).
  • Nutramigen with Probiotic LGG (Powder).
  • Nutramigen (Conc.).
  • Pregestimil (Powder).  
  • PurAmino Infant (Powder).
  • RCF - Ross Carbohydrate Free (Conc.).
  • Similac Alimentum (Powder and RTF).
  • Similac NeoSure (Powder and RTF).
  • Similac PM 60/40 (Powder).

Nursettes

RTU, 2 fl oz container

  • Enfamil Premature with Iron (24 cal).
  • Pregestimil (20 cal and 24 cal).
  • Similac Special Care with Iron (24 cal).

Children

The maximum approval length for all nutritionals in this category is six months.

WIC-eligible nutritionals

  • 3232A (Powder).
  • Alfamino Jr. (Powder).
  • Boost Kid Essentials (RTU).
  • Boost Kid Essentials 1.5 cal (RTU).
  • Boost Kid Essentials 1.5 cal with Fiber (RTU).
  • Compleat Pediatric (RTU).
  • Compleat Pediatric Reduced Calorie (RTU).
  • EleCare Jr. (Powder).
  • Glucerna Shake ((RTU).
  • Isosource 1.5 cal with Fiber (RTU).
  • Ketocal 3:1 and 4:1 (Powder).
  • Monogen (Powder).
  • Neocate Jr. with Prebiotics (Powder).
  • Neocate Jr. without Prebiotics (Powder).
  • Neocate Splash (RTU).
  • Nutren Jr. (RTU).
  • Nutren Jr. with Fiber (RTU).
  • PediaSure Grow and Gain (RTU).
  • PediaSure Grow and Gain with Fiber (RTU).
  • PediaSure 1.5 cal (RTU).
  • PediaSure 1.5 cal with Fiber (RTU).
  • PediaSure Enteral Formula 1.0 cal (RTU).
  • PediaSure Enteral Formula 1.0 cal with Fiber (RTU).
  • PediaSure Peptide 1.0 cal (RTU).
  • PediaSure Peptide 1.5 cal (RTU).
  • PediaSure SideKicks (RTU).
  • Peptamen Jr. (RTU).
  • Peptamen Jr. with Fiber (RTU).
  • Peptamen Jr. 1.5 cal (RTU).
  • Portagen (Powder).
  • Super Soluble Duocal (Powder).
  • Suplena with Carb Steady (RTU).

Women

The maximum approval length for all nutritionals in this category is six months.

WIC-eligible nutritionals

  • Boost (RTU).
  • Ensure (RTU).
  • Glucerna Shake (RTU).
  •  Isosource 1.5 cal with Fiber (RTU).
  • Monogen (Powder).
  • Portagen (Powder).
  • Super Soluble Duocal (Powder).
  • Suplena with Carb Steady (RTU).
  • Tolerex (Powder).
  • Vivonex T.E.N. (Powder).

Metabolic formulas

The maximum approval length for all formulas in this category is two months. Only the powder version is approved.

For information about medical eligibility for metabolic formula, please go to the DHSS Metabolic Formula program web page.

  • BCAD 1.
  • GA.
  • HCY 1. 
  • HCY 2.
  • I-Valex-1.
  • Ketonex 1.
  • Ketonex 2.
  • LMD.
  • MSUD ANAMIX Early Years.
  • MSUD Maxamum.
  • OA 1.
  • OA 2.
  • PKU Periflex Early Years.
  • PKU Maxamum.
  • PFD Toddler.
  • Phenex-1.
  • Phenex-2.
  • Phenyl-Free 1.
  • TYROS 1.
  • WND 1.
  • WND 2.