WIC Form FD 941C August 2016 This institution is an equal opportunity provider. Page 2 of 2
HAWAII WIC APPROVED CONTRACT AND NON-CONTRACT FORMULA
WIC participants with a qualifying medical condition are eligible to receive non-contract formulas listed below.
(Medical reason for request)
Contract – Milk-based formula (20 kcal/fluid oz.)
Contract – Milk-based, lactose-free formula (Requires Med Doc form due to 19 kcal/fluid oz.)
Contract – Lactose-free, sucrose-free, soy-based formula (20 kcal/fluid oz.)
For increased protein needs. Nutritionally incomplete.
Nutritionally complete formula for infants with Chylothorax or LCHAD deficiency.
Contains 84% of its fat from MCT oil. (30 kcal/fluid oz.)
Prematurity and/or low-birth weight infants. (22 kcal/fluid oz.)
Free Amino Acid Elemental Formulas:
EleCare for Infants / EleCare Jr /
Neocate / Neocate Jr / PurAmino
For infant or child with severe malabsorption, protein maldigestion, severe food allergies,
short bowel syndrome, and/or GI impairment.
Metabolic formulas: Cyclinex / I-Valex
Glutarex / Hominex / Ketonex / Phenex
Metabolic disorders. (WIC does not provide medical nutritional therapy for metabolic
Hypoallergenic formula for infants with an allergy or sensitivity to intact proteins in cow’s
milk and soy formulas, as well as other foods.
Pediatric Formulas: Child > 1 yr.
Nutren Jr. with or without fiber /
Pediasure with or without fiber
For children with chronic illness, oral motor feeding problems, tube feeding or medical
conditions which increase caloric needs beyond what is expected for age. WIC will not
provide for sole purpose of enhancing nutrient intake or managing body weight.
Note: Medicaid will provide formula for Medicaid blind and/or disabled infants &
children that are tube fed. Not for children with Galactosemia.
Children with GI impairment, e.g. Inflammatory Bowel, Cystic Fibrosis or Short Bowel
Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies. Not for infants.
Fat malabsorption and sensitivity to intact proteins. Contains 55% of fat from MCT oil.
Malabsorption of carbohydrate and/or fat; supplement for patient who requires increased
protein, minerals, and vitamins.
Inability to tolerate type or amount of carbohydrate in milk or conventional formula; or need
for ketogenic diet.
Similac Human Milk Fortifier (HMF)
Added to breastmilk for low birth weight and premature infants. HMF can be issued
until the infant reaches a maximum weight of 8 lbs.
Renal or cardiac conditions requiring low mineral level.
Treatment of medically diagnosed Gastroesophageal Reflux Disease.
Similac Special Care Advance 24
Premature and low-birth weight infants. Not intended for feeding low birth weight infants
after they reach a weight of 8 lbs.
Inability to tolerate whole cow-milk protein. (Partially hydrolyzed protein, milk-based
formula - 19 kcal/fluid oz.)
Children with severe GI impairment, e.g. Crohn’s disease, Short Bowel Syndrome, intestinal
failure, GI trauma/surgery, or Malabsorption syndrome.
Hawaii WIC is unable to provide the following formulas, even with medical documentation
No Similac soy infant formula: Similac Soy Isomil
No Similac or Enfamil Supplementation formula: Similac for Supplementation or Enfamil for Supplementing
No Gerber standard milk-based formula: Good Start Gentle or Good Start Soothe
No Enfamil standard infant formulas: Enfamil PREMIUM, Enfamil ProSobee, Enfamil AR, or Enfamil Gentlease