Appendix I: Nutritional products formulary
The Non-Insured Health Benefits (NIHB) program has established a nutritional products formulary for clients who require medically necessary nutrition products.
Clients who request and obtain approval will be granted access based on their condition. The length of approval and type of benefit will vary by nutrition product or life stage.
Select nutrition products are also included in the following special formularies: End of life care formulary, Formulary for chronic renal patients and Formulary for adjunct medications used during active cancer treatment.
Infant formula
Limited use benefit (prior approval required).
Criteria for infant formula coverage < 1 year of age (corrected gestational age for prematurity):
- contraindications for breastfeeding, HIV, active tuberculosis and herpetic lesions on breast. Please note, contraindications are in accordance with respective Health Canada and World Health Organization guidance
- prematurity or low birth weight
- failure to thrive or growth faltering
- cow milk protein allergy
- other medical conditions not listed
| DIN | Brand name |
|---|---|
| 95900000 | SIMILAC ALIMENTUM 237ML LIQ |
| 95900001 | SIMILAC ALIMENTUM 945ML LIQ |
| 95900003 | ENFAMIL A+ 385ML LIQ |
| 95900007 | ENFAMIL A+ 237ML LIQ |
| 95900152 | ENFAMIL A+ ENFACARE 385ML LIQ |
| 95900026 | NUTRAMIGEN A+ 945ML LIQ |
| 95900012 | ENFAMIL LOWER IRON 385ML LIQ |
| DIN | Brand name |
|---|---|
| 95900047 | SIMILAC ALIMENTUM 400G PDR |
| 95900164 | ENFAMIL A+ 663G PDR |
| 95900009 | ENFAMIL ENFACARE A+ 363G PDR |
| 95900025 | NEOCATE W/ DHA & ARA 400G PDR |
| 95900027 | NUTRAMIGEN A+ LGG 561G PDR |
| 95900035 | PURAMINO A+ 400G PDR |
| 95900036 | SIMILAC ADVANCE NEOSURE 363G |
| 95900155 | ENFAMIL LOW IRON FORMULA 900GM |
| 95900023 | NEOCATE 400G PDR |
| 95900047 | SIMILAC ALIMENTUM 400G PDR |
| 95900184 | SIMILAC LOWER IRON 850G PDR |
| 95900044 | SIMILAC PM 60/40 450G PDR |
CHILDREN AND YOUTH
Limited use benefit (prior approval required).
Criteria for Nutritional Supplement Coverage for Children and Youth (19 years and under)
- Sole source nutrition (more than 75% of intake is from nutrition supplement)
- Failure to thrive/growth faltering
- Pre or post-surgery (6 months before or after date of surgery)
- Other medical conditions not listed
| DIN | Brand name |
|---|---|
| 95900131 | COMPLEAT PEDIATRIC 250ML LIQ |
| 95900083 | NEOCATE SPLASH 237ML LIQ |
| 95900133 | NUTREN JR. 250ML LIQ |
| 95900177 | PEDIASURE 235ML LIQ |
| 95900142 | PEDIASURE COM. GROW&GAIN 235ML LIQ |
| 95900178 | PEDIASURE FIBRE 235ML LIQ |
| 95900179 | PEDIASURE PLUS WITH FIBRE 235 |
| 95900135 | PEPTAMEN JUNIOR 1.0 CAL 250ML LIQ |
| 95900136 | PEPTAMEN JUNIOR 1.5 CAL 250ML LIQ |
| 95900137 | RESOURCE JUST KIDS 1.5 CA 237ML LIQ |
| DIN | Brand name |
|---|---|
| 95900021 | NEOCATE JR 400G PDR |
| 95900132 | NEOCATE JR FIBER&IRON 400G PDR |
| 95900022 | NEOCATE ONE 400GR PDR |
| 95900143 | PEDIASURE GROW&GAIN 400G PDR |
| 95900112 | PURAMINO A+ JUNIOR 400G PDR |
ADULT
Limited use benefit (prior approval required).
Criteria for Nutritional Supplement Coverage for Adults
- Sole source nutrition (more than 75% of intake is from nutritional supplement)
- Unintentional weight loss
- Wound care
- Pre or post-surgery (6 months before or after date of surgery)
- Other medical conditions not listed
| DIN | Brand name |
|---|---|
| 95900061 | BOOST DIABETIC 237ML LIQ |
| 95900204 | ENSURE PROTEIN MAX 235ML LIQ |
| 95999963 | BOOST ORIGINAL 237ML LIQ |
| 95900069 | COMPLEAT MODIFIED 1000ML LIQ |
| 95900070 | COMPLEAT MODIFIED 250ML LIQ |
| 95900050 | ENSURE 235ML LIQ |
| 95900194 | ENSURE COMPACT MILK 118ML LIQ |
| 95900139 | ENSURE FIBRE 235ML LIQ |
| 95900140 | GLUCERNA 237ML LIQ |
| 95900076 | ISOSOURCE 1.0 HP 250ML LIQ |
| 95900071 | ISOSOURCE 1.2 CAL250ML LIQ |
| 95900072 | ISOSOURCE 1.2 CAL 1500ML LIQ |
| 95900073 | ISOSOURCE 1.5 CAL 250ML LIQ |
| 95900074 | ISOSOURCE FIBRE 1.5 CAL 250ML LIQ |
| 95900075 | ISOSOURCE FIBRE 1.5 CAL 1500ML LIQ |
| 95900077 | ISOSOURCE HN WITH FIBER 250ML LIQ |
| 95900078 | JEVITY 235ML LIQ |
| 95900181 | ENSURE PLUS CALORIES 235ML LIQ |
| 95900082 | JEVITY 1.5 CAL 235ML LIQ |
| 95900086 | PEPTAMEN 250ML LIQ |
| 95900087 | PEPTAMEN 1.5 250ML LIQ |
| 95900088 | PEPTAMEN 1.5 1000ML LIQ |
| 95900090 | PEPTAMEN WITH PREBIO 250ML LIQ |
| 95900091 | PEPTAMEN WITH PREBIO 1000ML LIQ |
| 95900062 | RESOURCE DIABETIC 250ML LIQ |
| 95900058 | RESOURCE 2.0 237ML LIQ |
| 95900207 | RESOURCE DIABETIC 1.5L |
| 95900130 | VITAL 1.5 CAL 1000ML LIQ |
| 95900128 | VITAL PEPTIDE 1 CAL 220ML LIQ |
| 95900129 | VITAL PEPTIDE 1.5 CAL 220ML LIQ |
| 95900209 | ISOSOURCE FIBRE 1.2CAL 250ML LIQ |
| DIN | Brand name |
|---|---|
| 95900182 | RESOURCE BENEPROTEIN 227G PDR |
| DIN | Brand name |
|---|---|
| 95900118 | SIMPLY THICK 64OZ BOTTLE PUMP |
| DIN | Brand name |
|---|---|
| 95900113 | RESOURCE THICKEN CLEAR 125G |
| 95900114 | RESOURCE THICKEN UP 6.4G |
| 95900185 | SIMPLY THICK HONEY 12G PDR |
| 95900186 | SIMPLY THICK NECTAR 6G PDR |
| 95900119 | SIMPLY THICK HONEY 200G |
| 95900120 | SIMPLY THICK NECTAR 200G |
| 95900123 | SOURCE THICKEN UP 227G PDR |
| 95900190 | GELMIX JAR 125G PDR |