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):

Table: ORAL LIQUID
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
Table: POWDER
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)

Table: ORAL LIQUID
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
Table: POWDER
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

Table: ORAL LIQUID
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
Table: POWDER
DIN Brand name
95900182 RESOURCE BENEPROTEIN 227G PDR
Table: THICKENING AGENT (KIT)
DIN Brand name
95900118 SIMPLY THICK 64OZ BOTTLE PUMP
Table: THICKENING AGENT (POWDER)
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
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