Grand Deluxe- Exclusively Breastfeeding Dyad
Grand Deluxe--Exclusively Breastfed- Infant
Food Pkg.#
Quantity
of
Formula
Exclusively Breastfeeding
Total
Ounces/
Month
Cereal
Baby Food
(Fruit/Veg)
Baby Food
(Meats)
Comments
0
0
0
Issue from birth up to 3 months.
0
0
0
Issue from 4 months up to 5
months.
24 oz. infant
cereal
64 -4 oz
containers/month
31-2.5 oz
containers/month
Issue from 6 months to 12 months.
0-12 months
422
0
0
505
0
0
605
Type
0
Breastmilk is
Mom's Priceless
Gift
Breastmilk is
Mom's Priceless
Gift
Breastmilk is
Mom's Priceless
Gift
0
Grand Deluxe--Exclusively Breastfeeding- Women
Package
Milk
Number
Standard-single infant
150
155
Cheese
6 gallons
milk
6 gallons milk
1) FP Tables-Grand Deluxe 2.1.13
1 lb
cheese
1 lb
cheese
Cereal
36 oz
36 oz
Whole grain
1 lb
Whole Wheat
Bread
1 lb
brown rice
tortillas
oatmeal
Eggs
Juice
FVV
Beans
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
64 oz
canned
beans
Peanut
Butter
Tuna/
Salmon
18 oz
peanut
butter
6- 5oz
cans
18 oz
peanut
butter
6- 5oz
cans
1/4/2013
Grand Deluxe- Exclusively Breastfeeding Dyad
Low Lactose-single infant
12-1/2 gallons
lactose free
160
milk1
165
12-1/2 gallons
lactose free
milk
0
36 oz
1 lb
Whole Wheat
Bread
2
doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
18 oz
peanut
butter
6- 5oz
cans
1 lb
cheese
36 oz
1 lb brown
rice tortillas
oatmeal
2
doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
18 oz
peanut
butter
6- 5oz
cans
0
36 oz
1 lb brown
rice tortillas
oatmeal
2
doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
18 oz
peanut
butter
6- 5oz
cans
0
3 - 48 oz
containers
(144 fl oz)
$10
2 lb dry
beans
0
0
18- 8oz
containers
(144 fl oz)
$10
64 oz
canned
beans
18 oz
peanut
butter
Soy Milk-single infant
170
11-1/2 gallons
soy milk
Food Allergy-single infant
175
6 gallons
milk
No Refrigeration-single infant
3 -25.6 oz
boxes non-fat
180
dry milk
1
1 lb
cheese
36 oz
0
36 oz
1 lb brown
rice tortillas
oatmeal
1 lb Whole
Wheat Bread
6- 5oz
cans
6- 5oz
cans
Participants requiring specialized packages should have reason for issuance documented in case notes.
1) FP Tables-Grand Deluxe 2.1.13
1/4/2013
Deluxe Packages –Partially Breastfeeding Dyad
Deluxe- Infant
Birth up to 1 month of age
Package #
Quantity of
Formula
Total
Ounces/
Month
Type
Cereal
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
No supplemental formula is provided in the first month.
1 month up to 3 months of age
(Federal Maximum Monthly Allowance- 364 – 435 fl oz)
407
2
180 fl. oz
Enfamil Premium Infant
powder
0
0
0
6 oz/day
409
4
360 fl. oz
Enfamil Premium Infant
powder
0
0
0
12 oz/day
451
2
184 fl. oz
Prosobee
powder
0
0
0
6 oz/day
452
4
368 fl. oz
Prosobee
powder
0
0
0
12 oz/day
441
2
174 fl. oz
Gentlease
powder
0
0
0
6 oz/day
442
4
435 fl. oz
Gentlease
powder
0
0
0
14 oz/day
2) FP Tables- Deluxe 2.1.13
1/4/2013
Deluxe Packages –Partially Breastfeeding Dyad
Deluxe- Infant
4th and 5th months
(Federal Maximum Monthly Allowance- 442 – 522 fl oz)
Baby
Baby Food
Comments
Food
(Fruit/Veg)
(Meats)
Package #
Quantity of
Formula
Total
Ounces/
Month
507
3
270 fl. oz
508
5
450 fl. oz
551
3
276 fl. oz
552
5
460 fl. oz
Prosobee
powder
0
0
0
15 oz/day
546
3
261 fl. oz
Gentlease
powder
0
0
0
8 oz/day
547
5
522 fl. oz
Gentlease
powder
0
0
0
16 oz/day
Type
Cereal
Enfamil Premium Infant
powder
0
0
0
9 oz/day
0
0
0
15 oz/day
0
0
0
9 oz/day
Enfamil Premium Infant
powder
Prosobee
powder
6 to 12 months
(Federal Maximum Monthly Allowance- 312 – 384 fl oz)
Enfamil Premium Infant
powder
Enfamil Premium Infant
powder
24 oz. infant
cereal
24 oz. infant
cereal
32- 4 oz
containers
32- 4 oz
containers
184 fl. oz
Prosobee
powder
24 oz. infant
cereal
4
368 fl. oz
Prosobee
powder
696
2
174 fl. oz
697
4
348 fl. oz
607
2
180 fl. oz
608
4
360 fl. oz
651
2
652
2) FP Tables- Deluxe 2.1.13
0
6 oz/day
0
12 oz/day
32- 4 oz
containers
0
6 oz/day
24 oz. infant
cereal
32- 4 oz
containers
0
12 oz/day
Gentlease
powder
24 oz. infant
cereal
32- 4 oz
containers
0
6 oz/day
Gentlease
powder
24 oz. infant
cereal
32- 4 oz
containers
0
11 oz/day
1/4/2013
Deluxe Packages –Partially Breastfeeding Dyad
Deluxe- Women
Package
Milk
#
Standard-single gestation
Cheese
Cereal
Whole grain
Eggs
Juice
FVV
Beans
Peanut
Butter
100
5 gallons and 2 qts
milk
0
36 oz
1 lb
Whole Wheat
Bread
1 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans/peas
18 oz
peanut
butter
105
4 gallons and 3 qts
milk
1 lb
cheese
36 oz
1 lb
brown rice
tortillas
oatmeal
1 doz
3 - 48 oz
containers
(144 fl oz)
$10
64 oz
canned
beans
18 oz
peanut
butter
36 oz
1 lb
Whole Wheat
Bread
1 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans/peas
18 oz
peanut
butter
36 oz
1 lb
brown rice
tortillas
oatmeal
1 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans/peas
18 oz
peanut
butter
36 oz
1 lb
brown rice
tortillas
oatmeal
1 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans/peas
18 oz
peanut
butter
36 oz
1 lb
brown rice
tortillas
oatmeal
0
3 - 48 oz
containers
(144 fl oz)
$10
2lb dry
beans/peas
0
36 oz
1 lb
Whole Wheat
Bread
0
18 -8oz
containers
(144 fl oz)
$10
64 oz
canned
beans
18 oz
peanut
butter
Low Lactose-Single Gestation
110
11-1/2 gallons
lactose free milk1
0
115
9-1/2 gallons and
1 quart
lactose free milk
1 lb
cheese
Soy Milk-single gestation
120
11-1/2 gallons
soy milk
0
Food Allergy-single gestation
125
4 gallons and 3 qts
milk
No Refrigeration-single gestation
2 -25.6 oz and
2 -9.6 oz boxes
130
non-fat dry milk
(22 qts)
1
1 lb
cheese
0
Participants requiring specialized packages should have reason for issuance documented in case notes.
2) FP Tables- Deluxe 2.1.13
1/4/2013
Breastfeeding Basic Dyad- Infant receives max formula, mom breastfeeding
Breastfeeding Basic – Infant (Birth - 3 months)
Package #
Quantity
of
Formula
Total
Ounces/
Month
Type
Cereal
Milk Based
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
(Federal Maximum Monthly Allowance- 806 - 870 fl oz)
400
9
810 fl. oz
Enfamil Premium Newborn
Powder
0
0
0
27 oz/day
410
9
810 fl. oz
Enfamil Premium Infant
powder
0
0
0
27 oz/day
411
31
806 fl. oz
0
0
0
26 oz/day
412
26
832 fl. oz
0
0
0
27 oz/day
Enfamil Premium Infant
concentrate
Enfamil Premium Infant
RTU
Partially Hydrolyzed
454
9
810 fl oz
Gentlease
powder
0
0
0
26 oz/day
429
9
828 fl. oz
Prosobee
powder
0
0
0
27 oz/day
430
31
806 fl. oz
Prosobee
concentrate
0
0
0
26 oz/day
431
26
832 fl. oz
Prosobee
RTU
0
0
0
27 oz/day
455
9
910 fl. oz
Enfamil AR
powder
0
0
0
27 oz/day
456
26
832 fl. oz
Enfamil AR
RTU
0
0
0
27 oz/day
404
104
832 fl. oz
Enfamil Premium Infant
RTU - 8 oz can
0
0
0
457
104
832 fl. oz
Prosobee
RTU - 8 oz can
0
0
0
Issue if no safe water AND
no refrigeration. Document
in case notes reason for
issuance.
Soy
Rice Thickened
Rarely Used
3) FP Tables-Breastfeeding Basic 2.1.13
1/4/2013
Breastfeeding Basic Dyad- Infant receives max formula, mom breastfeeding
Breastfeeding Basic Infant (4 & 5 months)
Package #
Quantity
of
Formula
Total
Ounces/
Month
Type
Milk Based
Cereal
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
(Federal Maximum Monthly Allowance- 884 - 960 fl oz)
510
10
900 fl.oz
Enfamil Premium Infant
powder
0
0
0
30 oz/day
511
34
884 fl. oz
Enfamil Premium Infant
concentrate
0
0
0
29 oz/day
512
28
896 fl. oz
Enfamil Premium Infant
RTU
0
0
0
29 oz/day
Partially Hydrolyzed
554
10
900 fl. oz
Gentlease
powder
0
0
0
29 oz/day
529
10
920 fl. oz
Prosobee
powder
0
0
0
30 oz/day
530
34
884 fl. oz
Prosobee
concentrate
0
0
0
29 oz/day
531
28
896 fl. oz
Prosobee
RTU
0
0
0
29 oz/day
555
10
910 fl.oz
0
0
0
30 oz/day
556
28
896 fl. oz
0
0
0
29 oz/day
504
112
896 fl. oz
Enfamil Premium Infant
RTU - 8 oz can
0
0
0
557
112
896 fl. oz
Prosobee
RTU - 8 oz can
0
0
0
Issue if no safe water
AND no refrigeration.
Document in case
notes reason for
issuance.
Soy
Rice Thickened
Enfamil AR
powder
Enfamil AR
RTU
Rarely Used
3) FP Tables-Breastfeeding Basic 2.1.13
1/4/2013
Breastfeeding Basic Dyad- Infant receives max formula, mom breastfeeding
Breastfeeding Basic Infant (6-11months)
Package
#
Quantity
of
Formula
Total
Ounces/
Month
Type
Milk Based
Cereal
Baby Food
(Fruit/Veg)
Baby Food
(Meats)
Comments
(Federal Maximum Monthly Allowance- 624 -696 fl oz)
32- 4 oz
24 oz
0
21 oz/day
jars/month
610
7
630 fl. oz
Enfamil Premium Infant
powder
611
24
624 fl. oz
Enfamil Premium Infant
concentrate
24 oz
32- 4 oz
jars/month
0
20 oz/day
612
20
640 fl. oz
Enfamil Premium Infant
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
7
630 fl. oz
Gentlease
powder
24 oz
32- 4 oz
jars/month
0
20 oz/day
600
7
644 fl. oz
Prosobee
powder
24 oz
32- 4 oz
jars/month
0
21 oz/day
634
24
624 fl. oz
Prosobee
concentrate
24 oz
32- 4 oz
jars/month
0
20 oz/day
635
20
640 fl. oz
Prosobee
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
Partially Hydrolyzed
654
Soy
Rice Thickened
655
7
637 fl. oz
Enfamil AR
powder
24 oz
32- 4 oz
jars/month
0
21 oz/day
656
20
640 fl. oz
Enfamil AR
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
604
80
640 fl. oz
Enfamil Premium Infant
RTU - 8 oz can
24 oz
32- 4 oz
jars/month
0
657
80
640 fl. oz
Prosobee
RTU - 8 oz can
24 oz
32- 4 oz
jars/month
0
Issue if no safe water
AND no refrigeration.
Document in case
notes reason for
issuance.
Rarely Used
3) FP Tables-Breastfeeding Basic 2.1.13
1/4/2013
Breastfeeding Basic Dyad- Infant receives max formula, mom breastfeeding
Breastfeeding Basic- Women
Cheese
Cereal
Whole
grains
Eggs
Juice
FVV
Legumes
4 gallons
0
36 oz
0
1 doz
2 - 48 oz
containers
(96 fl oz.)
$10
18 oz
peanut butter
205
4 gallons
0
36 oz
0
$10
1 lb
dry beans/peas
210
3 gallons and
1 quart
1 lb
36 oz
0
$10
64 oz canned
beans
8 -1/2 gallons
lactose free milk1
0
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
4 gallons
soy milk
0
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
3 gallons and
1 quart
1 lb
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
2 -25.6 oz boxes
non-fat dry milk
(16 qts)
0
36 oz
0
12 -8oz
containers
(96 fl oz)
$10
18 oz
peanut butter
Package #
Milk
(2%,1,% or Skim)
Standard w/Peanut Butter
200
Standard w/Beans
1 doz
1 doz
2 - 48 oz
containers
(96 fl oz.)
2 - 48 oz
containers
(96 fl oz.)
Low Lactose
215
1 doz
Soy Milk
220
1 doz
Food Allergy
225
1 doz
No Refrigeration
230
1 doz
Women over 6 months postpartum who breastfeed, but infant receives full formula package
240
1
Your Child Has You and You Have WIC
Participants requiring specialized packages should have reason for issuance documented in case notes.
3) FP Tables-Breastfeeding Basic 2.1.13
1/4/2013
Basic Packages- Fully Formula Dyad
Basic – Infant (Birth - 3 months)
Package #
Quantity
of
Formula
Total
Ounces/
Month
Type
Milk Based
Cereal
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
(Federal Maximum Monthly Allowance- 806 - 870 fl oz)
400
9
810 fl. oz
Enfamil Premium Newborn
Powder
0
0
0
27 oz/day
410
9
810 fl. oz
Enfamil Premium Infant
powder
0
0
0
27 oz/day
411
31
806 fl. oz
0
0
0
26 oz/day
412
26
832 fl. oz
0
0
0
27 oz/day
429
9
828 fl. oz
Prosobee
powder
0
0
0
27 oz/day
430
31
806 fl. oz
Prosobee
concentrate
0
0
0
26 oz/day
431
26
832 fl. oz
Prosobee
RTU
0
0
0
27 oz/day
9
810 fl oz
Gentlease
powder
0
0
0
26 oz/day
455
9
819 fl. oz
Enfamil AR
powder
0
0
0
27 oz/day
456
26
832 fl. oz
Enfamil AR
RTU
0
0
0
27 oz/day
404
104
832 fl. oz
Enfamil Premium Infant
RTU - 8 oz can
0
0
0
457
104
832 fl. oz
Prosobee
RTU - 8 oz can
0
0
0
Issue if no safe water AND
no refrigeration. Document
in case notes reason for
issuance.
Enfamil Premium Infant
concentrate
Enfamil Premium Infant
RTU
Soy
Partially Hydrolyzed
454
Rice Thickened
Rarely Used
4) FP Tables- Basic 2.1.13effective 2.1.13
1/4/2013
Basic Packages- Fully Formula Dyad
Basic Infant (4 & 5 months)
Package #
Quantity
of
Formula
Total
Ounces/
Month
Type
Milk Based
Cereal
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
(Federal Maximum Monthly Allowance- 884 - 960 fl oz)
510
10
900 fl.oz
Enfamil Premium Infant
powder
0
0
0
30 oz/day
511
34
884 fl. oz
Enfamil Premium Infant
concentrate
0
0
0
29 oz/day
512
28
896 fl. oz
Enfamil Premium Infant
RTU
0
0
0
29 oz/day
Partially Hydrolyzed
554
10
900 fl. oz
Gentlease
powder
0
0
0
29 oz/day
529
10
920 fl. oz
Prosobee
powder
0
0
0
30 oz/day
530
34
884 fl. oz
Prosobee
concentrate
0
0
0
29 oz/day
531
28
896 fl. oz
Prosobee
RTU
0
0
0
29 oz/day
555
10
910 fl.oz
0
0
0
30 oz/day
556
28
896 fl. oz
0
0
0
29 oz/day
504
112
896 fl. oz
Enfamil Premium
RTU - 8 oz can
0
0
0
557
112
896 fl. oz
Prosobee
RTU - 8 oz can
0
0
0
Issue if no safe water
AND no refrigeration.
Document in case
notes reason for
issuance.
Soy
Rice Thickened
Enfamil AR
powder
Enfamil AR
RTU
Rarely Used
4) FP Tables- Basic 2.1.13effective 2.1.13
1/4/2013
Basic Packages- Fully Formula Dyad
Basic Infant (6-11months)
Quantity
of
Formula
Total
Ounces/
Month
610
7
630 fl. oz
611
24
612
20
Package #
Baby
Food
Comments
(Meats)
(Federal Maximum Monthly Allowance- 624 -696 fl oz)
Enfamil Premium Infant
32- 4 oz
24 oz
0
21 oz/day
powder
jars/month
Type
Cereal
Baby Food
(Fruit/Veg)
624 fl. oz
Enfamil Premium Infant
concentrate
24 oz
32- 4 oz
jars/month
0
20 oz/day
640 fl. oz
Enfamil Premium Infant
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
Milk Based
Partially Hydrolyzed
654
7
630 fl. oz
Gentlease
powder
24 oz
32- 4 oz
jars/month
0
20 oz/day
600
7
644 fl. oz
Prosobee
powder
24 oz
32- 4 oz
jars/month
0
21 oz/day
634
24
624 fl. oz
Prosobee
concentrate
24 oz
32- 4 oz
jars/month
0
20 oz/day
635
20
640 fl. oz
Prosobee
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
655
7
637 fl. oz
Enfamil AR
powder
24 oz
32- 4 oz
jars/month
0
21 oz/day
656
20
640 fl. oz
Enfamil AR
RTU
24 oz
32- 4 oz
jars/month
0
21 oz/day
604
80
640 fl. oz
Enfamil Premium Infant
RTU - 8 oz can
24 oz
32- 4 oz
jars/month
0
657
80
640 fl. oz
Prosobee
RTU - 8 oz can
24 oz
32- 4 oz
jars/month
0
Issue if no safe water
AND no refrigeration.
Document in case
notes reason for
issuance.
Soy
Rice Thickened
Rarely Used
4) FP Tables- Basic 2.1.13effective 2.1.13
1/4/2013
Basic Packages- Fully Formula Dyad
Basic- Women
Cheese
Cereal
Whole
grains
Eggs
Juice
FVV
Legumes
4 gallons
0
36 oz
0
1 doz
2 - 48 oz
containers
(96 fl oz.)
$10
18 oz
peanut butter
205
4 gallons
0
36 oz
0
$10
1 lb
dry beans/peas
210
3 gallons and
1 quart
1 lb
36 oz
0
$10
64 oz
canned beans
8 -1/2 gallons
lactose free milk1
0
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
4 gallons
soy milk
0
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
3 gallons and
1 quart milk
1 lb
36 oz
0
2 - 48 oz
containers
(96 fl oz.)
$10
1 lb
dry beans/peas
2 -25.6 oz boxes
non-fat dry milk
(16 qts)
0
36 oz
0
12 -8oz
containers
(96 fl oz)
$10
18 oz
peanut butter
Package #
Milk
(2%,1,% or Skim)
Standard w/Peanut Butter
200
Standard w/Beans
1 doz
1 doz
2 - 48 oz
containers
(96 fl oz.)
2 - 48 oz
containers
(96 fl oz.)
Low Lactose
215
1 doz
Soy Milk
220
1 doz
Food Allergy
225
1 doz
No Refrigeration
230
1
1 doz
Participants requiring specialized packages should have reason for issuance documented in case notes.
4) FP Tables- Basic 2.1.13effective 2.1.13
1/4/2013
Breastfed Multiples Dyads
The following packages are designed for two or more infants who are exclusively breastfed, all of which must receive one of the following food
packages.
Exclusively Breastfed Multiples- Infant
Package #
Quantity
of
Formula
Exclusively Breastfeeding
Total
Ounces/
Month
0
0
505
0
0
0
Cereal
Baby Food
(Fruit/Veg)
Baby Food
(Meats)
Comments
0
0
0
Issue from birth up to 3 months.
0
0
0
Issue from 4 months up to 5
months.
24 oz. infant
cereal
64 -4 oz
containers/month
31-2.5 oz
containers/month
Issue from 6 months to 12 months.
0-12 months
422
605
Type
0
Breastmilk is
Mom's Priceless
Gift
Breastmilk is
Mom's Priceless
Gift
Breastmilk is
Mom's Priceless
Gift
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
Breastfed Multiples Dyads
The following packages are designed for women who are Exclusively Breastfeeding two or more infants. For the participant to receive the Full
Nutritional Benefit allowed, which is 1.5 times the amount of food for an exclusively breastfeeding woman, the CHP must enter two different
packages. For example, for a woman who prefers bread the CHP would enter FP #250 for 1 month and FP #150 for the next month. This
cycle would continue for the length of the certification period.
Exclusively Breastfeeding Multiples- Women
Package #
Milk
Cheese
Cereal
Whole grain
12 gallons
milk
2 lb
72 oz
Whole Wheat
Bread
6 gallons
milk
1 lb
36 oz
Whole Wheat
Bread
Beans
Peanut
Butter
Eggs
Juice
FVV
4 doz
288 fl oz
juice
$20
2 doz
144 fl oz
(3- 48 oz cont.)
$10
288 fl oz
juice
2 lbs
36 oz
4 doz
$20
dry
beans
peanut
butter
144 fl oz
(3- 48 oz cont.)
64 oz
18 oz
2 doz
$10
canned
beans
peanut
butter
Tuna/
Salmon
Standard
250
150
2 lbs
1 lb
255
2 lb
72 oz
brown rice
tortillas
oatmeal
36 oz
brown rice
tortillas
oatmeal
1 lb
155
6 gallons
milk
1 lb
FP Tables Breastfeeding MULTIPLES effective 2.1.13
36 oz
dry
beans
peanut
butter
1 lb
dry
beans
2 lbs
12 gallons
milk
2 lbs
1/4/2013
12 cans
18 oz
peanut
butter
6 cans
12 cans
6 cans
Breastfed Multiples Dyads
Exclusively Breastfeeding Multiples- Women
Package #
Milk
Cheese
Cereal
Whole grain
24-1/2 gallons
lactose free
milk1
2 lb
72 oz
Whole Wheat
Bread
0
36 oz
Whole Wheat
Bread
72 oz
brown rice
tortillas
oatmeal
36 oz
brown rice
tortillas
oatmeal
72 oz
brown rice
tortillas
oatmeal
36 oz
brown rice
tortillas
oatmeal
Eggs
Juice
FVV
4 doz
288 fl oz juice
$20
2 doz
144 fl oz
(3 - 48 oz cont)
$10
4 doz
288 fl oz juice
$20
2 doz
144 fl oz
(3 - 48 oz cont)
$10
4 doz
288 fl oz juice
$20
2 doz
144 fl oz
(3 - 48 oz cont)
$10
Peanut
Butter
Tuna/
Salmon
2 lbs
36 oz
dry
beans
peanut
butter
12
cans
1lb dry
beans
18 oz
peanut
butter
6 cans
2 lbs
36 oz
peanut
butter
12
cans
Beans
Low Lactose
260
160
265
165
12-1/2 gallons
lactose free
milk1
2 lbs
1 lb
2 lbs
24-1/2 gallons
lactose free
milk
2 lb
12-1/2 gallons
lactose free
milk
1 lb
cheese
1 lb
dry
beans
1lb
dry
beans
18 oz
peanut
butter
6 cans
Soy Milk
2 lbs
22-1/2 gallons
soy milk1
270
2 lb
2 lbs
dry beans
1 lb
170
1
11-1/2 gallons
soy milk1
0
1lb
dry beans
Participants needing specialized packages should have reason for issuance documented in case notes.
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
36 oz
peanut
butter
12
cans
18 oz
peanut
butter
6 cans
Breastfed Multiples Dyads
Exclusively Breastfeeding Multiples- Women
Package #
Milk
Cheese
Cereal
Whole grain
12 gallons
milk
2 lbs
72 oz
brown rice
tortillas
oatmeal
6 gallons
milk
1 lb
cheese
36 oz
brown rice
tortillas
oatmeal
0
72 oz
Cereal
Whole Wheat
Bread
36 oz
Whole Wheat
Bread
Eggs
Juice
FVV
0
288 fl oz juice
$20
Beans
Peanut
Butter
Tuna/
Salmon
0
12
cans
0
6 cans
0
12
cans
Food Allergy
2 lbs
275
1 lb
175
0
144 fl oz
(3 - 48 oz cont)
2 lbs
dry beans
2 lb
$10
dry
beans
No Refrigeration
6 -25.6 oz
boxes non-fat
1
dry milk
(48 qts)
280
180
1
3 -25.6 oz
boxes non-fat
dry milk1
2 lbs
0
1 lb
0
0
36- 8 oz cans
Juice
(288 fl oz)
18- 8oz
containers
(144 fl oz)
$20
128 oz
canned
Beans
$10
64 oz
18 oz
canned
beans
peanut
butter
Participants needing specialized packages should have reason for issuance documented in case notes.
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
6 cans
Breastfed Multiples Dyads
The following packages are designed for two or more infants who are partially breastfed, all of which must receive one of the following food
packages.
Partially Breastfed Multiples- Infant
Birth up to 1 month of age
Package #
Quantity of
Formula
Total
Ounces/
Month
Type
Cereal
Baby Food
(Fruit/Veg)
Baby
Food
(Meats)
Comments
No supplemental formula is provided in the first month.
1 month up to 3 months of age
(Federal Maximum Monthly Allowance- 364 – 435 fl oz)
407
2
180 fl. oz
Enfamil Premium Infant
powder
0
0
0
6 oz/day
409
4
360 fl. oz
Enfamil Premium Infant
powder
0
0
0
12 oz/day
451
2
184 fl. oz
Prosobee
powder
0
0
0
6 oz/day
452
4
368 fl. oz
Prosobee
powder
0
0
0
12 oz/day
441
2
174 fl. oz
Gentlease
powder
0
0
0
6 oz/day
442
4
435 fl. oz
Gentlease
powder
0
0
0
14 oz/day
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
Breastfed Multiples Dyads
Partially Breastfed Multiples- Infant
4th and 5th months
(Federal Maximum Monthly Allowance- 442 – 522 fl oz)
Baby
Baby Food
Food
Comments
(Fruit/Veg)
(Meats)
Package #
Quantity of
Formula
Total
Ounces/
Month
Type
Cereal
507
3
270 fl. oz
Enfamil Premium Infant
powder
0
0
0
9 oz/day
508
5
450 fl. oz
0
0
0
15 oz/day
551
3
276 fl. oz
0
0
0
9 oz/day
552
5
460 fl. oz
Prosobee
powder
0
0
0
15 oz/day
546
3
261 fl. oz
Gentlease
powder
0
0
0
8 oz/day
547
5
522 fl. oz
Gentlease
powder
0
0
0
16 oz/day
Enfamil Premium Infant
powder
Prosobee
powder
6 to 12 months
(Federal Maximum Monthly Allowance- 312 – 384 fl oz)
Enfamil Premium Infant
powder
Enfamil Premium Infant
powder
24 oz. infant
cereal
24 oz. infant
cereal
32- 4 oz
containers
32- 4 oz
containers
184 fl. oz
Prosobee
powder
24 oz. infant
cereal
4
368 fl. oz
Prosobee
powder
696
2
174 fl. oz
697
4
348 fl. oz
607
2
180 fl. oz
608
4
360 fl. oz
651
2
652
0
6 oz/day
0
12 oz/day
32- 4 oz
containers
0
6 oz/day
24 oz. infant
cereal
32- 4 oz
containers
0
12 oz/day
Gentlease
powder
24 oz. infant
cereal
32- 4 oz
containers
0
6 oz/day
Gentlease
powder
24 oz. infant
cereal
32- 4 oz
containers
0
11 oz/day
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
Breastfed Multiples Dyads
The following packages are designed for women who are Partially Breastfeeding two or more infants. These women are eligible to receive the
same amount of foods as women who exclusively breastfeed one infant.
Partially Breastfeeding Multiples- Women
Package #
Milk
Peanut
Butter
Tuna/
Salmon
18 oz
peanut
butter
6
cans
Cheese
Cereal
Whole grain
Eggs
Juice
FVV
Beans
1 lb
cheese
36 oz
1 lb
Whole Wheat
Bread
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
1 lb
cheese
36 oz
1 lb
brown rice
tortillas
oatmeal
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
160
12-1/2
gallons
lactose free
milk1
0
36 oz
1 lb
Whole Wheat
Bread
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
18 oz
peanut
butter
165
12-1/2
gallons
lactose free
milk1
1 lb
cheese
36 oz
1 lb
brown rice
tortillas
oatmeal
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
1lb dry
beans
18 oz
peanut
butter
36 oz
1 lb
brown rice
tortillas
oatmeal
2 doz
3 - 48 oz
containers
(144 fl oz)
$10
Standard
150
6 gallons
milk
155
6 gallons
milk
64 oz
canned
beans
18 oz
peanut
butter
6
cans
Low Lactose
6
cans
6
cans
Soy Milk
170
1
11-1/2
gallons
soy milk1
0
1lb dry
beans
18 oz
peanut
butter
Participants needing specialized packages should have reason for issuance documented in case notes.
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
6
cans
Breastfed Multiples Dyads
Partially Breastfeeding Multiples- Women
Package #
Milk
Cheese
Cereal
Whole grain
Eggs
Juice
FVV
Beans
Peanut
Butter
Tuna/
Salmon
0
3 - 48 oz
containers
(144 fl oz)
$10
2 lb dry
beans
0
6
cans
0
18- 8oz
containers
(144 fl oz)
$10
64 oz
canned
beans
18 oz
peanut
butter
Food Allergy
175
6 gallons
milk
1 lb
cheese
36 oz
1 lb
brown rice
tortillas
oatmeal
No Refrigeration
180
1
3 -25.6 oz
boxes
non-fat dry
milk1
0
36 oz
1 lb
Whole Wheat
Bread
Participants needing specialized packages should have reason for issuance documented in case notes.
FP Tables Breastfeeding MULTIPLES effective 2.1.13
1/4/2013
6
cans