Get Medical Formula and Nutritionals from WIC
WIC provides medical formulas and nutritionals when they are not covered by Medi-Cal. You can find more information on this page.
WIC Participants with Medi-Cal
- The healthcare providers should submit a “Prior Authorization” to Medi-Cal for the participant.
- Once the “Prior Authorization” is submitted, the participant can take the formula prescription to a Medi-Cal pharmacy.
- Complete the WIC Medical Formula & Nutritionals Request Form and give a copy to the WIC office.
Instructions for completing the WIC Medical Formula & Nutritionals Request Form
The form must include what is highlighted on the example to the right. You can also find a list below.
- Participants name
- Qualifying medical condition
- See the end of the form for diagnosis and conditions CA WIC may approve and those conditions that they will not approve.
- Name of the formula being requested.
- The formula must match the medical condition or diagnosis.
- Prescribed amount per day
- Length of time required. Up to 6 months
- WIC Food Restrictions (if appropriate)
- Healthcare provider signature or stamp with the date, address, contact information.
- Other formula tried and symptoms, if appropriate.
WIC Staff can issue these medical formulas on the WIC card with a complete prescription.
- Enfamil A.R. Powder 12.9 oz
- Nutramigen LGG Powder 12.6 oz
- Nutramigen Concentrate 13 oz
- Similac Alimentum Powder 12.1 oz
- Enfamil NeuroPro EnfaCare Powder 12.8 or 13.6 oz
- Similac NeoSure Powder 13.1 oz
You can still refer a patient to WIC if you are prescribing another medical formula or nutritional on the Medical Formula & Nutritionals Request Form.
Please note that getting these formulas can take longer, since they need to be specially approved and shipped to the WIC location.
WIC Participants without Healthcare Insurance
- Participants without healthcare insurance should be encouraged to apply for Medi-Cal.
- WIC can issue up to 2 months of formula while they are waiting for approval.
- Complete the WIC Medical Formula & Nutritionals Request Form and give a copy to the WIC office.
Instructions for completing the WIC Medical Formula & Nutritionals Request Form
The form must include what is highlighted on the example to the right. You can also find a list below.
- Participants name
- Qualifying medical condition
- See the end of the form for diagnosis and conditions CA WIC may approve and those conditions that they will not approve.
- Name of the formula being requested.
- The formula must match the medical condition or diagnosis.
- Prescribed amount per day
- Length of time required. Up to 6 months
- WIC Food Restrictions (if appropriate)
- Healthcare provider signature or stamp with the date, address, contact information.
- Other formula tried and symptoms, if appropriate.
WIC staff can issue these medical formulas on the WIC card with a complete prescription.
- Enfamil A.R. Powder 12.9 oz
- Nutramigen LGG Powder 12.6 oz
- Nutramigen Concentrate 13 oz
- Similac Alimentum Powder 12.1 oz
- Enfamil NeuroPro EnfaCare Powder 12.8 or 13.6 oz
- Similac NeoSure Powder 13.1 oz
You can still refer a patient to WIC if you are prescribing another medical formula or nutritional on the Medical Formula & Nutritionals Request Form.
Please note that getting these formulas can take longer, since they need to be specially approved and shipped to the WIC location.
WIC Participants with Private or Military Insurance
- The healthcare providers should submit a “Prior Authorization” to Medi-Cal for the participant.
- Once the “Prior Authorization” is submitted, the participant can take the formula prescription to a Medi-Cal pharmacy.
- Complete the WIC Medical Formula & Nutritionals Request Form and give a copy to the WIC office.
Instructions for completing the WIC Medical Formula & Nutritionals Request Form
The form must include what is highlighted on the example to the right. You can also find a list below.
- Participants name
- Qualifying medical condition
- See the end of the form for diagnosis and conditions CA WIC may approve and those conditions that they will not approve.
- Name of the formula being requested.
- The formula must match the medical condition or diagnosis.
- Prescribed amount per day
- Length of time required. Up to 6 months
- WIC Food Restrictions (if appropriate)
- Healthcare provider signature or stamp with the date, address, contact information.
- Other formula tried and symptoms, if appropriate.
WIC staff can issue these medical formulas on the WIC card with a complete prescription.
- Enfamil A.R. Powder 12.9 oz
- Nutramigen LGG Powder 12.6 oz
- Nutramigen Concentrate 13 oz
- Similac Alimentum Powder 12.1 oz
- Enfamil NeuroPro EnfaCare Powder 12.8 or 13.6 oz
- Similac NeoSure Powder 13.1 oz
You can still refer a patient to WIC if you are prescribing another medical formula or nutritional on the Medical Formula & Nutritionals Request Form.
Please note that getting these formulas can take longer, since they need to be specially approved and shipped to the WIC location.
This institution is an equal opportunity provider. California Department of Public Health