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 listed below.
SECTION I: Participant/Patient and Health Care Information
- Patient First Name
- Patient Last Name
SECTION II: Special Formula/Nutritionals and Qualifying Diagnosis
- Formula/Medical Food Prescribed – either check the name of one specific formula/nutritional listed or write out the name if not listed.
- Form (check one) – if Ready-to-Feed is checked, HCP must write out the justification (i.e., WHY it is necessary), unless it is the only form available
- Amount prescribed of resconstituted formula in fluid ounces or ounces of medical food
- Duration (check one) – maximum of 6 months
- Qualifying Diagnosis (must specify) – check one and specify where a space is provided
SECTION III: WIC Food Restrictions* Must check one, either :
- “No food restrictions”, or
- “With food restrictions”; and check specific food (s) restricted or write out additional food restrictions in the Comments section
SECTION IV: Health Care Provider Information
- Provider name, printed
- Date
- Phone Number
- Provider Signature
- Medical Office/Clinic Location
* Please note: At six months, WIC provides purees and baby cereal. At one year, WIC provides a standard WIC food package for the child.
WIC staff can issue these medical formulas on the WIC card with a complete prescription.
- 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 listed below.
SECTION I: Participant/Patient and Health Care Information
- Patient First Name
- Patient Last Name
SECTION II: Special Formula/Nutritionals and Qualifying Diagnosis
- Formula/Medical Food Prescribed – either check the name of one specific formula/nutritional listed or write out the name if not listed.
- Form (check one) – if Ready-to-Feed is checked, HCP must write out the justification (i.e., WHY it is necessary), unless it is the only form available
- Amount prescribed of resconstituted formula in fluid ounces or ounces of medical food
- Duration (check one) – maximum of 6 months
- Qualifying Diagnosis (must specify) – check one and specify where a space is provided
SECTION III: WIC Food Restrictions* Must check one, either :
- “No food restrictions”, or
- “With food restrictions”; and check specific food (s) restricted or write out additional food restrictions in the Comments section
SECTION IV: Health Care Provider Information
- Provider name, printed
- Date
- Phone Number
- Provider Signature
- Medical Office/Clinic Location
* Please note: At six months, WIC provides purees and baby cereal. At one year, WIC provides a standard WIC food package for the child.
WIC staff can issue these medical formulas on the WIC card with a complete prescription.
- 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 listed below.
SECTION I: Participant/Patient and Health Care Information
- Patient First Name
- Patient Last Name
SECTION II: Special Formula/Nutritionals and Qualifying Diagnosis
- Formula/Medical Food Prescribed – either check the name of one specific formula/nutritional listed or write out the name if not listed.
- Form (check one) – if Ready-to-Feed is checked, HCP must write out the justification (i.e., WHY it is necessary), unless it is the only form available
- Amount prescribed of resconstituted formula in fluid ounces or ounces of medical food
- Duration (check one) – maximum of 6 months
- Qualifying Diagnosis (must specify) – check one and specify where a space is provided
SECTION III: WIC Food Restrictions* Must check one, either :
- “No food restrictions”, or
- “With food restrictions”; and check specific food (s) restricted or write out additional food restrictions in the Comments section
SECTION IV: Health Care Provider Information
- Provider name, printed
- Date
- Phone Number
- Provider Signature
- Medical Office/Clinic Location
* Please note: At six months, WIC provides purees and baby cereal. At one year, WIC provides a standard WIC food package for the child.
WIC staff can issue these medical formulas on the WIC card with a complete prescription.
- 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