Get Medical Formula and Nutritionals
from WIC
WIC provides medical formulas and nutritionals when they are not covered by Medi-Cal.
You can find a full list of formulas and nutritionals provided by WIC, including whether they are covered by Medi-Cal, on the WIC Formulas and Nutritionals List.
- 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.
- 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.
- Healthcare providers can refer the participant to WIC.
Instructions for Healthcare Providers
To have WIC provide medical formulas and nutritionals, complete the WIC Medical Formula & Nutritionals Request Form.
The form must include:
- 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 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
- Enfamil A.R. Powder 12.9 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.
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