WIC referrals for medical formulas and nutritionals
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Guidance for Health Care Providers on WIC requirements and the need to submit Medi-Cal prior authorization when a WIC participant has Medi-Cal or when the prescribed product may be covered by Medi-Cal or private insurance. Applies to providers referring patients to California WIC for medical formulas or nutritionals.
No material clinical or coverage changes in this revision.
WIC Formula and Nutritionals Coverage Criteria
WIC formula/nutritional coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Complete medical documentation from a health care provider with prescriptive authority is provided.
- Documentation may be the WIC Medical Formula and Nutritionals Request Form (MFRF), prescription pad, hospital discharge papers, or equivalent.
- Complete medical documentation includes participant first and last name; qualifying diagnosis(es); name(s) of the medical formula or nutritionals for the stated qualifying diagnosis; formula amount needed per day and duration prescribed in months; WIC authorized food restrictions if applicable; signature (or signature stamp) and contact information of the HCP; and date signed by the HCP.
ALL of the following
Exclusions - WIC will not approve formulas or nutritionals for the following reasons:
- Colic, constipation, diarrhea, spitting up, picky eating, poor appetite, cramps, fussiness, or gas.
- Solely to enhance nutrient intake or manage body weight without an underlying qualifying condition.
- Non-specific formula intolerance or food intolerance.
- Patient or caregiver preference or food dislikes.
- If prescribing a product not on the WIC Formulas and Nutritionals List, contact Formula@cdph.ca.gov to request approval before referral.
Coding and Documentation Intervals
| No codes listed |
Provider Requirements and Referral Actions
Medi‑Cal prior authorization required when patient has Medi‑Cal
Submit a Medi-Cal Prior Authorization to Medi-Cal for the prescribed medical formula or nutritional product when the patient has Medi-Cal coverage before requesting WIC, because WIC is the payor of last resort.
Use the Medical Formula and Nutritionals Request Form or equivalent complete documentation
Use the WIC Medical Formula and Nutritionals Request Form (fillable PDF) or equivalent complete medical documentation when referring a patient to WIC for a prescribed medical formula or nutritional; do not alter the official form.
- Acceptable documentation formats include the MFRF, prescription pad, or hospital discharge papers.
- Complete documentation must include participant name, qualifying diagnosis(es), product name(s), amount per day and duration in months, WIC food restrictions if applicable, HCP signature/contact, and date signed.
Denial risk: excluded indications and preference-only requests
WIC will not approve formulas or nutritionals for non-specific or preference-only reasons such as colic, constipation, diarrhea, spitting up, picky eating, poor appetite, cramps, fussiness, gas, patient/caregiver preference, non-specific intolerance, or solely for weight management or enhancing nutrient intake without an underlying condition.
- Examples of excluded indications: colic, constipation, diarrhea, spitting up, picky eater, poor appetite, cramps, fussiness, or gas.
- Also excluded: non-specific formula or food intolerance, patient/caregiver preference, and requests solely to enhance nutrient intake or manage body weight absent an underlying condition.
Required Medical Documentation Elements
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