Dear Health Care Provider:

The national WIC Program supports the American Academy of Pediatrics position that breastfeeding and human milk are the normative standards for infant feeding and nutrition. For premature and otherwise sick babies, breastmilk may be regarded as medicine.

American Academy of Pediatrics The 2012 American Academy of Pediatrics Policy Statement on Breastfeeding and Use of Human Milk reads in part: “The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg.
If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”

Questions about Breastfeeding? You may discuss breastfeeding with Deborah Myers, chief of Nutrition and Breastfeeding Services, by phoning (323) 905-1235 or
e-mailing dmyers@slahp.org.

Breastfeeding Mothers With rare exception, we do not provide breastfeeding mothers with food checks for supplemental infant formula during the first 30 days of the infant’s life. Read our breastfeeding policy here>>

Infant Formula Although medical contraindications to breastfeeding and breastmilk are rare, breastfeeding and breastmilk feeding are still not universally practiced. WIC infants not exclusively breastfed or breastmilk-fed may receive infant formula, according to WIC guidelines.

Medical Conditions Occasionally medical conditions do dictate use of special formula.

What Is Therapeutic Formula? This formula is also known as formula for medical conditions. Therapeutic formula is specially designed to treat problems caused by prematurity, the medical and nutritional problems of soy and milk allergies, failure to thrive and very poor weight gain. A completed Pediatric Referral and Special Dietary Request Form (SDR Form) is required if we are to provide therapeutic formula to a WIC participant. The SDR is considered to be a prescription.

WIC Policy Regarding Therapeutic Formula WIC makes therapeutic formula available only to participants who do not have Medi-Cal (regardless of whether it is Fee-for-Service or Medi-Cal Managed Care) or any other means of coverage for therapeutic formula. This is a directive of the California Department of Public Health.

It is rarely necessary to ask WIC to provide therapeutic formula because therapeutic formula is a covered benefit under all Medi-Cal Managed Care plans.

Responding to Calls From the Pharmacy When you prescribe therapeutic formula for your WIC patients who are enrolled in Medi-Cal, we will refer their parents to specific pharmacies. We usually fax the medical prescription to the pharmacy, but at times we ask the parents to call the pharmacies. Either way, the pharmacy will contact you for any additional information needed to process the request. Responding immediately will be essential.

Therapeutic Formula From Medi-Cal Many of your patients participate in Medi-Cal. With your assistance, these infants will be able to receive therapeutic formula.

Receiving Therapeutic Formula A.S.A.P. To arrange for your patients to receive therapeutic formula as soon as possible, please refer those with a Medi-Cal Fee-For-Service or Medi-Cal Managed Care plan to one of the pharmacies listed on our handout “When Your Medi-Cal Patient Needs Therapeutic Formula.” Contact information for the pharmacies is included. Download the handout here>>

When your patient’s Medi-Cal Managed Care plan or Independent Physician Association (IPA) does not directly contract with the pharmacies on our list, you will need to submit a request for prior authorization to the utilization department of the Medi-Cal Managed Care plan or IPA in order to obtain therapeutic formula for your patient.

Once this request is approved, the Medi-Cal Managed Care plan or IPA will arrange for its contracted pharmacy to ship the therapeutic formula to the patient.

To ensure that the patient continues to receive the formula without interruption, please make sure to submit a request for prior authorization as often as required by the Medi-Cal Managed Care plan or IPA. Some require it monthly.

WIC–Payer of Last Resort WIC is the payer of last resort and only provides therapeutic formula when the participant does not have health coverage, the Medi-Cal application is being processed, the authorization is pending approval, or the participant has private insurance that does not cover therapeutic formula.

Special Nutrition Services Registered dietitians and degreed nutritionists at our WIC centers provide nutrition counseling to mothers for the qualifying medical condition and monitor the use and intake of therapeutic formula.

Sharing Therapeutic Formula Information With Us It is important that providers complete the WIC Pediatric and Special Dietary Requests (SDR) Form whether Medi-Cal covers the therapeutic formula or not. This form provides our Special Nutrition Services team information about the diagnosis, duration and amount of therapeutic formula needed or any WIC food restrictions to be considered. Access the SDR Form here>>

Our dietitian or nutritionist will contact the provider if information provided on the SDR form is not sufficient.

Therapeutic Formula Provided By WIC If your patient has no type of health coverage for the therapeutic formula, we will arrange for your patient to receive this formula under certain conditions.

• Please send your prescription to WIC on the Pediatric Referral and Special Dietary Request Form (SDR Form).

• A prescription for therapeutic formula must be justified by medical need.

• Include the diagnosis, name of the therapeutic formula, amount and duration needed.

• If the patient has any WIC food restrictions, indicate these on the form.

• List your phone number and extension and email address so our dietitian can contact you with any questions.

• WIC honors most of the eligible formula requests for up to three months.

• After the patient has received therapeutic formula for three months, the parent will be given a blank SDR form for you to complete if you decide this formula is still warranted.

• If your patient becomes enrolled in Medi-Cal, we will refer the parents to pharmacies that provide therapeutic formula.

Providing therapeutic formulas When necessary, we provide the following types of therapeutic formula, indicating them by name on our WIC food checks: premature discharge formulas, hypoallergenic formulas and formula for extra calories for children. Provision of any therapeutic formula requires a completed SDR Form.

The State WIC Division considers requests for other formulas when medical need is proven. Because delivery of the formula from State WIC to our WIC centers can take as long as three weeks, it would be helpful for you to provide samples to your WIC patient.

The majority of our WIC participants have Medi-Cal and rarely need us to provide formula.

Premature Discharge Formulas

• For infants who are not breastfed or receiving human milk, the American Academy of Pediatrics Pediatric Nutrition Handbook 2009 states that premature discharge formulas may be used until nine to 12 months corrected age.

• Provision of any premature discharge formula requires a completed SDR form.

• The two premature discharge formulas we provide are Similac Expert Care Neosure and Enfamil Enfacare.

• WIC educates the parents or other caregivers of premature infants on the feeding and development of their infants based on the corrected age, not the chronological age.

• Introduction of solids is encouraged at the corrected age of six months.

• An “extra formula, no solid food package” is provided to premature infants at the corrected age of four to five months. Because the infant is premature, the introduction of solids needs to be delayed until the infant reaches the corrected age of six months.

• If the participant has no other means of coverage, WIC will provide premature discharge formula or contract infant formula to children with a history of prematurity up to 12 months corrected age.

Hypoallergenic Formulas

• We provide Similac Expert Care Alimentum and Nutramigen LIPIL for infants with a protein allergy.

• Medi-Cal requires that patients try Alimentum before Nutramigen LIPIL.

• Patients must have a documented intolerance to Alimentum before Medi-Cal will provide coverage for Nutramigen LIPIL.

Formula After Age One WIC treats a request for regular infant formula for a child over one year of age as if it were a request for therapeutic formula. For a child of this age to receive infant formula, an SDR Form must be completed. And to justify its use there must be a medical condition, such as a history of prematurity or developmental delay with a very low calorie need. Picky eaters and children with poor appetite or lactose intolerance or anemia are not eligible.

Therapeutic Formula for Extra Calories

• When children need extra calories, we supply Pediasure.

• WIC only supplies Pediasure to children at ages 13 months and older.

• WIC supplies Pediasure to patients when certain medical needs exist. These include failure to thrive, developmental delay, g-tube feeding or very poor or no weight gain over an extended period of time.

• WIC does not provide Pediasure for children simply because they are picky eaters or have poor appetite, lactose intolerance or anemia.

Transitioning From Therapeutic Formula WIC needs a completed SDR Form when your patient is about to transition from therapeutic formula to one of the WIC contract (regular) formulas. These are:

• Enfamil Premium
• Enfamil ProSobee
• Enfamil Gentlease
• Enfamil AR

Food Checks For Healthy Children After Age One: WIC helps eligible children receive calcium and other important nutrients in two ways. We encourage mothers to continue breastfeeding and to continue adding certain solid foods purchased with WIC food checks. We also enable mothers who are no longer breastfeeding and other caregivers to select and purchase certain calcium-rich nutritious foods with their children’s WIC food checks.

Many children may:
• continue breastfeeding
• drink regular cow’s milk
• eat cheese

Vegan children may:
• continue breastfeeding
• drink soymilk. (Indicate on pediatric referral form.)
• eat tofu. (Indicate on pediatric referral form.)

Lactose-intolerant children may:
• continue breastfeeding.
• drink lactose-free milk. (No need to indicate this.)
• drink soy milk. (Indicate on pediatric referral form.)
• eat tofu. (Indicate on pediatric referral form.)

Questions About Therapeutic Formula? You can discuss therapeutic formula with Nancy Damiani, MPH, RD, CLE, Chief, Special Nutrition Services, by phoning her at (323) 757-7244 ext. 251 or e-mailing her at ndamiani@slahp.org.

Obtaining Our Forms You can obtain forms named on this page by clicking on the indicated links, accessing our WIC Referral Forms website page or phoning our Outreach and Provider Relations staff at (323) 757-7244 ext. 298. They will deliver any forms you request.