Therapeutic Formula

A WIC participant may have a medical condition and need therapeutic formula that is not a WIC contract formula. Therapeutic formulas should be covered by the WIC participant's health plan when the clinician provides adequate medical justification. Should a WIC participant be denied therapeutic formula coverage by his or her health plan (Medi-Cal or other health insurance), the WIC Program may provide the therapeutic formula.

Procedures

• Process for Therapeutic Formula Requests (PDF)
  
• Pediatric Referral Form Full Sheet Version (PDF)
• Pediatric Referral Form Instruction Sheet (PDF)
  
• Therapeutic Formula Fax Cover Page (PDF)
  
• Therapeutic Formulas and WIC-Eligible Nutritionals List (PDF) (also see the Formula Product Information links below)
  

Policies

• WPPM 390-10 Provision of Therapeutic Formula and WIC-Eligible Nutritionals (PDF)
• WPPM 390-20 Coordinating with Healthcare (PDF)

Training

• Therapeutic Formula Training Q and A (PDF)

Contact

For general inquiries and formula orders, contact us at Formula@cdph.ca.gov.

For additional information regarding Therapeutic Formula, please contact
Denay.Mintz@cdph.ca.gov or Asha.Camacho@cdph.ca.gov.

For additional information regarding Medi-Cal, please contact Cheryl.Barrios@cdph.ca.gov.