If one of WIC’s contract formulas is not appropriate for your patients, there may be a medical condition warranting a therapeutic formula. As part of the patient’s treatment plan, therapeutic formulas should be covered by the health plan when the clinician provides adequate medical justification. Should your patient be denied coverage by Medi-Cal or other health insurance, WIC may provide the therapeutic formula. WIC will require a letter of denial from the health plan and Medi-Cal.

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WIC is a nutrition program that is not funded to give formulas for medical conditions. Since WIC is not a medical program, Physicians should follow the procedures of the health plan below if they prescribe a therapeutic or special formula.

Private or Military Insurance:

• Physician must submit the required paperwork requesting the formula to the health plan.
• If the health plan denies the formula, patient should take the complete *prescription to their WIC site for Nutritionist evaluation. 

* Prescription contains patient name, birth date, name of formula, diagnosis, amount needed per day, duration and signature of healthcare provider.

Medi-cal Managed Care Plan (IEHP, Molina or SCAN):

• Physician must submit a request for prior authorization to the health plan. Medi-cal Managed Care Plans are required to provide medically necessary formulas.  For specific MMC policy information on therapeutic formula provision go to MMCD Policy Letter.
• Physician needs to provide complete Rx for formula and tell patient to take to a pharmacy that contracts with the specific MMC plan.
• The patient should call membership services for the plan if they need help. The phone number is on the back of their benefits card.
• If the patient is experiencing difficulty obtaining plan coverage, they should call the Medi-cal Managed Care Ombudsman at 1-888-452-8609 to resolve any problems.

Full Scope Medi-Cal (a.k.a. Regular Medi-Cal):

• The Physician should provide patient with a complete prescription written on office letterhead or script pad.
• Physician should tell patient to take Rx to pharmacy for filling.
• If the therapeutic formula is denied, the patient should return to the WIC clinic with verbal or written denial from the Pharmacist stating the reason for denial. Verbal denial will be verified by a WIC Nutritionist by calling the pharmacy.  Once denial verified WIC will issue formula.
• WIC Nutritionist will instruct participant to take a complete RX to a different pharmacy if initial pharmacy is unwilling to investigate and resolve the reason for the denial.

No Insurance:

• Refer patient to CHDP Gateway Program at 1-800-722-3777.