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State Plan Checklist - NUTRITION SERVICES 8/14/2026 Page 25

(5) The State agency requires medical documentation for exempt infant formula/WIC eligible nutritionals. Yes No

(6) State agency authorizes local agencies to issue a non-contract brand infant formula that meets the requirements of Table 4 in 7 CFR 246. 10(e)(12) without medical documentation in order to meet religious eating patterns

Yes No

(7) The State agency coordinates with medical payors and other programs that provide or reimburse for exempt infant formulas and WIC-eligible nutritionals per Section 7 CFR 246. 10(e)(3)(vi).

Yes No

If yes, describe the State agency reimbursement and/or referral system used for this coordination? Include describing monitoring/tracking tools in place to ensure program integrity. on This is not applicable for my state agency

If no, has the State agency met the requirement to annually contact their State Medicaid counterparts regarding the payment of WIC-eligible exempt infant formulas and medical foods to mutual program participants per WIC Policy Memo 2015-7? on This is not applicable for my state agency

Yes No Please attach and provide the citation for any existing written agreement between the State agency and the State Medicaid office as well as local government agencies or private agencies regarding payment of WIC- eligible exempt infant formulas and medical foods.

j. Include a copy of the current State-developed medical documentation form in Appendix C or cite the Procedure Manual reference:

AL WIC Procedure Manual Ch. 5 Supplemental Foods Attachments 5-5, 5-6, and 5-7