FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals Revised May 22, 2023 California WIC Policy and Procedure Manual Page 1 of 6 PURPOSE: To establish procedures for the provision of prescribed therapeutic formula (TF) and WIC-eligible nutritionals (WEN). This includes any TF/WEN issued on the WIC Card as well as state-ordered formula. POLICY: I. Local agency (LA) staff must issue TF/WEN when access to these products from another health care plan or program is unavailable and a documented qualifying medical condition exists. LA staff must obtain medical documentation provided by a health care provider (HCP) with prescriptive authority prior to issuing: • TF, WEN, or state-ordered formula. • The increased formula infant food package, which provides infants with additional formula in place of WIC authorized infant food beyond six months of age. • Jarred infant fruits and vegetables, in lieu of Cash Value Benefits (CVB), for children one to five years of age. PROCEDURES: I. Requesting and Processing Medical Documentation A. Medical documentation (e.g., WIC Medical Formula and Nutritionals Request Form, prescription pad, discharge papers, etc.) is required when issuing TF, WEN, state-ordered formula, the increased formula infant food package, or jarred infant fruits and vegetables for children one to five years of age. B. The medical documentation must include all the following information to be processed: 1. Participant’s first and last name. 2. Qualifying medical diagnosis/condition(s) which include but are not limited to: • Premature birth • Low birth weight • Failure to thrive • Inborn errors of metabolism and metabolic disorders • Gastrointestinal disorders • Malabsorption syndromes • Immune system disorders • Life-threatening disorders • Diseases and medical conditions that impair ingestion, digestion, absorption, or the use of nutrients that could adversely affect the participant's nutrition status • Severe food allergies that require an elemental formula (allergy must be specified)

FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals

Revised California WIC Policy and Procedure Manual Page 2 of 6 May 22, 2023

3. Name(s) of the TF/WEN for the stated medical condition. 4. Amount needed per day. 5. Length of time prescribed in months. 6. WIC authorized food restrictions, if applicable. 7. Signature (or signature stamp) and contact information of the HCP, with prescriptive authority, who wrote the medical documentation. 8. Date medical documentation was signed by the HCP. C. New medical documentation is required: 1. Every six months, or as specified on the medical documentation if less than six months. 2. When changing to a food package containing WIC authorized foods at six months and one year of age. This is to ensure that the HCP has determined that it is appropriate for the infant/child to consume the WIC-authorized foods contained in these packages. 3. When a different TF/WEN than the one initially prescribed is needed. D. LA staff must obtain a signed participant consent form prior to contacting the HCP, Medi-Cal, and/or pharmacies. The consent form allows LA and CDPH/WIC staff to share participant information. E. Missing or Incomplete Medical Documentation Information 1. A Competent Professional Authority (CPA) may obtain missing medical information by phone when absolutely necessary and on an individual participant basis. The CPA must: a. Promptly document the missing medical information in the WIC Web Information Exchange (WIC WISE) “General Notes” and indicate that the information was received verbally. b. Include the information in the formula request correspondence to CDPH/WIC (only applicable if the participant requires state-ordered formula). c. Obtain written confirmation of the medical documentation within 30 days after accepting the missing information by telephone. Scan the documentation into WIC WISE.

FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals

Revised California WIC Policy and Procedure Manual Page 3 of 6 May 22, 2023 2. After accepting missing information verbally, the LA is allowed to issue one month of TF/WEN while waiting for complete written medical information to be provided. F. Medical Documentation with Non-Qualifying Medical Diagnosis/Condition(s) 1. Staff must not issue TF/WEN if the medical documentation only contains non-qualifying medical diagnosis/condition(s). 2. Non-qualifying medical diagnoses/conditions include: a. Non-specific symptoms or diagnoses (e.g., colic, constipation, diarrhea, spitting up, picky eater, poor appetite, cramps, fussiness, gas, etc.) i. Additional documentation may be required from the HCP if diagnoses are missing, incomplete, non-specific, inconsistent with existing anthropometric data, or if clarification is needed. b. Solely for the purpose of enhancing nutrient intake or managing body weight. c. Non-specific formula intolerance or food intolerance. d. Preference or food dislikes. G. Out-of-State Prescriptions 1. LA staff may issue TF/WEN to a transferring participant with a valid Verification of Certification (VOC), who was receiving TF/WEN from an out-of- state WIC LA or the WIC Overseas Program. Refer to WPPM 250-10 for information on VOC requirements. 2. Obtaining medical documentation. LA must: a. Request medical documentation from the participant and scan it into WIC WISE. The transferring participant may receive the prescribed TF/WEN up to the duration specified on the medical documentation. New documentation is required in situations listed in Procedures I.C. b. Contact the sending agency to request a copy of the medical documentation if the transferring participant does not possess medical documentation, and/or to verify the TF/WEN the participant was receiving in the other state. Scan the documentation to WIC WISE if obtained. i. Receipt of medical documentation is not required for transfer of benefits.

FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals

Revised California WIC Policy and Procedure Manual Page 4 of 6 May 22, 2023 II. Issuing Prescribed Formula or WEN A. The LA Registered Dietitian (RD) or Degreed Nutritionist (DN) is responsible for ensuring that appropriate WIC nutrition services are provided to participants. Refer to WPPM 130-10 and 130-50. Prior to issuing TF/WEN, a RD or DN must: 1. Ensure that a qualifying medical condition is documented by the HCP and that the TF/WEN requested is consistent with the manufacturer’s recommended usage. 2. Contact the HCP if additional information is needed regarding the qualifying medical condition(s) or it is determined that the TF/WEN does not match the diagnosis. B. LA staff must not issue a different TF/WEN without prior written approval from the HCP. C. If the TF/WEN can be issued on the WIC Card, LA staff must: 1. Document in WIC WISE “General Notes” whether follow-up with Medi-Cal is necessary or if a Medi-Cal denial for the TF/WEN was received. Refer to WPPM 390-20. 2. Notify CDPH/WIC if a Medi-Cal denial is received. CDPH/WIC will correspond with Medi-Cal to verify that the TF/WEN was not wrongfully denied. D. If the TF/WEN is not available on the WIC Card, LA staff must: 1. Email or fax a copy of the medical documentation, Medi-Cal denial letter (if applicable), and participant consent form to CDPH/WIC to request the TF/WEN. 2. Include the LA shipping address as well as the LA contact’s name, email address, phone number, and fax number (if applicable). 3. An authorization form from CDPH/WIC will be emailed or faxed to the LA, unless follow-up is needed. E. Issuance of Standard Non-Contract Formula on the WIC Card 1. LA staff may issue standard non-contract formula (i.e., Enfamil A.R.) as a TF only if the participant provides medical documentation containing an appropriate qualifying diagnosis as well as the other required information specified in Procedures I. 2. CDPH/WIC may allow standard non-contract formula to be available only if no alternative exists in the marketplace.

FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals

Revised California WIC Policy and Procedure Manual Page 5 of 6 May 22, 2023 III. Changing from Therapeutic Formula to Standard Contract Formula A. When the participant is switching from a TF to a standard contract formula after their TF prescription has expired, the LA must: 1. Ensure that a RD/DN reviews the change for appropriateness and documents in WIC WISE before the contract formula is issued. 2. If there are concerns from the RD/DN, attempt to contact the HCP for updated medical documentation before issuing the contract formula. IV. Maintenance of Records A. LA staff must scan the following documentation into WIC WISE: 1. Medical documentation. 2. Signed participant consent form. 3. Denial letters from Medi-Cal. Refer to WPPM 390-20 for provision of formula by Medi-Cal. B. LA staff must ensure that all documents are scanned properly, are readable in WIC WISE, and contain the participant's individual ID and date of birth. V. Individual Nutrition Tailoring A. LA staff must issue less than the maximum monthly allowances for the TF/WEN only when: 1. Medi-Cal provides less than the maximum amount of TF/WEN. The participant may provide either written confirmation of the amount provided by Medi-Cal or self-report the amount. 2. A child is over 12 months old and the HCP prescribes less than the maximum monthly allowance of TF/WEN. B. Document in WIC WISE when the maximum monthly allowances are not issued and the reason why. Refer to WPPM 320-10 for more information on food package tailoring. AUTHORITY: 7 CFR §246.10(d) 22 CCR §51313.3(e)(2) RESOURCE: Formula Job Aid with WIC Card Benefits (on Local Agency SharePoint Site (LASS)) CDPH/WIC Therapeutic Formula Webpage California Children’s Services

FOOD DELIVERY SYSTEM WPPM #390-10 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Provision of Therapeutic Formula and WIC-Eligible Nutritionals

Revised California WIC Policy and Procedure Manual Page 6 of 6 May 22, 2023 Regional Center Listings – CA Department Of Developmental Services Child Health and Disability Prevention (CHDP) WPPM 970-10 Glossary CROSS REFERENCE: WPPM 130-10 Registered Dietitian: Requirements and Responsibilities WPPM 130-50 Degreed Nutritionist (DN): Requirements and Responsibilities WPPM 250-10 Verification of Certification WPPM 320-40 Food Package Tailoring WPPM 390-20 Coordinating with Healthcare