DC WIC POLICY & PROCEDURE MANUAL

Policy 9.008 1 | P a g e Title: Qualifying Medical Conditions Category: Food Delivery CFR Reference 7 CFR 246.10(e)(3) Policy Number 9.008 Effective Date 3/2022 Revised Date: 11/17/2025

POLICY STATEMENT: The State Agency will make available in the MIS specialized food packages designed to meet the cultural, medical, and dietary needs of participants with qualifying medical conditions that allow up to the Monthly Maximum Allowance (MMA)* of authorized supplemental foods* as part of Food Package III in accordance with 7 CFR 246.10(b)(2)(ii). Food package III may not be issued solely for the purpose of enhancing nutrient intake or managing body weight or for infants whose only condition is a diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein, or soy protein that does not require the use of an exempt infant formula or a non-specific formula or food intolerance (7 CFR 246.10(e)(3)(ii)). *See DC WIC policy 9.004 Federal Food Packages for definition of MMA and supplemental foods. DEFINITIONS Qualifying medical condition – any diagnosed medical condition which requires the issuance of a WIC formula, exempt infant formula, or WIC-eligible nutritional as deemed appropriate by a healthcare provider per medical documentation. Examples include preterm birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, and severe food allergies. Reconstituted Fluid Ounces (RFO) – the amount of formula prepared from one can or container of formula product when prepared with water according to standard mixing instructions. PROCEDURE Only a CPA may issue a WIC infant formula, noncontract infant formula*, or WIC-eligible nutritional as part of Food Package III with appropriate medical documentation in accordance with 7 CFR 246.10(d) as described below. Required Medical Documentation Any issuance of a WIC infant formula, noncontract infant formula, or WIC-eligible nutritional as part of Food Package III requires a completed DC WIC Medical Prescription Form or other medical documentation form from a licensed healthcare provider with prescriptive authority in the District of Columbia. The following information is required and may be obtained in writing or received verbally (see further guidance on this below): A. The name of the formula or WIC-eligible nutritional being requested, including the amount needed per day (this can be determined by the CPA if indicated as so). B. The authorized supplemental food(s)* appropriate for the qualifying condition(s) and their prescribed amounts. C. Length of time the prescribed WIC formula and/or supplemental food is required by the participant. D. The qualifying condition(s) for issuance of the authorized supplemental food(s).

DC WIC POLICY & PROCEDURE MANUAL

Policy 9.008 2 | P a g e E. Signature, date, and contact information (or name, date, and contact information) if the initial medical documentation was received verbally and the signed document is forthcoming. All medical documentation requesting a formula or WIC-eligible nutritional must be uploaded into the participant’s record. All requests are subject to approval by a CPA. If a medical provider has prescribed a formula or feeding plan that, based upon the nutritional assessment of the CPA is not appropriate or indicated, the CPA should contact the medical provider to discuss alternative options. *See DC WIC policy 9.005 Infant Food Packages for definitions of noncontract infant formula. In accordance with 7 CFR 246.10(d)(4)(iii)(B), medical documentation may be provided by telephone to a CPA who must promptly document the information. The collection of the required information by telephone for medical documentation purposes may only be used until written confirmation is received from a licensed healthcare provider with prescriptive authority and used only when absolutely necessary on an individual participant basis. Written medical documentation must be received no later than 2 weeks after accepting the initial medical documentation by phone. Licensed healthcare providers with prescriptive authority In accordance with District of Columbia Code § 3–1201.02 the following healthcare providers are authorized to complete a DC WIC Medical Prescription Form or other written medical documentation to prescribe WIC authorized foods: • Doctor of Medicine (MD) • Doctor of Osteopathy (DO) • Physician Assistant (PA) • Certified Registered Nurse Anesthetist (CRNA) • Certified Nurse-Midwife (CNM) • Certified Nurse-Practitioner (CNP, CRNP, NP, DNP) • Clinical Nurse Specialist (CNS) Hospital discharge forms Hospital discharge forms may be used to prescribe and issue a special formula or WIC-eligible nutritional for up to two months of food benefits. The DC WIC Medical Prescription Form or other completed written medical documentation must then be obtained and uploaded into the participant’s record. Recommended prescription duration length DC WIC recommends that all approved requests for special formula for infants be reassessed at a duration of no greater than three months from issuance. The recommended maximum duration of a prescription for women and children is six months. CPAs may approve special formula and WIC-eligible nutritional requests beyond these ranges as they deem appropriate. Food Package III issuance in HANDS The following food packages descriptions are used to indicate Food Package III issuance in HANDS (i.e. contain special formula or WIC-eligible nutritionals to tailor and issue): Infants (IFF, IPN+, IPN) • Special Formula

DC WIC POLICY & PROCEDURE MANUAL

Policy 9.008 3 | P a g e • No Solid Foods Children and Women (C1, C2, C3, C4, PG1, PG2, P, PN+, PN) • Special with Formula • Formula Only No Solid Foods Packages In lieu of infant foods (cereal, fruit, and vegetables), infants older than 6 months of age in Food Package III may receive WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritionals) at the same MMA as infants ages 4 through 5 months of age of the same feeding option (i.e. fully formula feeding or partially (some) breastfeeding, and partially (mostly) breastfeeding). Children and Women Special with Formula – Additional Tailoring Options For a participant receiving Food Package III, the healthcare provider must indicate which WIC-authorized supplemental foods and their forms (e.g. pureed fruits and vegetables or whole fruits and vegetables) to issue to the participant or indicate that the WIC CPA may determine the supplemental foods, forms, and amounts to issue to the participant on the written medical prescription form. Standard tailoring options for each participant category and accompanying food package can be found in DC WIC policies 9.005 Infant Food Packages, 9.006 Children Food Packages, and 9.007 Women Food Packages. In addition to the standard tailoring options available to each participant category, the following additional tailoring options are available in the “Special with Formula” food packages: Category(s) Additional Food Item Substitution Food Category to Substitute From Children 1-year-old Nonfat yogurt Whole milk Infant cereal Breakfast cereal Infant fruit and vegetable CVB for fruits and vegetable Juice Children 2 to-4-years Pregnant women Postpartum women (all feeding statuses) Whole milk Low-fat or nonfat milk Whole milk yogurt Infant cereal Breakfast cereal Infant fruit and vegetable CVB for fruits and vegetable Juice

DC WIC NONCONTRACT FORMULA TAILORING GUIDE The following tables can assist the CPA in tailoring the amount of powdered formula for participants issued food package III. Ready-to-feed (RTF) formulas should be issued in quantities that match the total amount needed for one month up to the MMA. A full listing of formulas offered in DC WIC can be found in the DC WIC Formula Guide. Formula Reconstituted Fluid Ounces (RFO) Range # of daily ounces of formula # of cans to issue Exempt Infant formula Reconstituted Fluid Ounces (RFO) Range # of daily ounces of formula # of cans to issue Neocate Infant 14.1 oz 97 to 112 ounces < 3 oz 1 can

DC WIC POLICY & PROCEDURE MANUAL

Policy 9.008 4 | P a g e Pepticate 14.1 oz Pregistimil 16 oz PurAmino 14.1 oz Similac PM 60/40 14.1 oz 4 to 6 oz 2 cans 7 to 9 oz 3 cans 10 to 12 oz 4 cans or up to MMA 13 to 15 oz 5 cans or up to MMA 16 to 18 oz 6 cans or up to MMA 19 to 21 oz 7 cans or up to MMA 22 to 24 oz 8 cans or up to MMA 25 or more 9 cans or up to MMA Alfamino Infant 14.1 oz Elecare Infant 14.1 oz Enfamil AR 12.9 oz Enfamil NeuroPro Enfacare 13.6 oz Gerber Extensive HA 14.1 oz Nutramigen 12.6 oz Nutramigen Jr Similac Alimentum 12.1 oz Similac Neosure 13.1 oz 86 to 96 ounces < 3 oz 1 can 4 to 6 oz 1 to 2 cans 7 to 9 oz 2 to 3 cans 10 to 12 oz 3 to 4 cans or up to MMA 13 to 15 oz 4 to 5 cans or up to MMA 16 to 18 oz 5 to 6 cans or up to MMA 19 to 21 oz 6 to 7 cans or up to MMA 22 to 24 oz 7 to 8 cans or up to MMA 25 to 27 oz 8 to 9 cans or up to MMA >28 oz 10 cans or up to MMA

Elecare Jr 14.1 oz PurAmino Jr 14.1 oz Neocate Jr 14.1 oz Alfamino Jr 14.1 oz

64 to 66 ounces < 3 oz 1 can 4 to 6 oz 2 cans 7 to 9 oz 3 to 4 cans 10 to 12 oz 4 to 5 cans 13 to 15 oz 6 to 7 cans 16 to 18 oz 7 to 8 cans 19 to 21 oz 9 to 10 cans 22 to 24 oz 10 to 11 cans 25 to 27 oz 11 to 13 cans >28 oz 14 cans

Exempt Formula and WIC-Eligible Nutritionals - Liquid concentrate and RTF amounts See DC WIC policy 9.005 Infant Food Packages for tailoring guidance on liquid concentrate and RTF formula. Customized Food Package Creation and Issuance Additional formulas and WIC-eligible nutritionals may be available for issuance in DC WIC beyond those listed in this policy and the DC WIC Formula Guide. The CPA should contact the State Agency to assist with food package issuance for any of the following:

DC WIC POLICY & PROCEDURE MANUAL

Policy 9.008 5 | P a g e 1. A request for a formula or product not currently available as a tailoring option for the participant’s age and category. 2. A request to issue two or more formulas within the same benefit cycle. Example – a healthcare provider requests that both Similac Advance and Similac Neosure be issued in the same month to help the infant transition to a standard formula. 3. A change in benefits mid-cycle if the participant has already redeemed partial benefits for the month (see DC WIC policy 9.002 Replacement of Food Benefits). REFERENCES 7 CFR 246.10(b)(2)(ii) District of Columbia Code § 3–1201. DC WIC policies 9.002 Replacement of Food Benefits, 9.004 Federal Food Packages, 9.005 Infant Food Packages, 9.006 Children Food Packages, 9.007 Women Food Packages ATTACHMENTS & FORMS DC WIC Medical Prescription Form DC WIC Formula Guide