WIC and Nutrition Manual 600 Policy Group Food Package Assignment

Table of Contents

Policy 600

Food Package Issuance

Policy 601

Issuance of Standard Infant Food Package

Policy 602

Issuance of Exempt Infant Formula Food Packages

Policy 603 Handling Returned Formula and Formula Benefit Replacement

Policy 604 Assigning Standard Food Packages for Women and Children

Policy 605 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation

Policy 606 Issuance of WIC Nutritionals to Women and Children

Policy 600 Appendices Food Package Assignment

Page 1 Food Package Issuance Policy 600 October 2024 Policy 600 Food Package Issuance POLICY Certifying Health Professionals must select a participant’s food package in accordance with federal regulations and state policy. PURPOSE To ensure food benefits are appropriate for each participant’s health and nutrition needs. PROCEDURES Food Package Assignment A. The Certifying Health Professional must select, in consultation with the participant or caregiver, the appropriate food package for the WIC participant. 1. The Certifying Health Professional must assign the food and quantities allowed for the participant’s category. a. The food package shall take into account the individual’s age, dietary needs, medical and nutrition conditions, cultural eating patterns, willingness to consume certain foods, and living situations. b. During disasters or food shortages, food packages should be tailored/make substitutions and adjustments to provide available allowable options. c. In case of a shortage for participants receiving exempt infant formula or medical foods, the State WIC Office will work with USDA to request a waiver allowing one-month issuance without a prescription. In addition, we encourage local agencies to work with their physicians for participants with documented qualifying conditions to write prescriptions for multiple appropriate products so that participants do not have to make repeat visits to their healthcare providers and may readily access available food. d. See Policy 220 for further information on food package waivers during a disaster or food shortage. 2. Food package assignment changes are the responsibility of the Certifying Health professional. a. The Certifying Health Professional is the only staff member who can make any change to a participant’s food package. This includes a breastfeeding infant requesting formula.

Page 1 Issuance of Standard Food Packages Policy 601 December 2024 Policy 601 Issuance of Standard Infant Food Packages POLICY The certifying health professional shall issue approved WIC formulas in accordance with the Policies for Prescribing Food Packages, Food Package Tables and Requirements for Issuing Infant Formulas, Exempt Infant Formula and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC formulas and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation.

PROCEDURES Issuance of Infant Food Packages A. Requirements for issuing each infant formula (milk, soy, milk-based lactose reduced, milk based lactose free, reflux) must be followed. B. All infants receiving formula must receive contract brand infant formula unless contraindicated or a comparable product is not available. C. Noncontract rates for an agency shall be 5% or less. The 1924 formula report is available via e- Reports for local WIC agencies to monitor their non-contract formula rates. D. Whole, low-fat, fat-free/skim or goat’s milk cannot be issued for infants. E. Cereal must not be issued to an infant until six months of age. F. Infants fruits and vegetables may be provided at six months of age. G. Fresh fruits and vegetables may be provided at nine months of age for half of the jarred infant fruits and vegetables.

Infant Food Package Assignment A. Fully Breastfed Infant Package-BF1 1. Fully breastfeeding or exclusive breastfeeding is recommended by the American Academy of Pediatrics for the first six months of life with continued breastfeeding in conjunction with complementary food introduction until 1 year of age or longer as desired by mother and infant. 2. Fully breastfed infants will not receive any formula from WIC but will receive foods at six months of age. 3. The maximum amount of foods received at six months of age include: a. Iron Fortified Cereal-16 oz. total b. Infant Fruits and Vegetables-128 oz. total i. The infant may receive $20 in cash value benefit or $10 in cash value benefit and 64 oz. in jarred infant fruits and vegetables. c. Infant meats-40 oz. total B. Infant Receiving Only Infant Foods-F1 1. This package will be issued to infants whose family will be purchasing formula or the infant is obtaining formula from another source. 2. Document in the medical record the reason for issuance of the F1 package. 3. The infant will receive the following infant foods at six months of age. a. Iron Fortified Cereal-8 oz. total b. Infant Fruits and Vegetables-128 oz. total

Page 2 Issuance of Standard Food Packages Policy 601 December 2024 4. In order for the infant to count as an active participant, the F1 food package must be issued.

C. Partially Breastfed Infant Formula Package 1. The Certifying Health Professional shall individually tailor the partially breastfeeding infant food package amount of formula based on the assessed needs of the breastfeeding infant. Provide the minimal amount of formula that meets the infant’s nutrition needs. 2. Infant formula for a partially breastfeeding infant will be issued in the following amounts. Age Formula Maximum Quantity Allowable

•

Birth through 3 months • Up to 435 fluid ounces of reconstituted powder formula 4 months through 5 months • Up to 522 fluid ounces of reconstituted powder 6 months through 11 months • Up to 384 fluid ounces of reconstituted powder 3. The infant will receive the following infant foods at six months of age. a. Iron Fortified Cereal-8 oz. total b. Infant Fruits and Vegetables-128 oz. total 4. The infant may receive $10 in cash value benefits and 64 oz. in jarred infant fruits and vegetables or $20 in cash value benefit. 5. If a noncontract formula is requested, the challenge guidelines must be followed unless contraindicated. a. The infant may receive one can of formula for the first month but this shall not be routine practice. b. The infant will receive approximately one-half of the formula provided by a full formula package for months two through eleven. i. The Certifying Health Professional shall individually tailor the amount of formula based on the assessed needs of the breastfeeding infant. Assess and provide the minimal amount of formula that meets the infants nutritional needs. ii. Provide counseling on breastfeeding and pumping to establish and maintain adequate breastmilk supply. iii. Counseling shall include recommendation to only purchase as much formula is needed. 6. The Certifying Health Professional shall use the below chart to assist in determining the number of cans needed each month for partially breastfeeding infants based on the amount of formula the infant is taking per day. 0-3 oz. per day → 1 can powder per month 4-6 oz. per day → 2 cans powder per month 7-9 oz. per day → 3 cans powder per month 10-12 oz. per day → 4 cans powder per month 13-15 oz. per day → 5 cans powder per month 16-18 oz. per day → 6 cans powder per month 19-21 oz. per day → 7 cans powder per month 22-24 oz. per day → 8 cans powder per month 25-27 oz. per day → 9 cans powder per month D. Full Formula Infant Package 1. Contract formula will be provided to all non-medically fragile infants. Other formulas may be provided based upon information provided in the medical documentation form a. For the partially breastfeeding infant receiving the full formula package: i. The Certifying Health Professional shall individually tailor the amount of formula based on the assessed needs of the breastfeeding infant.

Page 3 Issuance of Standard Food Packages Policy 601 December 2024 Provide the minimal amount of formula that meets the infants nutritional needs. ii. Counseling shall include recommendation to only purchase as much formula is needed. iii. For infants needing less than half of the formula provided per month, the infant shall be assigned a Partially Breastfeeding Infant Formula Package. 2. The infant may receive a maximum monthly allowance of formula in the amounts of: Age Formula Maximum Quantity Allowable Birth through 3 months • Up to 870 fluid ounces reconstituted powder • Up to 823 fluid ounces reconstituted liquid concentrate • Up to 832 fluid ounces ready-to-feed 4 months through 5 months • Up to 960 fluid ounces reconstituted powder • Up to 896 fluid ounces reconstituted liquid concentrate • Up to 913 fluid ounces ready-to-feed 6 months through 11 months • Up to 696 fluid ounces reconstituted powder • UP to 630 reconstituted liquid concentrate • Up to 643 fluid ounces ready-to-feed E. Full Formula Tube Feeding or Medical Provider request to delay introduction of solids Food Package 1. This package is only provided based upon instructions on the medical documentation form. 2. The maximum amount of formula provided will be: Birth through 3 months • Up to 870 fluid ounces reconstituted powder • Up to 823 fluid ounces reconstituted liquid concentrate • Up to 832 fluid ounces ready-to-feed 4 months through 11 months • Up to 960 fluid ounces reconstituted powder • Up to 896 fluid ounces reconstituted liquid concentrate • Up to 913 fluid ounces ready-to-feed

Contract Brand Formula A. The current infant formula rebate contract is with Abbott Laboratories. B. All infants who are not medically fragile must receive Similac Advance formula. C. Due to increased incidence of osteopenia (bone volume reduction), soy formulas should not be used for preterm infants. D. If the infant has not be receiving Similac formula the transition guidelines must be followed. 1. All caregivers must be counseled to try each formula for 72 hours exclusively. a. Some exceptions may be made for severe reactions such as rash, projectile vomiting, a medically fragile infant or professional judgement. 2. Counseling must include information about changing the infant from the current formula to the contract brand formula. a. Day 1-Offer infant ¾ current formula mixed with ¼ new formula. b. Day 2-Offer infant ½ current formula mixed with ½ new formula. c. Day 3-Offer infant ¼ current formula mixed with ¾ new formula. d. Day 4- Offer new formula exclusively.

Page 4 Issuance of Standard Food Packages Policy 601 December 2024 3. All formulas tried and problems encountered must be documented in the participant’s medical record. E. The contract brand standard formulas that are appropriate to provide to infants during the first year of life are Similac Advance, Similac Total Comfort, Similac Sensitive,or Similac Soy Isomil. F. Infants who come to clinic on one of the non-contract brand formulas and are not medically fragile, must have tried and encountered problems with Similac Advance unless contraindicated. 1. The infant then may try one of the remaining contract brand products.

Requests for Noncontract Formula A. Infants who come to clinic on noncontract formula and are not medically fragile must be provided a Similac Advance formula using the following challenge guidelines: 1. If requesting noncontract brand milk based formula (Gerber Good Start Gentle, Enfamil Infant, etc.), the infant must have tried the contract brand milk based formulas below, unless contraindicated and encountered problems: First Trial: Similac Advance Second Trial: Similac Total Comfort 2. If requesting noncontract soy based formula (Enfamil ProSobee Soy or Gerber Good Start Soy, etc.), the infant must have tried the contract brand soy based formulas below, unless contraindicated, and encountered problems: First Trial: Similac Soy Isomil Second Trial: Similac Sensitive or Similac Total Comfort (if no milk allergies exist) 3. If requesting milk based lactose free or lactose reduced formula (i.e. Enfamil Gentlease, Good Start Soothe, etc.), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Total Comfort Second Trial: Similac Sensitive or Similac Soy Isomil 4. If requesting a formula for management of reflux or gastroesophageal reflux (GER) or gastrophageal reflux disease (GERD), (Enfamil AR) there is no comparable contract brand product. Enfamil AR may be issued with a valid prescription. 5. If requesting noncontract milk based products for 9 to12 months of age (Enfagrow Toddler Transitions), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Advance Second Trial: Similac Total Comfort 6. If requesting noncontract soy based products for 9 to 12 months of age (Enfagrow Toddler Soy Transitions), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Soy Isomil Second Trial: Similac Sensitive or Similac Total Comfort (if no milk allergies exist) 7. If requesting noncontract milk based, hydrolyzed protein with probiotics formula (Enfamil Reguline), the participant must try the contract formulas below, unless contraindicated, and encountered problems: First Trial: Similac Total Comfort Second Trial: Similac Sensitive 8. If requesting for Kosher or Halal formula due to religious beliefs, the infant must have tried the contract brand formula below, unless contraindicated, and encountered problems: First Trial: Similac Advance

Second Trial: Similac Total Comfort B. If the infant is medically fragile (e.g., LBW, premature, recent long hospitalization, heart problems, etc.), WIC will not require this infant to try contract brand formula. C. If the infant is not medically fragile, there must be supporting documentation concerning the contract formulas tried and the problems encountered.

Page 5 Issuance of Standard Food Packages Policy 601 December 2024 D. It is required that the client be provided only 3 months of noncontract formula. At the end of 3 months, it is required that the health professional assess the continued need for the noncontract formula and that the challenge guidelines be followed for non-medically fragile infants. If the health professional determines the infant should not be challenged until the next one-to-three- month issuance, the reason for not challenging must be documented in the medical record. 1. During the assessment, determine if the infant has tried the contract formula within the last 3-4 weeks and followed the transition guidelines.

Requests for Ready-to-Feed Formulas A. Ready-to-feed formula can be provided when the health professional determines and documents: 1. Restricted or unsanitary water supply 2. Poor or no refrigeration 3. The caretaker is unable to properly prepare formula 4. Formula is only manufactured/available in ready-to-feed form 5. Homelessness. a. A medical documentation form will be needed for noncontract formula issuance. b. The 32 oz. size may be issued in situations where the individual has access to refrigeration and dishwashing facilities. c. If the participant does not have access to refrigeration and dishwashing facilities, the formula product shall be issued in individual ready to feed servings. 6. Contact the State WIC Office if you have questions about issuing a Ready to Feed Formula.

Requests for Low Iron Formula A. All low iron formula have been discontinued by the formula companies based on the American Academy of Pediatrics guidelines.

Medical Documentation Requirements for WIC Non-Contract Formulas A. WIC Non-Contract Formulas 1. Medical documentation for issuance of formulas other than the contract brand a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See Appendix-Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PA’s) and Advanced Practice Registered Nurse (APRN’s) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation or not authorized by the Program. d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain: i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document date of telephone call and signature of person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return

Page 6 Issuance of Standard Food Packages Policy 601 December 2024 the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed 12 months or one (1) year. g. A medical documentation form remains in effect until expiration even when a participant’s category changes from infant to child. However, need for the formula shall be reviewed with the physician, physician assistant or APRN and parent/caretaker due to the difference between an infant and child’s package. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Medical documentation for issuance of noncontract infant formulas a. If the infant is medically fragile (e.g., LBW, premature, infant released after long hospitalization, heart problems etc.), WIC will not require this infant to try contract brand formula(s). b. If the infant is not medically fragile, there must be supporting documentation concerning the contract formulas tried and the problems encountered. The challenge guidelines must be followed before approving the use of noncontract formula. c. The following information must be on the medical documentation form prior to issuing noncontract standard formula: i. Formulas tried and problems encountered; ii. The diagnosis/diagnoses; iii. Specific name of the formula requested; iv. Prescribed period of time; and v. Signature of MD, DO, PA or APRN. d. Diagnosis for non-contract formulas should include valid medical condition. For infants whose only condition is diagnosed as formula intolerance, food allergy to sucrose, or any other nonspecific intolerance, the request will not be approved.

3. Medical documentation for issuance of ready-to-feed formulas a. Ready-to-feed formula can be provided when the participants medical provider determines and documents: i. Restricted or unsanitary water supply; ii. Poor or no refrigeration; iii. Caretaker is unable to properly prepare formula; iv. Formula is only manufactured/available in the ready-to-feed form; or v. Homelessness

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Page 7 Issuance of Standard Food Packages Policy 601 December 2024 Requirements of Issuing Infant Formula

FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL INFANT FORMULA - CONTRACT BRAND- SIMILAC Similac Advance (primary milk based formula) Similac Sensitive Similac Total Comfort Similac Soy Isomil No

No No INFANT FORMULA - NONCONTRACT Enfamil AR Enfamil Gentlease Enfamil Infant Enfamil ProSobee Soy Enfamil Enfagrow Toddler Transitions* Enfamil Enfagrow Soy Toddler Transitions* Good Start Gentle Good Start Soy Good Start Soothe Pro

Yes – Diagnosis

Documentation must include contract formulas tried and problems encountered. See WIC Policies for Prescribing Food Packages for Issuance of Noncontract Standard Formula

See WIC Policies for Prescribing Food Packages Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis (ICD-9/10)

Follow State WIC Office and Agency Policies

Infants with Special Dietary Needs A. Kosher formula requested due to religious or cultural beliefs. 1. Similac Advance formula meets the guidelines for kosher. B. Vegetarian/Vegan requested due to family lifestyle or cultural preference. 1. Similac Soy Isomil Formula meet the guidelines for vegan or vegetarian since it is prepared with soybeans.

Page 1 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 Policy 602 Issuance of Exempt Infant Formula Food Packages POLICY The certifying health professional shall issue approved Exempt Infant Formulas in accordance with the Policies for Prescribing Food Packages, Food Package Tables and Requirements for Issuing Infant Formulas, Exempt Infant Formula, and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC exempt formulas and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation 21 CFR 107.3 – Exempt Infant Formula

DEFINITIONS Exempt Infant Formula -- infant formula that is represented and labeled for use by infants who have inborn errors of metabolism or low birth weight, or who otherwise have unusual medical or dietary problems.

PROCEDURES Requests for Exempt Formula and WIC Nutritionals A. Exempt infant formulas can be provided when the health professional has a medical documentation form or valid prescription. B. Issuance of these formulas requires a medical documentation form and prior approval by the designated local WIC agency personnel who have been trained by the State WIC Office or State WIC Office-identified training. C. The formula must be designed for internal digestion.

Issuance of Exempt Infant Formula Packages A. Infants with valid prescriptions for exempt infant formulas are not required to try contract brand formulas. B. If the infant is medically fragile (e.g. LBW, premature, recent long hospitalization, heart problems, etc.), WIC will not require this infant to try contract brand formula. C. Exempt infant formulas do not have to be challenged.

Medical Documentation Requirements for Exempt Infant Formulas A. Exempt Infant Formulas 1. Medical documentation for issuance of formulas other than the contract brand a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See Appendix-Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PA), and Advanced Practice Registered Nurses (APRNs) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation, or not authorized by the Program.

Page 2 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain: i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document the date of the telephone call and the signature of the person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed 12 months or one (1) year for an infant and six months for a woman or child. g. A medical documentation form remains in effect until expiration, even when a participant’s category changes from infant to child. However, the need for the formula shall be reviewed with the physician, physician assistant or APRN, and parent/caretaker due to the difference between an infant’s and child’s package. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Issuance of Food Package III (nonstandard infant food package) may not be issued for the following reasons: a. For infants whose only condition is diagnosed as formula intolerance, food allergy to sucrose, or any other nonspecific intolerance. B. The chart at the bottom of this section provides guidance on what documentation is necessary for product issuance.

State Agency Approval A. If State Agency approval is needed to issue an Infant Formula or WIC Nutritional, after receiving verbal approval from a State WIC Office Registered Dietitian, complete the WIC State Agency Formula/WIC Nutritional Approval Form and fax or email it to the State WIC Office. See Appendix WIC State Agency Formula Approval Form.

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Medicaid Denial Letters for Exempt Infant Formula When a physician prescribes a formula that WIC does not authorize or if the physician prescribes more than WIC can provide for a Medicaid participant, a Medicaid Denial Letter shall be provided to the participant. See Appendix-Medicaid Denial Letter. A. Contact the State WIC Office if you have questions about Medicaid Denial Letters.

Page 3 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 Requirements of Exempt Infant Formula Chart

FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL EXEMPT INFANT FORMULAS and WIC NUTRITIONALS (Examples) Nutramigen/Nutramigen with Enflora LGG Nutramigen Toddler with Enflora LGG Pregestimil Pregestimil 24 Similac Alimentum Alfamino PurAmino Gerber Extensive HA Yes – Diagnosis Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow State WIC Office and Agency Policies EXEMPT FORMULA AND WIC NUTRITIONALS (Examples)– LOCAL APPROVAL Yes – Diagnosis

Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional Foods

Yes.

Agency Personnel designated by and trained be the State WIC Office to approve special formulas.

Elecare for Infants Elecare Jr Enfamil EnfaCare Enfamil Enfaport Neocate Infant/Neocate SYNEO Infant

PediaSure PediaSure with Fiber PediaSure Enteral PediaSure Peptide 1.0 Peptamen Junior Similac NeoSure

EXEMPT INFANT FORMULAS AND WIC NUTRITIONALS – STATE APPROVAL Any formulas not found in the above tables or formula used outside the intended use. Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Yes.

Complete the WIC STATE AGENCY FORMULA/WIC NUTRITIONALS APPROVAL FORM (see 600 Appendix) for State WIC Office approval. FOOD PACKAGE III For infants, formulas may include: Exempt Infant Formula Exempt Infant Formulas and WIC Nutritionals (Local Approval) Exempt Infant Formulas and WIC Nutritionals (State Agency Approval)

Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow the approval process for each specific type of formula.

Page1 Handling of Returned Formula and Formula Benefit Replacement Policy 603 December 2024 Policy 603 Handling of Returned Formula and Formula Benefit Replacement

POLICY Local WIC Agencies shall track all formula that has been returned to the WIC Program and reissue the appropriate food package.

PURPOSE To ensure program accountability, participant safety, and consistency in handling returned formula, including inventory and destruction of returned formula and accurate re-issuance.

RELEVANT REGULATIONS 7 CFR 246.16(a) – Infant Formula Cost Containment 7 CFR 246.10(c)(1)(2) – Food Packages

PROCEDURES When a Formula May be Returned A. A parent/caretaker may have redeemed all, or part of an infant’s food benefits for one month, and the physician changes the infant to a different formula. B. A food package change could also occur for an infant, child, or woman receiving exempt infant formula or WIC Nutritionals on a Food Package III.

Handling Returned Formula A. The unused formula must be returned to the local WIC agency. 1. The unused formula cannot be returned to a vendor to exchange for another formula. 2. Opened cans of formula may not be returned. a. Local WIC agency staff must verify that the formula is unopened before the re- issuance of eWIC benefits. 3. If a formula change is made for a formula product the participant has not previously tried, encourage the participant to redeem benefits for only one can or the smallest unit of sale to determine if the formula product is well tolerated. B. Accountability of the returned formula must be maintained at the Local WIC Agency. C. Returned formula is not safe for human or animal consumption and must be destroyed. 1. Returned formula must be properly disposed of and cannot be distributed or reissued in any way, including another WIC participant, emergency food bank/pantry, used as animal food, charitable organization, or another WIC agency. D. Inventory for returned and destroyed formula must be maintained. E. Consult Environmental Health Staff regarding proper disposal or returned formula. F. See Policy 804 Food Benefit Replacement Policy.

Formula Benefit Replacement A. If the parent/caretaker or participant returns only unused formula to the local WIC agency. 1. Document in the participants’ medical record the return of the original formula and the reason for issuance of replacement food benefits. 2. Issuance of formula must follow the WIC Policies for Prescribing Food Packages. a. See Policy 601-Issuance of Standard Infant Formula, Policy 602-Issuance of Exempt Infant Formula, Policy 606 WIC Nutritionals Issuance. 3. All unopened cans of formula that need to be replaced must be returned and entered into the CDP Portal System prior to changing the food package. 4. Choose the appropriate food package code for the replacement formula.

Page2 Handling of Returned Formula and Formula Benefit Replacement Policy 603 December 2024 5. The system will automatically calculate the appropriate quantity of formula to be issued and adjust the benefits on the EBT account. a. Contact the State WIC Office at 502-564-3827 with any questions about the amount of formula issued. B. If the parent/caretaker or participant returned unused formula and has unused food benefits remaining on their card for the month. 1. Document in the medical record the return of the original formula, the amount of the unused food benefits, and the reason for replacement. 2. Issuance of formula must follow the WIC Policies for Prescribing Food Packages. a. See Policy 601-Issuance of Standard Infant Formula, Policy 602-Issuance of Exempt Infant Formula, Policy 606 WIC Nutritionals Issuance. 3. Choose the appropriate food package code for the replacement formula. 4. The system will automatically calculate the appropriate quantity of formula to be issued and adjust the benefits on the EBT account. a. Contact the State WIC Office at 502-564-3827 with any questions about the amount of formula issued.

Page 1 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 Policy 604 Assigning Standard Food Packages for Women and Children

POLICY A Certifying Health Professional will select, tailor and assign participants food package in accordance with the federal regulations and state policies.

PURPOSE To ensure all participants receive food benefits appropriate for their status, health and nutritional needs.

RELEVANT REGULATIONS 7 CFR 246.10 – Participant Benefits – Supplemental Foods

PROCEDURES Prescribing Standard Food Packages A. The food package must be appropriate for the participant's category/status and age and cannot exceed the maximum allowed for that category/status and age. The maximum package must be provided for all participants. If a tailored food package is provided, the reason must be documented in the participant’s medical record. B. The Certifying Health Professional is responsible for selecting the appropriate food package in accordance with the policies in the appropriate section of this manual. 1. This includes the following situation: a. New participants enrolled in the program b. Change in the food package per client or medical personnel request c. Change in status d. Receipt of Verification of Transfer (VOC)-out of state C. Food package selection and food package changes must be done by the health professional based on the person’s nutrition needs, risk, access to refrigeration, cooking and storage facilities and sanitary water supply. Foods shall be issued on appropriate form and quantities to meet the person's individualized needs. D. Participants shall be encouraged to purchase all the items on their assigned food package. E. Food packages are assigned based on their status. F. If a woman or child needs a specialized food package or WIC Nutritional, see Issuance of WIC Infant Food Packages and WIC Nutritionals policy and Issuance of Supplemental Foods Requiring Medical Documentation policy.

Standard Woman and Child Food Package Descriptions Below are the food packages that may be assigned to women and children needing a standard food package. A. Fully Breastfeeding Woman/Pregnant with Multiple Fetuses/Partially Breastfeeding Multiple Infants, Pregnant Woman Fully or Partially Breastfeeding. The maximum amount of food provided includes: 1. Milk- 24 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Issuance of Supplemental Foods Requiring Medical Documentation Policy. d. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of

Page 2 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 Supplemental Foods for Women and Children Requiring Medical Documentation Policy section. e. Soy milk may be substituted for milk on a quart-for-quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy section. 2. Cheese-1 pound 3. Juice-144 ounces 4. Cereal-36 ounces 5. Eggs-2 dozen 6. Whole Wheat/whole grain bread or other whole grain-1 pound 7. Fish-30 ounces 8. Fruits/vegetables-$49.00 9. Legumes/beans-1 pound dry or 64 ounces canned beans, and 10. Peanut butter- 18 ounces B. Fully Breastfeeding Multiple Infants. The maximum amount of food provided includes: 1. Milk- 36 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Cheese-1 pound and 8 ounces 3. Juice-216 ounces 4. Cereal-54 ounces 5. Eggs-3 dozen 6. Whole Wheat/whole grain bread or other whole grain-24 ounces (system will issue 32 oz./16 oz. every other month as products are only authorized in 16 oz. size containers) 7. Fish-45 ounces 8. Fruits/vegetables-$73.50 9. Legumes/beans-1 pound dry or 64 ounces canned beans, and 10. Peanut butter- 36 ounces C. Pregnant Woman/Partially Breastfeeding Woman (infant receives partial breastfeeding package, woman receives food package up to one year postpartum if infant continues on partially breastfeeding formula package). The maximum amount of food provided includes: 1. Milk- 22 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation.

Page 3 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-144 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Whole Wheat/whole grain bread or other whole grain-1 pound 6. Fruits/vegetables-$44.00 7. Legumes/beans-1 pound dry or 64 ounces canned beans, and 8. Peanut butter- 18 ounces D. Postpartum/Partially Breastfeeding Woman (infant receiving full formula package, woman receives a food package until baby is 6 months old). The maximum amount of food provided includes: 1. Milk-16 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-96 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Fruits/vegetables-$44.00 6. Legumes/beans-1 pound dry or 64 ounces canned beans. E. If the partially breastfeeding woman is providing breastmilk to her 6-month-old infant (infant receiving a fully formula package) at least one time per day, she continues on the program as a breastfeeding woman but does not receive a food package. The infant continues on the program and receives a fully formula-fed food package. F. Child Food Package. The maximum amount of food provided includes: 1. Milk-16 quarts a. Child age two and older i. Low-fat (1%) or less is the standard issuance. ii. Whole milk is not authorized for this package. iii. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Issuance of Supplemental Foods Requiring Medical Documentation Policy. iv. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. v. Soy milk may be substituted for milk on a quart-for-quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. b. Child age 12 through 23 months i. Whole milk is the standard issuance.

Page 4 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 ii. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. iii. Low-fat (1%) or less milk may only be issued per medical documentation. iv. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. v. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-128 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Whole wheat/whole grain bread or other whole grains- 2 pounds 6. Fruits/vegetables-$25.00 7. Legumes/beans-1 pound dry or 64 ounces canned beans or peanut butter-18 ounces (peanut butter will not be provided on the age 12 through 23 months package due to choking hazards)

Page 1 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 Policy 605 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation POLICY The certifying health professional shall issue approved supplemental foods to women, infants and children with medical documentation from a prescriptive authority and in accordance with the Policies for Prescribing Food Packages.

PURPOSE To comply with federal requirements for medical documentation for issuance of Supplemental foods and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation

DEFINITION Food Package III - a food package that is issued to a woman or child that contains an infant formula, exempt infant formula, or WIC Nutritional.

PROCEDURES Medical Documentation Requirements A. Participants receiving Food Package III must have a Certificate of Medical Necessity or prescription (medical documentation form or valid prescription) which contains the following: 1. Diagnosis; 2. Name of Formula/WIC Nutritional/Supplemental Food requested; 3. Prescribed period of time the formula/WIC nutritional/supplemental food will be needed. (WIC issuance shall not exceed six months) 4. Other foods requested; 5. Special instructions; and 6. Signature of MD, DO, PA, or APRN.

Medical Documentation for Issuance of Milk and Milk Substitutions A. Requests for whole milk/whole milk yogurt for women and children ≥ 2 years of age 1. Women and children ≥ 2 years of age issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical condition may receive whole milk and/or whole milk yogurt with medical documentation (WIC-300 or WIC-400). See 600 Appendix Medical Necessity Form. 2. Women and children issued a standard food package may not receive whole milk or whole milk yogurt, even with medical documentation requesting whole milk and/or whole milk yogurt. If cheese is an appropriate food for the participant, the participant may be offered a food package with cheese substituted for a portion of the milk. 3. Document the reason for issuing whole milk and/or whole milk yogurt. B. Request for reduced fat milk (2%) milk for women and children ≥ 2 years of age 1. Women and children ≥ 2 years of age issued a Food Package III (infant formula, exempt infant formula or WIC Nutritional) for special dietary/medical condition, may receive reduced fat (2%) milk with medical documentation (WIC-300 or WIC-400). 2. Reduced fat (2%) milk may be issued under the following conditions: a. Medical documentation WIC-300 or WIC-400; or

Page 2 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for need for reduced fat (2%) milk): i. Underweight; ii. Maternal weight loss during pregnancy; iii. Weight loss; c. Document reason for issuance of reduced fat (2%) milk. C. Requests for reduced fat milk (2%) milk for children 12 to 23 months of age. 1. Whole milk is the standard milk for issuance to 1-year-old children. 2. Reduced fat (2%) milk may be issued under the following conditions: a. Medical documentation WIC-300; or b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for need for reduced fat (2%) milk): i. High Weight for Length ii. At risk for overweight 3. For children issued a Food Package III for infant formula, exempt infant formula or WIC Nutritional, reduced fat milks may be issued to a 1-year-old only when determined appropriate by the health care provider per medical documentation. 4. Nutrition counseling must be provided on the importance of fat for development and growth for toddlers and how to incorporate healthy oils in the diet as appropriate. a. The American Academy of Pediatrics (AAP) recommends approximately 30% of calories from the diet of toddlers come from fat. Due to the rapid growth and development requiring increased calories for children under 2 years of age, the AAP generally does not recommend the use of low-fat and nonfat milk for this age group. b. Whole milk is the primary source of saturated fat in young children’s diets. Healthy fats used in moderation can provide needed fat and calories for children who are consuming reduced-fat milks. 5. Reasons for issuance of reduced fat milk must be documented in the medical record. D. Requests for low-fat (1%) or less (1/2% or skim/nonfat) milk and/or low-fat/nonfat yogurt for children 12 to 23 months of age. 1. Low-fat or less milk may only be issued to 1-year-old children on the standard child food package or food package III only, per medical documentation. 2. Low-fat/nonfat yogurt may be issued to 1-year-old children under the following conditions: a. Medical documentation on WIC-300; or b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for the need for low-fat/nonfat yogurt). i. High Weight or Length ii. At risk for Overweight 3. Reasons for issuance of low-fat or less milk and/or low-fat/nonfat yogurt must be documented in the participant’s medical record. E. Requests for Cheese 1. Cheese may be issued upon participant request or when lactose intolerance is suspected or diagnosed. The medical documentation form is not required for the issuance of cheese. 2. Cheese may be substituted for milk at the rate of 1 pound of cheese per three quarts of milk.

Page 3 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 a. For children, pregnant, partially breastfeeding, and postpartum women, no more than 1 pound of cheese may be substituted for milk, and no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. b. For fully breastfeeding women, no more than 2 pounds of cheese may be substituted for milk, and no more than 6 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. F. Requests for Lactose-Free Milk 1. May be issued when lactose intolerance is suspected or diagnosed. Lactose intolerance may be self-reported by the participant/parent/caretaker and does not require a medical documentation form. 2. The reason for issuance must be documented in the participant’s medical record. 3. Lactose-free and lactose-reduced milk is packaged in half-gallon containers. 4. Whole lactose-free milk is required for children age 1 to 2. For children age two and older and women, low-fat lactose-free milk is required. G. Requests for Soy Milk and Tofu 1. The medical documentation form is not required for the issuance of soy milk or tofu; however, the Certifying Health Professional must assess the need for soy milk or tofu prior to issuance and provide counseling on the importance of milk in the diet. Certifying Health Professionals may consult with the health care provider as needed to assist with assessment. 2. Provide counseling on the value of milk in the diet. The following are counseling topics: a. Children’s diets may be nutritionally inadequate when milk is replaced with other foods. Milk is particularly important in the development of bone mass for children. b. Milk provides important nutrients for health, growth, and development. Milk contains protein for muscles, calcium, and Vitamin D for strong teeth and bones. c. Milk is a source of Vitamin A. Vitamin A is important for vision, strong immune system, and cancer prevention. d. If milk is replaced with milk alternatives that are not Vitamin D fortified, Vitamin D intake may be inadequate. 3. Soy milk and tofu may be issued up to the maximum allowance for milk when the following conditions apply: a. Lactose intolerance is suspected or diagnosed that cannot be managed with lactose-free or lactose-reduced fortified dairy products. b. Milk protein allergy c. Vegan diet d. Religious/Cultural presence. 4. Soy milk may be substituted for milk on a quart-by-quart basis up to the maximum allowance of milk. 5. Tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk. 6. A combination of cheese, yogurt, and tofu can be substituted for milk. a. For children, pregnant, partially breastfeeding, and postpartum women, no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. b. For fully breastfeeding women, no more than 2 pounds of cheese may be substituted for milk, and no more than 6 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. c. The reason for issuance must be documented in the participant’s medical record. H. Requests for Yogurt 1. Yogurt may be issued upon participant request. The medical documentation form is not required for issuance of yogurt unless one of the conditions below applies.

Page 4 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 a. Women and children ≥ 2 years of age issued a Food Package III for special dietary/medical condition may receive whole milk yogurt with medical documentation. b. Low-fat/nonfat yogurt may be issued to 1-year-old children under the following conditions: i. Medical documentation on WIC-300; or ii. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with the participant’s health care provider as needed to assist with assessment for the need for low-fat/nonfat yogurt). a) High Weight for Length b) At Risk for Overweight 2. Yogurt may be substituted for milk at the rate of 32 oz. per 1 quart of milk. a. No more than 32 oz. may be substituted for milk, and no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. I. Requests for Other Milk 1. No other milk substitutions are authorized for issuance, including evaporated, condensed, almond, rice, or goat milk.

Women and Children with Special Dietary Needs A. Requests for pureed fruits and vegetables for women and children 1. Women and children issued a standard food package may not receive jarred infant fruits and vegetables. 2. Women and children issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical conditions may receive commercial jarred infant food fruits and vegetables in lieu of fresh/frozen fruits and vegetables with medical documentation. a. Children may receive 128 oz. of commercial jarred infant fruits and vegetables. b. Women may receive 160 oz. of commercial jarred infant fruits and vegetables. 3. Reasons for issuance must be documented in the medical record. B. Requests for infant and cereals for women and children 1. Women and children issued a standard food package may not receive infant cereal in lieu of “adult” breakfast cereal. 2. Women and children issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical conditions may receive 32 dry oz. infant cereal in lieu of 36 oz. of “adult” breakfast cereal with medical documentation. C. Requests for Kosher Foods 1. Participants requesting Kosher Food packages may be issued a Kosher Food Package for their status and age that allows the least expensive brand of Kosher Milk. The following are appropriate food packages. a. Pregnant or Partially Breastfeeding with Kosher designated milk and cheese-P2K b. Postpartum or Partially Breastfeeding with Kosher designated milk and cheese- PPK c. Fully Breastfeeding, Pregnant with Multiples, Partially Breastfeeding Multiples, or Pregnant Partially Breastfeeding with Kosher designated milk and cheese-FBFK d. Child Package with Kosher designated milk and cheese-CBK e. Some products on the WIC Food List that have variations of the Kosher label include: i. Cereal-General Mills selections, Post selections, Quaker selections, Malt-O-Meal-Crispy rice, B and G food selections, Kellogg’s selections ii. Milk-Meijer, Lactaid, Kroger, Trauth, Fresh and Healthy 1%

Page 5 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 iii. Cheese-Hoalam Cheddar Cheese and Hoalam Mozzarella & Cheddar Cheese iv. Tofu-NaSoya v. Brown Rice-Uncle Ben’s Fast and Natural Whole Grain Instant Brown Rice, Mahatma, Minute Instant Brown Rice, Success Boil in Bag Brown Rice D. Requests for Gluten enteropathy, celiac disease, or celiac spruce gluten-free food packages. 1. The participant should be referred for Medical Nutrition Therapy. 2. Guidance from the primary care provider shall include instructions to avoid wheat products. 3. Appropriate infant cereals would include rice cereal and shall be discussed during counseling. 4. Other ingredients the participant may need to avoid include: barley, bran, bulgur, couscous, dairy substitutes, dextrin, dingle, durum, einkorn, emmer, farina, faro, fu, gliadin, gluten, gluten peptides, glutenin, graham four, hydrolyzed protein, kamut, kumut, malt, malt flavoring, malt vinegar, matza, matzo, matzah, mir, modified food starch, orzo, panko, rye, seasoning, seitan, semolina, soy sauce, spelt, triticale, udon, wheat, wheat berry, wheat germ, wheat grass, wheat gluten, wheat nut, and wheat starch. E. Requests for Decreased Fat and Calorie Food Packages 1. Food Package issuance based on instructions of medical documentation form. 2. Provide appropriate food package for age and category/status. 3. Counseling the caregiver/parent/participant on purchasing low-fat or skim milk and reduced-fat or fat-free cheese. 4. Encourage the participant to purchase beans instead of peanut butter. F. Homeless packages 1. Certifying Health Professionals shall assess whether the issuance of the homeless package best meets the needs of the participant. 2. Participants needing formula shall be provided ready-to-feed formula if needed. A medical documentation form will be needed for noncontract, exempt infant formula, and WIC Nutritionals. See Policy 601-Issuance of Standard Infant Food Packages, Policy 602-Issuance of Exempt Infant Formula, and Policy 606-Issuance of WIC Nutritionals to Women and Children. a. The 32 oz. size may be issued in situations where the individual has access to refrigeration and dishwashing facilities. b. If the participant does not have access to refrigeration and dishwashing facilities, the formula product shall be issued in individual ready-to-feed servings. 3. Participants needing regular foods shall receive the appropriate food package based upon age and status. 4. These participants shall be provided the Kentucky WIC Approved Food List Displaced Participant Insert and counseled concerning the differences in the food packages. a. Baked beans instead of dry beans or canned beans b. 100% single strength juice c. 18 oz. peanut butter will replace 1 dozen eggs d. 9.6 oz. containers of dry milk will replace fluid milk and e. For participants issued soy milk, quart size shelf stable soy milk-Pacific Ultra Soy Original. G. Unsanitary Water Supply 1. For families who do not have access to safe water: a. Frozen juice shall not be an option for the family.

Page 1 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 Policy 606 Issuance of WIC Nutritionals to Women and Children

POLICY The certifying health professional shall issue approved WIC nutritionals in accordance with the Policies for Prescribing Food Packages, Food Package Tables, and Requirements for Issuing Infant Formulas, Exempt Infant Formula, and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC nutritionals and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation

DEFINITIONS WIC Nutritionals – enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible Nutritionals must serve the purpose of a food, meal, or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food, drug, flavoring, or enzyme. WIC-eligible Nutritionals include many, but not all, products that meet the definition of medical food in Section 5(b)(3) of the Orphan Drug Act (21 USC 360ee(b)(3)).

PROCEDURES Requests for WIC Nutritionals A. WIC Nutritionals can be provided when the health professional has a medical documentation form or valid prescription. B. Issuance of these formulas requires a medical documentation form, and prior approval by the designed local WIC agency personnel who have been trained by the State WIC Office or State WIC Office identified training. C. The formula must be designed for internal digestion.

Medical Documentation Requirements WIC Nutritionals A. WIC Nutritionals 1. Medical documentation for issuance of WIC Nutritionals a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See 600 Appendix Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PAs), and Advanced Practice Registered Nurse (APRNs) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation, or not authorized by the Program. d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain:

Page 2 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document the date of the telephone call and the signature of the person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed six months. g. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Issuance of Food Package III may not be issued for the following reasons: a. For women and children who have a food intolerance to milk protein or lactose, that can be successfully management with the use of a standard food package. B. The chart at the bottom of this section provides guidance on what documentation is necessary for product issuance.

State Agency Approval A. If State Agency approval is needed to issue a WIC Nutritional, after receiving verbal approval from a State WIC Office Dietitian, complete the WIC State Agency Formula/WIC Nutritional Approval Form and fax or mail to the State WIC Office. See 600 Appendix-State Agency Approval Form.

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Medicaid Denial Letters for Formula/WIC Nutritional A. When a physician prescribes a WIC Nutritional that WIC does not authorize or if the physician prescribes more than WIC can provide for a Medicaid participant, a Medicaid Denial Letter shall be provided to the participant. See 600 Appendix-Sample Medicaid Denial Letters. B. Contact the State WIC Office if you have questions about Medicaid Denial Letters.

Page 3 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 Requirements of Issuing WIC Nutritionals Chart FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL EXEMPT INFANT FORMULAS and WIC NUTRITIONALS (Examples) Nutramigen/Nutramigen with Enflora LGG Nutramigen Toddler with Enflora LGG Portagen (for women and children only) Pregestimil Pregestimil 24 Similac Alimentum Alfamino PurAmino Gerber Extensive HA Yes – Diagnosis Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow State WIC Office and Agency Policies EXEMPT FORMULA AND WIC NUTRITIONALS – LOCAL APPROVAL (Examples) Yes – Diagnosis

Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional Foods

Yes.

Agency Personnel designated by and trained be the State WIC Office to approve special formulas.

Boost Boost Glucose Control Boost High Protein Boost Kid Essentials Boost Plus Bright Beginnings Soy Pediatric Drink Elecare for Infants Elecare Jr Enfamil EnfaCare Enfamil Enfaport Ensure Ensure Plus

Neocate Infant/Neocate SYNEO Infant Neocate Junior Osmolite 1 Cal PediaSure PediaSure with Fiber Peptamen Peptamen Junior Peptamen Junior 1.5 Similac NeoSure Tolerex Vital HN Vivonex Pediatric Vivonex Plus Vivonex T.E.N.

EXEMPT INFANT FORMULAS AND WIC NUTRITIONALS – STATE APPROVAL Any formulas not found in the above tables or formula used outside the intended use. Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Yes.

Complete the WIC STATE AGENCY FORMULA/WIC NUTRITIONALS APPROVAL FORM (see 600 appendix) for State WIC Office approval. FOOD PACKAGE III For women/children when a formula &/or other foods are needed. Formulas may include the following: Infant Formula - Contract Infant Formula - Noncontract Exempt Infant Formula Exempt Infant Formulas and WIC Nutritionals (Local Approval) Exempt Infant Formulas and Medical food Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow the approval process for each specific type of formula.

Section 600 Appendices Food Package Assignment

Page 1 Section 600 Food Package Assignment Appendices December 2024

INDEX Certificate for Medical Necessity for Formula and WIC Food Exceptions... 3 Formula/WIC Nutritional Approval Form ....................................................10 Medicaid Denial Letters .............................................................................12 Multiple Product Medical Necessity For Exempt Formula………………......14

Page 2 Section 600 Food Package Assignment Appendices December 2024

Medical Necessity for Formula and WIC Food Exceptions Forms

The following pages provide the Medical Documentation for Exception for WIC Program Foods form for the woman, infant, or child and are to be used to receive information regarding the specific food package the doctor or nurse practitioner is requesting due to exceptions from the standard WIC food package.

The WIC - 200 is to be used for the infant, WIC - 300 for the child, and the WIC - 400 for the woman.

The Kentucky WIC contract is with Abbott Laboratories for Similac Products. The primary Milk based formula will be Similac Advance and the Soy formula will be Similac Isomil.

Page 3 Section 600 Food Package Assignment Appendices December 2024

Kentucky WIC Program Infant (< 1 year old) Certificate for Medical Necessity for Formula and WIC Food Exceptions The WIC Program provides Similac Infant Formulas to all non-medically fragile infants. Noncontract standard formula request: Complete sections A, B and D (C if needed) Exception to WIC foods requests: Complete Sections A, C and D. Exempt formula or WIC Nutritionals: Complete sections A, B, C and D. WIC Clinic: Clinic Fax number: Attention: Kentucky Guidelines for issuance of infant formula: Client must try: Requests for milk based formula Similac Advance, Similac Total Comfort, Similac Sensitive Requests for soy based formula Similac Soy Isomil and Similac Sensitive or Similac Total Comfort (if no milk allergies) Requests for lactose free/reduced formula Similac Sensitive and Similac Total Comforts or Similac Soy Isomil

A. Patient Information Patient’s name: DOB: mm/dd/yyyy Parent/Caregiver’s Name: Medical diagnosis/qualifying condition (ICD-9/10 code): (Justifies the medical need for formula/food ) Medical documentation valid for: ☐ 1 mo. ☐ 2 mos. ☐ 3 mos. ☐ 4 mos. ☐ 5 mos. ☐ 6 mos. ☐ 7 mos. ☐ 8 mos. ☐ 9 mos. ☐ 10 mos. ☐ 11 mos. ☐ 12 mos. B. Medical Formula/Food Name of formula or WIC Nutritionals requested: Prescribed amount: per day OR ☐ maximum allowable Special instruction/comments: Provide information regarding Formulas tried & length of time tried: Problems encountered: C. WIC Supplemental Foods for Infants < 1 year old Supplemental foods:. Supplemental foods will be provided in addition to the formula at six months of age, if no boxes are checked below. Please mark the appropriate boxes below to indicate any foods that would be contraindicated and/or require special instructions WIC Supplemental Foods(provided at 6 months of age) Restrictions/Special Instructions ☐Infant cereal ☐Infant fruits ☐Infant vegetables ☐Infant meats (fully breastfeeding infants only) ☐No supplemental foods: omit all supplemental foods and provide exempt infant or medical formula/food only. D. Health care provider information Signature of health care provider: Provider’s name: ☐ MD ☐ DO ☐ PA ☐ NP Medical office/clinic: Phone number: Fax number: Date: mm/dd/yyyy Adapted from Oregon Medical Documentation Form. This institution is an equal opportunity provider.

WIC – 200 See back for most commonly provided exempt infant formulas/WIC Nutritionals. Rev. 10/23

Page 4 Section 600 Food Package Assignment Appendices December 2024

This certification for medical necessity is necessary for providing the following products from the WIC Program for medically fragile infants. The most commonly used products are listed below: Hypoallergenic formulas: • Nutramigen • Pregestimil • Similac Alimentum • Gerber Extensive HA

Impaired kidney function/hypocalcemia • Similac PM 60/40

Premature formulas • Enfamil EnfaCare • Enfamil Premature with Iron 20 • Enfamil Premature with Iron 24 • Enfamil Premature with Iron 30 • Similac NeoSure • Similac Special Care 24 with Iron • Similac Special Care 30 with Iron

Reflux formulas • Enfamil AR

Severe cow’s milk allergy/multiple food protein allergy • Neocate Infant/Neocate SYNEO Infant • Neocate Infant DHA & ARA • Elecare for Infants • PurAmino • Alfamino

For additional products available from WIC please view the website at: http://chfs.ky.gov/dph/ach/ns/Nutrition+Education+Materials.htm

Use the above link and click on “WIC Formula Resource Guide” from the list of materials. WIC is a registered service mark of the U. S. Department of Agriculture for USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children.

Page 5 Section 600 Food Package Assignment Appendices December 2024

Children Age 1 to 5 Certificate for Medical Necessity for Formula and WIC Food Exceptions

Exception to WIC foods requests: Complete Sections A, C and D Exempt formula or WIC Nutritionals: Complete A, B, C and D

This form should be used to provide guidance in regard to failure to thrive, lactose intolerance, gluten free diets, foods to avoid due to allergies, developmental delays or inability to tolerate solid foods, medical conditions that impair ingestion, digestion or absorption of nutrients, etc. These foods may not be issued solely for the purpose of enhancing nutrient intake or managing body weight. A. Patient Information Patient’s name (Last, First, MI): DOB: mm/dd/yyyy Parent/Caregiver’s Name (Last, First, MI): Medical diagnosis/qualifying condition (ICD-9/10 Code): (Justifies the medical need for formula/food ) Medical documentation valid for: ☐ 1 mo. ☐ 2 mos. ☐ 3 mos. ☐ 4 mos. ☐ 5 mos. ☐ 6 mos. (not to exceed 6 months) B. Medical formula/medical food and WIC supplemental foods Name of medical formula/medical food requested: Prescribed amount: per day OR ☐ maximum allowable Special instruction/comments: C. Supplemental Foods Supplemental foods will be provided in addition to the formula, if no boxes are checked below. ☐ Omit all supplemental foods and provide formula only. ☐ Provide only the following checked foods. ☐ Whole Milk ☐ Reduced Fat (2%) Milk Special Instructions: ☐ Low-fat (1%) Milk ☐ Nonfat Milk (Skim) ☐ Soy Milk ☐ Cheese ☐ Tofu ☐ Yogurt ☐ Whole OR ☐ Low-fat/Nonfat ☐ Cereal ☐ Eggs ☐ Juice ☐ Peanut butter ☐ Fresh/frozen fruits and vegetables ☐ Whole grain bread/tortillas or brown rice ☐ Infant jarred fruits and vegetables ☐Beans ☐Infant Cereal D. Health care provider information Signature of health care provider: Provider’s name: ☐ MD ☐ DO ☐ PA ☐ NP Medical office/clinic: Phone number: Fax number: Date: mm/dd/yyyy Adapted from Oregon Medical Documentation Form. This institution is an equal opportunity provider. WIC – 300 Whole milk is the standard issuance for children 12-23 months of age. (For children, 12-23 months requesting yogurt, whole milk yogurt will be standard issuance.) Low-fat (1%) milk/nonfat is the standard issuance for children 2-5 years of age. (For children 2-5 years old, low-fat/non-fat yogurt will be standard issuance.) For the 2-5 year old, whole milk or whole milk yogurt may only be authorized if a child requires a formula/WIC Nutritional. Infant jarred fruits and vegetables and infant cereal may only be authorized if a child requires a formula/WIC Nutritional. See back for most commonly provided formulas and WIC Nutritionals. Rev. 10/23 Page 6 Section 600 Food Package Assignment Appendices December 2024 WIC Clinic: Clinic Fax number: Attention:

This certification for medical necessity is necessary for providing the following products from the WIC Program. The most commonly used products are listed below:

Hypoallergenic formulas: • Nutramigen • Nutramigen Toddler • Portagen • Pregestimil • Similac Alimentum • Gerber Extensive HA

Impaired kidney function/hypocalcemia • Similac PM 60/40

Pediatric Drinks for higher calories/FTT • Boost Kid Essentials Immunity Protection • Boost Kid Essentials 1.5 CAL • Boost Kid Essentials 1.5 CAL with Fiber • Boost Plus • Bright Beginnings Soy Pediatric Drink • Nutren Junior • Nutren Junior with Fiber • Nutren Junior with Prebiotics • PediaSure • PediaSure with Fiber • PediaSure 1.5 Cal • PediaSure 1.5 Cal with Fiber • PediaSure Peptide 1.0 Cal • Peptamen Junior • Peptamen Junior with Fiber • Peptamen Junior with Prebio • Peptamen Junior 1.5 • Vivonex Pediatric

Severe cow’s milk allergy/multiple food protein allergy • Neocate Infant/Neocate SYNEO Infant • Neocate Junior • Neocate Junior with Prebiotics • Elecare for Infants • Elecare Jr. • Alfamino Jr. • PurAmino

For additional products available from WIC please view the website at: http://chfs.ky.gov/dph/ach/ns/Nutrition+Education+Materials.htm

Use the above link and click on “WIC Formula Resource Guide” from the list of materials. WIC is a registered service mark of the U. S. Department of Agriculture for USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children.

Page 7 Section 600 Food Package Assignment Appendices December 2024

Pregnant, Breastfeeding and Postpartum Women Certificate for Medical Necessity for Formula and WIC Food Exceptions

Exception to WIC foods requests: Complete Sections A, C and D Exempt formula or WIC Nutritionals: Complete A, B, C and D This form should be used to provide guidance in regard to failure to thrive, lactose intolerance, gluten free diets, foods to avoid due to allergies, developmental delays or inability to tolerate solid foods, medical conditions that impair ingestion, digestion, or absorption of nutrients, etc. These foods may not be issued solely for the purpose of enhancing nutrient intake or managing body weight.

A. Patient Information Patient’s name (Last, First, MI): DOB: mm/dd/yyyy Medical diagnosis/qualifying condition (ICD-9/10 Code): (Justifies the medical need for formula/food ) Medical documentation valid for: ☐ 1 mo. ☐ 2 mos. ☐ 3 mos. ☐ 4 mos. ☐ 5 mos. ☐ 6 mos.(not to exceed 6 months) B. Medical formula/medical food Name of medical formula/medical food requested: Prescribed amount: per day OR ☐ maximum allowable Special instruction/comments: C. Supplemental foods Supplemental foods appropriate will be provided in addition to the formula if no boxes are checked below. ☐ Omit all supplemental foods and provide formula only. ☐ Omit Formula/Medical Food. ☐ Provide only the following checked foods. ☐ Whole Milk ☐ Reduced Fat (2%) Milk Special Instructions: ☐ Low-fat (1%) Milk ☐ Nonfat Milk (Skim) ☐ Soy Milk ☐ Cheese ☐ Tofu ☐ Yogurt (☐Whole OR ☐ Low-fat/Nonfat) ☐ Cereal ☐ Eggs ☐ Juice ☐ Peanut butter ☐ Fresh/frozen fruits and vegetables ☐ Whole grain bread/tortillas or brown rice ☐ Infant jarred fruits and vegetables ☐Beans ☐Infant Cereal ☐ Canned fish (fully breastfeeding women only) D. Health care provider information Signature of health care provider: Provider’s name: ☐ MD ☐ DO ☐PA ☐ NP Medical office/clinic: Phone number: Fax number: Date: mm/dd/yyyy Adapted from Oregon Medical Documentation Form. This institution is an equal opportunity provider. WIC – 400 Low-fat (1%) milk/nonfat is the standard issuance for women. Rev: 10/23 Whole milk or whole milk yogurt may only be authorized if a woman requires a formula/WIC Nutritional. Infant jarred fruits and vegetables and infant cereal may only be authorized if a woman requires a formula/WIC Nutritional

See back for most commonly provided formulas and WIC Nutritionals.

Page 8 Section 600 Food Package Assignment Appendices December 2024 WIC Clinic: Clinic Fax number: Attention:

This certification for medical necessity is necessary for providing the following products from the WIC Program. The most commonly used products are listed below:

GI Malabsorption/chronically impaired GI function • Tolerex • Vital HN • Vivonex Plus • Vivonex T.E.N. • Neocate Splash

Glucose Control • Boost Glucose Control

Higher calories/Higher nutrients • Boost • Boost High Protein • Boost Plus • Ensure • Ensure High Protein • Ensure Plus

Impaired GI function • Peptamen

Isotonic/altered taste • Osmolite 1 Cal • Neocate Splash

Impaired kidney function/hypocalcemia • Similac PM 60/40

For additional products available from WIC please view the website at: http://chfs.ky.gov/dph/ach/ns/Nutrition+Education+Materials.htm

Use the above link and click on “WIC Formula Resource Guide” from the list of materials. WIC is a registered service mark of the U. S. Department of Agriculture for USDA’s Special Supplemental Nutrition Program for Women, Infant and Children.

Page 9 Section 600 Food Package Assignment Appendices December 2024

FORMULA/WIC NUTRITIONAL APPROVAL FORM

1. Contact the Nutrition Services Branch at 502-564-3827, option 2 for the Clinical Nutrition Section. 2. Fax or email the Formula Approval Form and WIC-200, WIC-300, or WIC-400 to the State WIC Office.

Page 10 Section 600 Food Package Assignment Appendices December 2024

WIC STATE AGENCY FORMULA/WIC NUTRITIONAL APPROVAL

Step 1: Contact Nutrition Services Branch (502)564-3827, option 2 for Clinical Nutrition Section to request State Approval.

Step 2: Local Agency to complete this section of the State Approval Form: Agency/Site Participant Name

(FIRST AND LAST NAME) (DATE OF BIRTH) Formula/Medical Food Requested Length of Time Requested Length of Time Approved Date of Medical Documentation Form MM/DD/YY

Health Professional Initiating Request:

(NAME) (TITLE) (PHONE) (DATE) Verbal approval granted MM/DD/YY in phone conversation with (DATE) (NUTRITION SERVICES BRANCH PERSONNEL) Step 3: Attach a copy of the Medical Documentation Form to the State Agency Approval form. Fax both to Nutrition Services Branch Fax (502)564-4217.

Step 4: File the original Medical Documentation form and State agency signed and completed form in the participant medical record.

A NEW REQUEST MUST BE SUBMITTED TO THE STATE AGENCY UPON EXPIRATION OF CURRENT MEDICAL DOCUMENTATION FORM.

(DO NOT COMPLETE BELOW THIS LINE)

STATE AGENCY REVIEW ONLY

IS NOT APPROVED. (REASON)

IS APPROVED.

THIS APPROVAL IS EFFECTIVE UNTIL .

(NAME) (TITLE)

(DATE)

Comments:

Revised 7/2019

Page 11 Section 600 Food Package Assignment Appendices December 2024

MEDICAID DENIAL LETTERS

1. When a physician prescribes a formula/WIC Nutritional that WIC does not authorize, or if the physician prescribes more formula/WIC Nutritional than WIC can provide for a Medicaid participant, a Medicaid Denial Letter should be provided to the participant. 2. The Medicaid denial letter should be provided in the following circumstances: a) The physician is requesting a product that is not covered by the WIC Program. b) The physician has requested more formula/medical food per month than the maximum issuance allowed by the WIC Program. c) The physician has requested two (2) products. 3. Once the letter is complete, it is to be taken by the parent to the Durable Medical Equipment (DME) provider. a). A DME is a pharmacy or medical provider that takes Medicaid and is enrolled as a DME provider with Medicaid and meets the standards for that provider type.

Page 12 Section 600 Food Package Assignment Appendices December 2024

Sample Medicaid Denial Letters

One Product Medicaid Denial Letter

Date Dear Provider:

On (date), we certified (name of participant + Medicaid number if available) for the WIC Program. For the next (specify time period), WIC (will/cannot) provide (_name of formula_) based upon the prescription received from the doctor. The doctor has requested cans of the above mentioned product for this client each month. WIC (can only/cannot ) provide cans. We are requesting that Medicaid provide the additional cans each month.

If you have any questions about this information, please contact me at . Sincerely, Name Title

Two Product Medicaid Denial Letter

Date Dear Provider:

On (date), we certified (name of participant + Medicaid number if available) for the WIC Program. For the next (specify time period), WIC will provide (name of formula) based upon the prescription received from the doctor. The doctor has requested cans of the above mentioned product for this client each month. WIC can only provide

cans. We are requesting that Medicaid provide the additional cans each month. The physician has also requested be provided for this client. WIC can only provide one product and therefore cannot provide this additional product. We are requesting that Medicaid provide it each month. If you have any questions about this information, please contact me at . Sincerely, Name Title

Page 13 Section 600 Food Package Assignment Appendices December 2024

Kentucky WIC Program For Infant Medical Formulas

Complete sections A, B, C, and D.

B. Medical Formula/Food Formula requested. Please check all products that would be appropriate: ☐ Similac Alimentum ☐ Enfamil Nutramigen ☐ Store Brand Hypoallergenic (Kroger, Meijer and Walmart) ☐ Pregestimil ☐ Gerber Extensive HA ☐ Similac PM 60/40 ☐ Neocate/Neocate Syneo ☐ Elecare Infant ☐ PurAmino ☐ Alfamino ☐ Enfamil Premature ☐ Enfamil Premature 24 ☐ Enfamil Premature 30 ☐Similac Special Care 24 ☐ Similac Special Care 30 ☐ Similac NeoSure ☐ Enfamil EnfaCare ☐ Similac Human Milk Fortifier ☐ Enfamil Human Milk Fortifier Other Please List: Prescribed amount: per day OR ☐ maximum allowable Special instruction/comments:

Provide information regarding Formulas tried & length of time tried: Problems encountered:

C. WIC Supplemental Foods for Infants < 1 year old Supplemental foods: Please mark the appropriate boxes below to indicate any foods that would be contraindicated and/or require special instructions. If no boxes are marked, the infant will receive the WIC foods. WIC Supplemental Foods (provided at 6 months of age) Restrictions/Special Instructions ☐ Infant cereal

☐ Infant fruits ☐ Infant vegetables ☐ Infant meats (fully breastfeeding infants only) ☐ No supplemental foods: omit all supplemental foods and provide exempt infant or medical formula/food only. D. Health care provider information Signature of health care provider: Provider’s name: ☐ MD ☐ DO ☐ PA ☐ NP

Medical office/clinic: Phone number: Fax number: Date: mm/dd/yyyy Adapted from Oregon Medical Documentation Form. This institution is an equal opportunity provider.

WIC – 200

Rev. 6/22 Page 14 Section 600 Food Package Assignment Appendices December 2024 A. Patient Information Patient’s name:

DOB: mm/dd/yyyy Parent/Caregiver’s Name:

Medical diagnosis/qualifying condition (ICD-9/10 code):

(Justifies the medical need for formula) Medical documentation valid for: ☐ 1 mo. ☐ 2 mos. ☐ 3 mos. ☐ 4 mos. ☐ 5 mos. ☐ 6 mos. ☐ 7 mos. ☐ 8 mos. ☐ 9 mos. ☐ 10 mos. ☐ 11 mos. ☐ 12 mos.