Division of Community Nutrition
Subject: Formula /Medical Foods For Medicaid Participants Policy: FDS 03.2.3 Reference: N/A Effective: August 12, 2013 Supersedes: August 1, 2009
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I. Policy:
Medicaid is the primary payer for all Virginia WIC approved contract and Special Exempt Formulas and Medical Foods for WIC participants receiving Medicaid. The quantity received may exceed the maximum amount allowed by WIC as prescribed by a physician in accordance with FDS 02.2.
II. Procedure(s):
a. The applicant / participant shall currently be receiving Medicaid at the time of the certification or subsequent certification visit. A current Medicaid number shall be entered in Crossroads.
b. Verify Medicaid in Crossroads and in First Health Automated Response System in accordance with FDS 03.2.4.
1) If a participant has a co-pay or third party liability (additional insurance), they shall not receive over the maximum amount of formula.
c. The Virginia Request for Special Food Package (WIC-395) shall be completed in accordance with FDS 03.2.
d. The following medical reasons must be indicated on the WIC-395 to provide over the maximum amount of any formula:
1) Contract Formula
B. Concentrating calories C. Gastro-esophageal Reflux Disease (GERD) D. Tube Feeding (formula is sole source of nutrition)
2. Special Exempt Formula
B. Concentrating calories C. Gastro-esophageal Reflux Disease (GERD) D. Tube Feeding (formula is sole source of nutrition) E. Malabsorption F. Metabolic Disorders G. Diseases that impair ingestion, digestion or absorption of nutrients
Division of Community Nutrition
Subject: Formula /Medical Foods For Medicaid Participants Policy: FDS 03.2.3 Reference: N/A Effective: August 12, 2013 Supersedes: August 1, 2009
Page 2 of 2
e. For contract formula:
1) If the amount of formula required exceeds the maximum amount allowed by WIC, the formula may be redeemed at the local retailer.
f. For Pediasure, Alimentum and Nutramigen:
1. If the amount of formula required exceeds the maximum amount allowed by WIC, the formula cannot be redeemed at a local store. Select the “State Ordered” box in Crossroads and order a one month supply through CAP. Issue only one food prescription for each CAP order in accordance with FDS 03.2.2.