Division of Community Nutrition

Subject: Medical Documentation for Special Formula and Supplemental Foods Policy: FDS 03.2 Reference: CFR §246.10 Effective: August 12, 2013 Supersedes: September 1, 2010

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I. Policy: Special formulas (include exempt infant formulas and medical foods) and supplemental foods are only allowed when a licensed health care professional, authorized to write medical prescriptions under State law, determines that a participant has a qualifying medical condition that restricts the use of Similac Advance, Similac Sensitive, or Similac Soy Isomil.

II. Procedure

A. Participants who are eligible to receive special formula shall have one or more qualifying conditions which include but are not limited too:

1) Premature birth 2) Low birth weight 3) Failure to thrive 4) Inborn errors of metabolism 5) Metabolic disorders 6) Gastrointestinal disorders 7) Malabsorption syndromes 8) Immune system disorders 9) Severe food allergies 10) Diseases or disorders that impair ingestion, digestion, absorption or utilization of nutrients

B. Refer to FDS 03.3 for special formulas approved for use in the Virginia WIC Program.

C. A Request for Special Food Package Form, WIC-395, shall be completed for all special formulas and supplemental foods. A new WIC-395 is required each certification period or whenever the special formula supplemental food is changed to another special formula supplemental food.

1) If a ready to feed formula is requested, the Request for Ready to Feed Formula form, WIC-407, shall be electronically submitted to the SWO, and a copy filed in the participant’s record. If the formula is only available in the ready to feed form, the WIC-407 does not need to be completed.

2) Ready to feed formula shall be authorized when the CPA determines one or more of the following:

a. Unsanitary or restricted water supply.

Division of Community Nutrition

Subject: Medical Documentation for Special Formula and Supplemental Foods Policy: FDS 03.2 Reference: CFR §246.10 Effective: August 12, 2013 Supersedes: September 1, 2010

Page 2 of 4 b. Parent / legal guardian or caretaker has difficulty in correctly diluting concentrated or powdered formula.

c. If a ready to feed form better accommodates the participant’s condition.

d. If a ready to feed form improves the participant’s compliance in consuming the prescribed formula.

D. Obtain a completed WIC-395 from the health care professional.

1) The CPA shall ensure the request form is complete and shall sign the form.

All medical documentation shall include the following:

a. The name of the approved WIC formula prescribed and the amount needed per day.

b. The authorized supplemental foods appropriate for the qualifying conditions and their amounts.

c. The 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 formula and/or supplemental food.

e. Signature, date and contact information of the licensed health care professional authorized to write medical prescriptions under State Law.

f. The CPA shall determine if the special formula is approved by the Virginia WIC Program in FDS 03.3.

i. If the special formula requested is not on the list of approved formulas, the CPA shall consult the Approved Infant Formula list or contact the State Nutrition Liaison, and notify the health care professional.

ii. If the special formula is not a WIC eligible formula that is approved by USDA, the CPA shall notify the health care professional.

2) Medical documentation shall be written and may be provided as an original document, and electronic document, by facsimile or by telephone to a CPA until written confirmation is received.

Division of Community Nutrition

Subject: Medical Documentation for Special Formula and Supplemental Foods Policy: FDS 03.2 Reference: CFR §246.10 Effective: August 12, 2013 Supersedes: September 1, 2010

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E. If the health care professional submits a referral form, note or hospital discharge sheet this may be used in place of the WIC-395 providing all information and the health care professional’s signature is obtained.

1) Staple the referral form, note, or hospital discharge sheet to the WIC-395. The CPA shall sign and date. Scan into the participant’s record.

F. Contact the health care professional if all of the information on the WIC-395 is not submitted.

1) Medical documentation may be provided by telephone to a CPA until written confirmation is received from the health care professional.

2) The missing information and the health care professional’s signature shall be provided in writing within 5 business days.

G. If a written request is not available, contact the health care professional to obtain a completed WIC-395. The CPA shall sign and date. File in the participant’s record.

H. Special formula shall not be issued without a completed WIC-395.

I. The CPA shall determine the maximum allowable amount of formula the WIC Program can provide. See the FDS 02.2 for the Maximum Formula Allowed.

1) If the requested amount of formula is more than the maximum amount allowed, the CPA shall notify the health care professional.

a. Inform the health care professional that the total amount requested can not be provided and explain the maximum amount WIC can provide.

b. Document in the participant’s record.

2) More than one special formula may be provided, but the total formula amount shall not exceed the maximum formula allowed.

J. For Nutramigen, Alimentum and Pediasure:

1) Food benefits for these special formulas shall be redeemed at a local store. Uncheck the “State Ordered” check box. Crossroads will automatically adjust the number of food benefits issued.

2) If the formula cannot be obtained at the local store, follow CAP ordering procedures in accordance with FDS 03.2.3.

3) Food instruments shall not exceed the $125.00 limit.

Division of Community Nutrition

Subject: Medical Documentation for Special Formula and Supplemental Foods Policy: FDS 03.2 Reference: CFR §246.10 Effective: August 12, 2013 Supersedes: September 1, 2010

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K. Whenever a formula is changed, instruct the parent / legal guardian, caretaker or proxy to return all unused formulas to the local agency. Formula shall not be returned to retail stores.

1) Follow the procedure for replacing formula or partial month’s food instruments in Crossroads.

2) The CPA shall change the food package.

3) Returned formula shall be provided to other participants in need of that specific formula.

4) Obtain a completed WIC-395 if a new special formula, medical food or supplemental food is requested or changed to a contract formula.