FD: 11 Issuance of Special Medical Nutrition Products (New)
|Effective Date: 10/09||Downloads: PDF Version||Revised Date: 07/15|
For a participant to be issued ANY special WIC eligible nutritionals a completed WIC Program medical documentation form (prescription) must be obtained from a health care professional licensed to write medical prescriptions under State law and presented to the clinic before Food Instruments can be issued. A copy of the completed form must be kept in the participant’s file.
Medical documentation is required for the issuance of the following supplemental foods:
- Any non-contract brand infant formula
- Any infant formula prescribed to a child or adult who receives food Package III
- Any exempt formula
- Any WIC eligible nutritionals
- Any authorized supplemental food issued to participants who receive Food Package III
- The health care professional must complete the Nevada WIC Medical Documentation for WIC Formula and Approved WIC Foods form. No substitutions. Medical documentation means that a health care professional made a medical determination that the participant has a qualifying condition that dictates the use of supplemental foods.
- The local clinic will provide the participant with the required form for Infants and Children (through 4 years of age) or the Pregnant, Breastfeeding and Non Breastfeeding Post Partum Woman.
- Each participant with a special need is required to have a Medical Documentation form completed and on file prior to receiving any WIC eligible nutritionals.
- Medical documentation must be written and may be provided as an original written document, electronic document (health care providers signature required) or by facsimile.
- It is the responsibility of the WIC competent professional authority to ensure that only the amounts of supplemental foods prescribed by the participant’s health care provider are issued in the participant’s food package.
Food Package III Issuance-WIC Eligible Nutritionals
Participants with Qualifying Conditions
This food package is reserved for issuance to women, infants and child participants who have a documented qualifying condition that requires the use of a WIC formula (infant formula, exempt infant formula or WIC eligible nutritionals) because the use of conventional foods is precluded, restricted, or inadequate to address their special nutritional needs.
Participants who are eligible to receive this food package must have one or more qualifying conditions, as determined by a health care professional. The qualifying conditions include but are not limited to premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, severe food allergies that require an elemental formula, and life threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or the utilization of nutrients that could adversely affect the participant’s nutrition status.
This food package may not be issued solely for the purpose of enhancing nutrient intake or managing body weight.
This food package is not authorized for:
Infants whose only condition is:
- A diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein or soy protein that does not require the use of an exempt infant formula; or
- A non-specific formula or intolerance
- Women and children who have a food intolerance to lactose or milk protein that can be successfully managed with the use of one of the other WIC food packages (i.e., Food Packages IV-VII); or
- Any participant solely for the purpose of enhancing nutrient intake or managing body weight without an underlying qualifying conditionAuthorized Categories of Supplemental FoodsThe supplemental foods authorized in this food package require medical documentation for issuance and include infant formula (for children or women), exempt infant formula, WIC eligible nutritionals, infant cereal, infant food fruits and vegetables, Milk and milk alternatives, cheese, eggs, canned fish, fruits and vegetables, breakfast cereal, whole wheat bread, or other whole grains, juice, legumes and/or peanut butter.
Authorized Categories of Supplemental Foods
The supplemental foods authorized in this food package require medical documentation for issuance and include infant formula (for children or women), exempt infant formula, WIC eligible nutritionals, infant cereal, infant food fruits and vegetables, Milk and milk alternatives, cheese, eggs, canned fish, fruits and vegetables, breakfast cereal, whole wheat bread, or other whole grains, juice, legumes and/or peanut butter.
Participants with Qualifying Conditions – Women, Infants, and Children
- WIC regulations state that the maximum monthly allowance of formula authorized for women and children with qualifying conditions (refer to Medical Nutrition Products for exceptions) is 455 fluid ounces of liquid concentrate WIC Formula or eligible WIC medical food.
- WIC regulations prohibit exceeding the maximum amount of formula for infants. If an infant has increased needs or a physician is recommending additional formula, the CPA will refer the participant to Early Intervention Services and Medicaid.
- Dietitian/Nutritionist’s may not approve the issuance of additional formula on an individual basis. Participants are to receive no more than the maximum allowable amounts of supplemental foods.
Infants over 6 months of age whose medical condition prevents them from consuming supplemental infant foods, such as infant cereal, jarred fruits, vegetables, or meat may receive exempt infant formula or WIC eligible medical foods at the same maximum monthly allowance as infants age 4-5 months of age in lieu of complementary infant foods.
- A food package containing formula for a woman or child >12 months old can only be issued to the participant with medical documentation.
- WIC regulations allow whole milk as a substitute for reduced fat milk for children
- > 24 months of age and women only with medical documentation for qualifying conditions in Food Package III (they are receiving a WIC-approved medical formula)
Food Packages IV, V, VI and VII Substitutions
Food Package IV: 1 through 4 years
For children, cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. No more than 1 pound of cheese may be substituted for milk.
For children, soy-based beverage and calcium-set tofu may be substituted for milk
Soy-Based Beverage-may be substituted for milk, for children in Food Package IV on a quart for quart basis up to the total maximum allowance of milk.
Calcium-set Tofu-may be substituted for milk, for children in food package IV at the rate of 1 pound of per 1 quart of milk up to the maximum allowance of milk.
Food Packages V, VI, and VII
For women, cheese or calcium-set tofu may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk or 1 pound of tofu per 1 quart of milk. A maximum of 4 quarts of milk can be substituted in this manner in Food Package V and VI; however no more than 1 pound of cheese may be substituted for milk. A maximum of 6 quarts of milk can be substituted in this manner in Food Package VII; therefore no more than 2 pounds of cheese may be substituted for milk.
Special Needs Formula
A participant presenting valid medical documentation for a special needs formula (Nutriamigen, Pregestimil, Alimentum, etc.) may be issued food instruments without a dietitian or nutritionist approval. WIC staff will document in the participant’s chart as to the length of time the formula will be issued (not to exceed 6 months) and reevaluate at each certification or mid-certification screening.
Many special needs formulas are available in the stores and food codes are available. Refer to the Special Formula Availability List. If the formula is not available in your location, follow the procedure for ordering formulas below. All special needs formula must be ordered through the State, do not contact retail pharmacies.
A participant presenting valid medical documentation for a metabolic formula (Phenyl-Free, MSUD, Vivonex, etc.) or a formula not available at retail (Kindercal, Nutren) may be ordered without a dietitian or nutritionist approval. WIC staff will document in the participant’s chart as to the length of time the formula will be issued (not to exceed 6 months) and reevaluate at each certification or mid-certification screening.
Follow the procedure for ordering formulas below. All metabolic formulas must be ordered through the State office, do not contact retail pharmacies.
Clinic staff are required to refer all children who receive metabolic formulas from the WIC program to Early Intervention Services.
Non-Contract formula is defined as ANY formula other than conventional contract brands for milk, soy or lactose-free. Non-contract formulas will not be approved by the State or Local Agency, even with a physician’s prescription.
Ordering/Issuing Special Formulas
The maximum formula allowed per federal guideline is:
For women and children whose prescription is written for less than the maximum amount, clinic staff are instructed to issue the amount requested only. Infants are not allowed to exceed the federal guidelines, even if a medical need is documented. Refer these clients to Early Intervention Services and Medicaid (if applicable) for assistance.
All special order formula requests must be e-mailed to the State Office. Refer to the Special Order Formula Request form and instructions. All orders must be placed by case lot. Orders may not exceed a 2 month supply.
If the participant does not require the full package for a woman/child, please list the specific amount needed or indicate decline on the form, otherwise the maximum will be sent.
Due to the packaging of certain formulas, to obtain the maximum amount for the participant, you may choose to order an additional case to cover the difference. However, you may not exceed the total quantity permitted to be given to the participant; therefore the exact # of cans issued must be recorded in the participant’s chart.
When issuing formula directly to the participant/parent/guardian in place of the standard WIC food instruments, clinic staff must obtain a signed receipt for the total number of cans issued each month from the participant/parent/guardian. The receipt must then be placed in the participant’s chart.
A WIC-eligible nutritional means certain enteral products that are specifically formulated to provide nutritional support for individuals with a diagnosed medical condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible nutritionals may be nutritionally complete or incomplete, but they must serve the purpose of a food, provide a source of calories and one or more nutrients, and be designed for enteral digestion via an oral or tube feeding. WIC-eligible nutritionals include many, but not all products that meet the definition of medical foods in Section 5(b)(3) of the Orphan Drug Act [21 U.S.C. 360ee(b)(3)].