Health Care Providers

Infant Formula Information

The Arizona WIC program provides contract formula to infants not breastfed or partially breastfed.  The contract company company is Abbot Nutrition.  Infants on WIC recieve Similac Advance, Isomil Advance, or Similac Sensitive.  Other infant formulas can be provided if special circumstances apply (listed below).

WIC is a supplemental food program; the amount of infant formula provided by WIC is not designed to meet 100% of the infant's needs.

AHCCCS participants may be able to recieve oral supplementation or tube feeding formulas from AHCCCS. Please refer these patients to their AHCCCS primary care provider for coordination. The tube feeding/oral supplement formula is a covered AHCCCS expense and should be processed as a prior authorization.

Infants born < 37 weeks gestation, low-birth-weight infants, and/or immuno-compromised infants for up to six months corrected age are provided commercially sterile concentrated infant formulas per Arizona Department of Health Services policy, unless ready to feed or powder formula is specifically requested by the medical provider.

Special Circumstances

• Non-contract standard formulas (such as Enfamil Lipil, Enfamil AR, Enfamil Lactofree Lipil, Prosobee Lipil, Gentlease Lipil, Good Start products) are provided by prescription* only under the following circumstances and under no other exceptions:

   

  1. Transition to a contract formula is medically contraindicated for pre- or post-operative recovery where formula transition would put the infant at risk for compromised nutritional status impacting growth and development.

  2. NICU discharge warrants continuation of a tolerated non-contract formula to avoid weight loss in the recovery of a previous failure to thrive infant or infant who has experienced inadequate growth.

  3. Infants with a medical birth history of a congenital defect where formula transition would put infant at risk for compromised nutritional status impacting growth and development.

  4. Infants with a medical history of central nervous system disorders and genetic/congenital disorders where formula transition would put infant at risk for compromised nutritional status impacting growth and development.

• Special infant formulas (such as Nutramigen, Alimentum, Neocate, Peptamen products, Similac Sensative RS, Vivonex products, or 22/24 Kcal per ounce formulas are provided by prescription* only.

• Oral supplements/enteral formulations (such as Pediasure) are provided by prescription* only under the following circumstances and under no other exceptions:

  1. Child must be currently underweight by WIC standards (Birth to 2 years, less than or equal to 5th percentile weight for length; 2 to 5 years, less than or equal to 5th percentile BMI for age) or

  2. Child must have been underweight during the previous WIC certification period (in the past 6-12 months) by WIC standards, or

  3. Have another medical condition not-related to weight (i.e. being tube fed)

• Low-Iron Infant Formulas are provided by prescription* only under the following circumstances and under no other exceptions:

  1. Vitamin E hemolytic anemia (0-3 months of age)

  2. Thalassemia Major (Cooley's anemia)

  3. Iron overload secondary to repeat blood transfusion

  4. Iron utilization anemia (sideroblastic anemia)

  5. Hemochromatosis

WIC Presciption Forms

Medical providers are asked to use the appropriate pre-printed WIC prescription forms

• Arizona WIC Special Formula Authorization Form for Children, Women, and Healthy Infants

• Arizona WIC Special Formula Authorization Form for Premature and Medically Fragile Infants

• Arizona WIC Milk Alternative Request Form

If the pre-printed forms are not used; prescriptions written to WIC must include all of the following:

1. Name of authorized WIC formula (infant formula, exempt formula, WIC-eligible medical food) prescribed, including amount needed per day

2. Qualifying condition(s) for issuance of WIC formula prescribed and/or supplemental food authorized for the participant

3. Lenth of time the prescribed WIC formula and/or supplemental food is required by the participant

4. Name, date and contact information of the requesting health care provider.  Signature, including title, of the prescriptive authority (must be MD, DO, PA-C, or NP).

5. Name of authorized supplemental food(s) appropriate for the qualifying condition(s) and their prescribed amounts.

Signature stamps and facsimiles are acceptable, but incomplete prescriptions cannot be accepted. Non-contract and special formulas must also be approved by the WIC nutritionist.

For more information, please visit http://www.azwic.gov/physicians.htm