Arizona Women, Infants & Children (WIC)
Information For Physicians
Arizona WIC Formula List
Please note that while all formulas are authorized, many require a prescription/medical documentation for issuance and may not be provided solely based on preference. Arizona WIC follows federally mandated cost containment contract and medical documentation procedures that are outlined below prior to any formula issuance.
Medical Documentation Requirements
The United States Department of Agriculture requires the need for detailed medical documentation for specialty formula, milk alternatives, and formula for premature and medically fragile infants. To help meet the needs of Arizona Physicians' and to be in compliance with the USDA, Arizona WIC has made these three forms available to download.
Please contact Adrienne Udarbe with any questions or concerns.
- 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
Medical documentation is now required in the following situations:
- Any infants receiving non-contract/exempt or specialty infant formula or WIC eligible medical food and amount
- For those participants receiving formula or medical foods, allowable supplemental foods to be provided in addition to the formula including amount
- Children receiving milk substitutions of soy beverage, tofu, or goat's milk
- Requests for children to receive additional cheese that exceeds the maximum substitution rate
- Requests for women to receive additional tofu and cheese that exceeds the maximum substitution rate
Medical documentation form requirements:
- Name of authorized WIC formula (infant formula, exempt formula, WIC-eligible medical food) prescribed, including amount needed per day
- Qualifying condition(s) for issuance of WIC formula prescribed and/or supplemental food authorized for the participant
- Length of time the prescribed WIC formula and/or supplemental food is required by the participant
- Signature, date and contact information (or name, date and contact information if initial documentation was received by phone) of the requesting health care provider
- Name of authorized supplemental food(s) appropriate for the qualifying condition(s) and their prescribed amounts
What if my patient is a participant of both AHCCCS and WIC?
If your patient has AHCCCS healthcare coverage and is an EPSDT member who is also a WIC client, WIC is a secondary provider of specialty exempt formulas. Please submit the Exhibit 430-3 – Arizona Health Care Cost Containment System Certificate of Medical Necessity for Commercial Oral Nutritional Supplements directly to the healthcare plan for coverage of specialty exempt formulas.
What does WIC have to do with me as a healthcare provider/clinician?
- WIC can give patients nutrition counseling and free nutritious foods at critical periods of growth and development.
- WIC counts on clinicians to provide medical information on women and children at risk and to help eligible people know about WIC services.
- Please refer your patients to WIC! WIC wants to serve every eligible person.
WIC appreciates the support received from clinicians and is always open to ways to improve collaboration with you!
How can I help my patients receive WIC benefits?
- Make it routine! Put a WIC brochure in every new-patient packet.
- Mention WIC to everyone. Tell your patients that WIC is a health and nutrition program and encourage them to call a local WIC program or 1-800-2525-WIC.
- Give your patients a complete Medical Referral Form. This helps WIC identify the medical or nutritional risk factor(s) needed for enrollment.
- Display WIC posters and brochures in your office in the languages your patients speak.
Why does the Arizona WIC Program encourage the use of certain infant formula?
Arizona WIC entered into an agreement with Abbott Laboratories (Ross Products Division) to provide Similac Advance with Iron, Similac Isomil Advance Soy and Similac Sensitive as the sole source milk-based and soy-based formulas for WIC participants.
The agreement is a federally mandated cost containment system. It provides a savings to the Arizona WIC Program. This savings allows the Arizona WIC Program to serve additional case load with the WIC grant.
In accordance with federal regulations, WIC-eligible formulas are mainly issued in powdered forms. The issuance of a ready-to-feed formula is limited to exceptions when there is an unsanitary or restricted water supply, there is poor refrigeration, the infant caretaker may have difficulty in correctly diluting a concentrated liquid or powdered product, or the product is available in only a ready-to-feed form. All other standard milk-based or soy-based infant formulas require a prescription from a prescriptive authority.
How can a special formula be prescribed for a WIC participant?
A WIC participant who is prescribed any formula other than Similac Advance with Iron, Similac Isomil Advance Soy or Similac Sensitive must have a completed prescription. It must include the participant's name, diagnosis, formula prescribed, and original signature/date. The form may either be returned to the participant to give to WIC staff or faxed directly to the WIC clinic.
Why does the Arizona WIC Program not allow cow's milk for WIC participants until one year of age?
The Arizona WIC Program does not allow cow's milk before the age of one. The Committee on Nutrition of the American Academy of Pediatrics (AAP) recommends the consumption of breast milk or iron-fortified infant formula, along with age-appropriate solid foods and juices, during the first twelve months of life. The AAP recommends that whole cow's milk and low-iron formulas not be used during the first year of life (AAP, The Use of Whole Cow's Milk in Infancy, Pediatrics, 1992, 89:1105-1109).
Please visit our food package page for more information on the exciting changes to the WIC food packages.