CDPH 247: California WIC Medical Formula and Nutritionals Request Form

CDPH 247 PDF Details

Section IV is Health Care Provider Information.

Medi-Cal: if the patient has Medi-Cal, the Health Care Provider (HCP) must submit a Prior Authorization (PA) to Medi-Cal; patient takes Rx to a Medi-Cal pharmacy.

Diagnosis: the Qualifying Diagnosis in Section II must be specified.

Not approved: WIC will not approve medical formula or medical food for non-specific symptoms or diagnoses; non-specific formula intolerance or food intolerance.

Also not approved: patient/caregiver preference or food dislikes; solely to enhance nutrient intake or manage body weight without an underlying condition.

More information: visit www.wicworks.ca.gov and click on Health Care Providers, or call 1-800-852-5770.