Massachusetts WIC-Approved Formulas.  Effective October 2014

Enfamil Infant and Enfamil ProSobee (soy) are WIC's standard infant formulas.

WIC also provides special and metabolic formulas for participants with special medical needs. A completed Request for Special Formula Form pdf format of Request for Special Formula Form
rtf format of Request for Special Formula Form requesting a special or metabolic formula with a nutrition-related ICD code must be provided outlining the patient’s qualifying medical condition(s) warranting need prior to issuance.

MassHealth is the payer of first choice for special medical formulas for WIC participants who are MassHealth members. While waiting for MassHealth approval, WIC will provide one month of benefits for the prescribed formula from WIC (after the medical provider has completed the Request for Special Formula and Food form) and will act as a safety net for families should the process take longer.  WIC staff can guide WIC participants and medical providers through the process of receiving special or prescription formulas through MassHealth insurance. (Reference ‘For Healthcare Providers>What if my patient needs special formula?’ at www.mass.gov/wic). MassHealth members requiring Enfamil Gentlease and Enfamil A.R. will receive these formulas through WIC without needing to pursue prior authorization from MassHealth. A Request for Special Formula and Food form is required for Enfamil A.R. before issuance will be approved. 

Note: For Type, P = Powder, C = Concentrate and R = Ready-to-Use (RTU) or Ready-to-Feed (RTF).  WIC does not permit the issuance of RTU or RTF formulas when more than one type of a formula is available (i.e., if available in Powder or Concentrate) unless there are concerns regarding safe preparation of the formula.  
 

FormulaTypeFormulaType

3232A

P

Nutramigen (liquid forms)

C, R

Boost Kid Essentials 1.0

R

Nutramigen with Enflora LGG

P

Boost Kid Essentials 1.5

R

Osmolite 1.5

R

Boost Kid Essentials 1.5 with Fiber

R

PediaSure

R

Bright Beginnings

R

PediaSure with Fiber

R

EleCare DHA/ARA (for infants)

P

PediaSure 1.5

R

EleCare Jr.

P

PediaSure Peptide 1.0

R

Enfamil A.R.

P, R

Peptamen Junior

R

Enfamil EnfaCare

P

PKU-2

P

Enfamil Gentlease

P

PKU-3

P

Enfamil Infant

P, C, R

Pregestimil

P

Enfamil ProSobee (soy)

P, C, R

Pulmocare

R

Enfaport

R

RCF

C

Ensure

P

Similac Alimentum Hypoallergenic

P, R

Ensure Plus

R

Similac ExpertCare NeoSure

P

KetoCal 4:1

P

Similac PM 60/40

P

Meyenberg Evaporated Goat Milk

C

Similac Sensitive

P

MSUD-2

P

Similac Special Care 30

R

Neocate Infant

P

Vivonex Pediatric

P

Neocate Jr.

P

XPhe Maxamum

P