WIC special or prescription formula requests

Learn how to request special formulas for Women, Infants, & Children (WIC) Nutrition Program participants with special medical needs.

Table of Contents

Request form

WIC offers over 45 special formulas for participants with special medical needs. To request a special formula, you will need to complete the Massachusetts WIC Nutrition Program Request for Special Formula and Food (RSFF) (PDF) | (DOCX) to document the diagnosis warranting a medical need for the formula. A thorough dietary assessment and counseling will be provided by a WIC nutritionist to resolve more common conditions not requiring special formulas such as constipation, spit-up or loose stools.

Please note: To support special formula access for families during the formula shortage, it is recommended that health care providers list all formulas on the request that would be appropriate for the documented need. For example, for a condition associated with a need for hypoallergenic formula, providers should list Nutramigen, Alimentum, Good Start Extensive HA or other similar hypoallergenic formula as appropriate on the Request for Special Formula and Food form.

Downloads

WIC formula list

The list below reflects our WIC formulary as of January 2024.

For WIC participants enrolled in MassHealth

MassHealth has primary responsibility for payment of special formulas for MassHealth members who are eligible to receive benefits through the WIC Program. WIC participants who are MassHealth members will be guided to receive special formulas through their MassHealth insurance.

Please Note:

Effective May 17, 2022, in response to the formula shortage, MassHealth expanded coverage for formula dispensed through pharmacies to include all medically necessary formula. These items were added to the MassHealth Non-Drug Product List. In each case, a valid prescription is required. MassHealth strongly encourages prescribers to write down any appropriate substitute products on the prescriptions for formula, in addition to the preferred product. MassHealth has allowed and will continue to allow formula to be dispensed by pharmacy providers without Prior Authorization (PA). This suspension of PA will continue until additional guidance is published by MassHealth. The most recent bulletin related to this policy can be found here: MassHealth All Provider Bulletin 373 July 2023 (PDF) | (DOCX)  

To assist families, Massachusetts WIC will provide 2 months of benefits in order to allow sufficient time for participants to obtain special formula through the pharmacy or the MassHealth Prior Approval process and will act as a safety net for families should the process take longer.

For MassHealth, FFS, PCACO, and PCC Plans Customer Service 1-800-841-2900 (Monday – Friday, 8 a.m. – 5 p.m.)

Special or prescription formulas for WIC participants enrolled in MassHealth

If you have questions regarding the MassHealth process for prescribing special formulas to MassHealth WIC participants, please contact the following Customer Service Centers, depending on your patients MassHealth coverage type:

  • Fallon Health
    • Contact: Prior Authorization Department. Tel: (508) 368-9138, Fax: (508) 368-9700 or urgent fax request (508) 368-9133
  • Health New England (HNE)
    • Contact: Health Services Department. Tel: (413) 787-4000 x5027, Fax:(413) 233-2700
  • Mass General Brigham ACO
    • Contact: DME-Nutritional Authorizations Team—Department; Clinical Operations. Tel: (855) 444-4647 (toll free), Fax: (617) 586-1700
  • Tufts Health Plan
    • Contact: Tel: (888) 257-1985, Fax: (888) 415-9055
  • WellSense (formerly BMCHP)
    • Special Instructions: Choose a DME supplier from the list of Northwood contracted suppliers available on WellSense.
    • Providers should fax the prescription and additional medical information to the DME supplier directly. The DME supplier will confirm the order and ship it.

Some MassHealth plans require Medical Providers to submit a completed MassHealth Medical Necessity Review Form (DOC) when prescribing special or prescription formulas.

MassHealth - WIC participants will continue to receive all other WIC services including nutrition counseling and education, immunization screenings, health and social service referrals, and Farmers' Market coupons in the summer, as well as a WIC food package, including infant foods, that is appropriate for their nutrition and medical needs.

Downloads

Contact   for WIC special or prescription formula requests

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