To get a specialized or non-contract infant formula covered by Pennsylvania WIC, your healthcare provider must complete the Pennsylvania WIC Formula Authorization Form and submit it to your local WIC agency. The form is a single page, available under the Health Care Providers tab at pawic.com, and the current version took effect January 1, 2026.1Pennsylvania WIC. Pennsylvania WIC Program Formula Authorization Form Once the local office reviews and approves it, the authorized formula is loaded onto your eWIC card for purchase at approved retailers.
When the Form Is Required
Pennsylvania WIC holds a contract with Abbott Nutrition for standard Similac infant formulas. Those don’t need extra paperwork. Anything outside that contract does.2Pennsylvania WIC. Pennsylvania WIC Formulary Guide for Healthcare Providers The form covers two categories:
- Alternate infant formulas: non-contract standard formulas prescribed for conditions like documented formula intolerance, food allergies, or inappropriate growth patterns.3Pennsylvania Department of Health. Pennsylvania Department of Health Policy and Procedure Manual – Infant Formula
- Exempt infant formulas and WIC-eligible nutritionals: specialized products for participants whose medical condition prevents them from using conventional foods or standard formulas. This includes extensively hydrolyzed and amino acid-based formulas, metabolic formulas, renal formulas, and pre- or post-discharge premature formulas.2Pennsylvania WIC. Pennsylvania WIC Formulary Guide for Healthcare Providers
The request has to be tied to a qualifying medical condition. WIC won’t authorize a specialized formula because a caregiver prefers a brand or wants to boost nutrient intake.4Pennsylvania Department of Health. Pennsylvania Code 5.10 – Exempt Infant Formula and WIC-Eligible Nutritionals
What the Provider Fills In
Every field matters. The PA WIC Formulary Guide emphasizes that complete forms get formula to patients fastest.2Pennsylvania WIC. Pennsylvania WIC Formulary Guide for Healthcare Providers
Patient Information
The top section collects the client’s first and last name, date of birth, and the parent or caregiver’s name. These details need to match the WIC record exactly. A misspelled name or wrong birthdate can delay processing.
Formula and Dosing
The provider enters the formula’s name, the daily amount in ounces per day (or tablespoons per day for modular formulas), and whether ready-to-feed form is required. Ready-to-feed must be justified by a medical condition; convenience isn’t enough. The form also asks whether the formula will be given by tube feeding.1Pennsylvania WIC. Pennsylvania WIC Program Formula Authorization Form
A separate special instructions field covers preparation details like non-standard caloric concentration. If an infant needs formula mixed to 22 or 24 calories per ounce rather than the standard 20, that goes here.
Medical Justification
Two fields work together: the ICD-10 diagnosis code and a description of the qualifying medical condition. Both are required. PA WIC policy treats the documentation as incomplete without the condition and the ICD-10 code.4Pennsylvania Department of Health. Pennsylvania Code 5.10 – Exempt Infant Formula and WIC-Eligible Nutritionals This is where most incomplete forms get sent back.
Length of Use
The form offers four duration options: one month, three months, six months, or a custom end date, with a six-month maximum.1Pennsylvania WIC. Pennsylvania WIC Program Formula Authorization Form After that, new medical documentation is needed. Premature pre-discharge formulas are the exception; those must be renewed monthly.4Pennsylvania Department of Health. Pennsylvania Code 5.10 – Exempt Infant Formula and WIC-Eligible Nutritionals
Food Restrictions and Dairy Authorization
The bottom of the form has checkboxes for WIC food restrictions that apply to the participant and a dairy authorization section for women and children. Providers should check every box that applies so the WIC nutritionist can adjust the full food package accordingly.1Pennsylvania WIC. Pennsylvania WIC Program Formula Authorization Form
Who Can Sign
Pennsylvania’s form lists five categories of authorized signers:
- Physicians
- Certified Registered Nurse Practitioners
- Certified Nurse Midwives
- Physician Assistants
- Licensed Dietitian Nutritionists
The provider also fills in their printed name, the medical office or clinic name, telephone number, address, and fax number so WIC nutritionists can follow up if anything needs clarification.1Pennsylvania WIC. Pennsylvania WIC Program Formula Authorization Form
How to Submit It
The completed form goes to your local WIC agency. Federal regulations allow medical documentation to be submitted as an original paper document, an electronic document, or by fax.5eCFR. 7 CFR 246.10 The most common options are bringing the form to a scheduled WIC appointment or having the provider’s office fax it directly. Use the clinic locator at pawic.com to find your clinic’s contact information.6Pennsylvania WIC. Find WIC Clinics and Stores
In urgent situations, a provider can call in a verbal order to a competent professional authority at the WIC clinic. PA WIC accepts verbal orders on a case-by-case basis, but the signed written form has to reach the clinic within one month of the phone call and before any additional benefits are issued beyond the initial authorization.4Pennsylvania Department of Health. Pennsylvania Code 5.10 – Exempt Infant Formula and WIC-Eligible Nutritionals It’s meant to keep an infant from going without nutrition while paperwork catches up, not to replace the written submission.
After Approval
Once WIC staff verify the form is complete and the product is available, they load the authorized formula onto your eWIC card. The card reflects the specific brand and type (powder, concentrate, or ready-to-feed), so only that exact product can be purchased.7Pennsylvania WIC Program. WIC Retail Vendor Handbook Specialized formulas are stocked at authorized WIC vendors across the state, but not every store carries every product. If yours doesn’t, ask the store manager or call the WIC clinic about where to find it.
Check your card balance before shopping to confirm the specialized benefits are active. The WICShopper App shows current benefits on a phone, and the Family Portal at wic.health.pa.gov lets participants manage their account online.7Pennsylvania WIC Program. WIC Retail Vendor Handbook
Renewing the Authorization
Because the form maxes out at six months, ongoing conditions need a fresh form before the current authorization expires. Premature pre-discharge formulas renew monthly.4Pennsylvania Department of Health. Pennsylvania Code 5.10 – Exempt Infant Formula and WIC-Eligible Nutritionals Don’t wait until benefits run out. Raise it at the pediatrician visit before the current period ends so there’s no gap.
If the Form Is Incomplete or Denied
The most common delay is a form missing the ICD-10 code or the condition description. When that happens, the WIC clinic contacts the provider for the missing information. You can speed this along by letting the doctor’s office know WIC reached out, since the fax or message can sit in a queue.
If WIC denies the request outright (for example, because the condition doesn’t qualify for an exempt formula and can be managed with a standard food package), you have the right to request a fair hearing. Federal WIC regulations require notice of adverse actions and an opportunity to appeal. Contact your local WIC clinic or the Pennsylvania WIC state office to start the hearing process.