MaineCare and Medical Formula
The following process should be followed for participants in the MaineCare program who require medical infant formula.
- Patient is in need of a medical formula product. The Health Care Provider fills out the Medical Documentation for WIC Medical Formula form or the Medical Food/MaineCare Prior Authorization Form for Medical Formula or Medical Food form.
- Parent brings the form to the WIC office or health care provider faxes both forms to the WIC office or the State WIC Agency office (207-287-3993).
- WIC Staff member has parent sign Authorization for Release of Information for Special Formula Prescriptions form.
- WIC staff member reviews WIC prescription form to ensure the health care provider has included all necessary information, and diagnosis is consistent with the formula prescribed.
- WIC staff member provides parent with first month (30 days) of benefits for participant if additional clarification is needed, or formula is to be covered by MaineCare. If the form is complete, the WIC staff member may issue up to three months of formula benefits to the parent.
- Staff member fills out Fax Cover sheet (will all information filled in) and faxes both the cover sheet and the Medical Documentation for WIC Medical Formula or Medical Food/MaineCare Prior Authorization form to GHS only if formula is to be covered by MaineCare.
- The following formula items are covered by MaineCare:
- Tube feeding formulas
- Metabolic formulas
- Elemental formulas
- WIC staff member follows up with parent at the end of the first 30 days to ensure the parent is able to get future months filled at pharmacy if the formula is covered by MaineCare.
- WIC staff member follows up with parent at the end of the first 30 days if additional information was needed from the health care provider. Once all clarifying information is obtained, WIC staff member may issue up to three months of formula.
- When infant is approaching six months of age, staff member sends Medical Documentation for WIC Medical Formula form to health care provider for prescription of WIC infant foods (cereal, fruits and vegetables).
- When infant is approaching 12 months of age, staff member sends Medical Documentation for WIC Medical Formula form tto health care provider. Health care provider may indicate if formula is to be continued past a year; documentation of formula as well as any supplemental foods to be excluded is required. Transition to whole milk may be verified with a verbal or written order from the health care provider.
Note:Participants not enrolled in MaineCare will continue to receive all formula benefits from the WIC Program.
- Monday - Friday 8am-5pm
- Voice: (207) 287-3991
In-state Toll Free:
TTY: Maine relay 711
Fax: (207) 287-3993
- Mailing address:
11 State House Station
Augusta, ME 04333
Phone Number to your
Local WIC Clinic
East Wilton 207-645-3764
Presque Isle 207-768-3026
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