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25-1169 Provider Guide: Accessing Therapeutic Infant Formula

Date: 11/04/25

Prior authorization required for infants up to 12 months

Therapeutic infant formula for infants under 1 year requires prior authorization (PA) to ensure timely access and continuity of care. This guide explains the PA process for inpatient and outpatient settings, emergency supply options and special program considerations (Women, Infants and Children (WIC), California Children’s Services (CCS)).

Key points

  • PA is mandatory for all therapeutic infant formulas, including emergency two-week supplies.
  • Where to obtain the formula:
    • Participating pharmacies.
    • Durable medical equipment (DME) providers.
    • Other contracted suppliers who bill under the medical benefit.

Note: Requests under the pharmacy benefit follow Medi-Cal Rx guidelines.

  • Authorization timelines:
    • Standard: 5 business days.
    • Urgent: 72 hours.
    • Immediate emergencies: PA may be bypassed to prevent serious harm.

Prior authorization steps

Providers participating through a participating physician group (PPG) should follow their guidelines for prior authorization.

If a patient, physician or other provider encounters difficulties with an authorization request, contact Health Net Case Management Services at:

Inpatient

  1. The specialist orders therapeutic formula during hospitalization.
  2. If formula is needed post-discharge, complete the Prescription Drug Prior Authorization or Step Therapy Exception Form and fax it to Pharmacy Services at 833-963-3436 (Attention: Prior Authorization) several days before discharge, when possible.

Outpatient

1 For infants already on therapeutic formula and new to your care:

  • Request prior medical records.
  • Confirm medical necessity through a comprehensive assessment.

2 If formula is required:

3 After a PA decision:

  • Approved: Contact the patient with instructions for obtaining formula.
  • Denied: Schedule a follow-up or conduct additional tests for PA resubmission.

Emergency two-week supply

For urgent situations requiring immediate access to formula:

  • Complete the Prescription Drug Prior Authorization or Step Therapy Exception Form, and fax it to 833-953-3436 (Attention: Prior Authorization).
  • Supplies are available within 24 hours of the request.
  • Write a prescription and explain that the two-week supply does not guarantee ongoing approval.
  • To continue beyond two weeks, fax a new PA request with clinical documentation to 833-953-3436 (Attention: Prior Authorization) or the PPG.

Special considerations

Special Supplemental Nutrition Program for WIC:

  • WIC does not provide therapeutic formulas for Medi-Cal managed care patients.
  • Health Net Medi-Cal covers formula when medically necessary.
  • Do not refer patients to WIC if:
    • Waiting for an authorization.
    • Facing a denied request.
    • Requiring therapeutic formula.

CCS:

  • For patients under age 21 with CCS-eligible conditions (e.g., malabsorption, genetic disorders, inborn errors of metabolism):
    • ­Enteral nutrition is covered.
    • ­CCS approval is required based on medical necessity.

Helpful resources

More information on the following topics can be accessed in the Provider Library under Medi-Cal:

Other available resources:

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6110.
 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary Providers.

For Medi-Cal, this information applies to Los Angeles.



Last Updated: 11/03/2025