25-690m Accessing Therapeutic Infant Formula With Prior Authorization

Date: 07/03/25

A guide for providers supporting infants up to age 1

Providing therapeutic infant formula for infants up to age 1 year requires prior authorization (PA) to ensure proper access and continuity of care. This guide outlines the prior authorization process, emergency supply options and guidance for specific cases to help providers support their patients effectively. By following these guidelines and utilizing the outlined resources, health care providers can ensure timely and uninterrupted access to therapeutic infant formula for their patients.

Key points to remember

• Therapeutic infant formula requires PA: All therapeutic infant formula—including a one-time emergency two-week supply—requires prior authorization.
• Obtaining formula: Therapeutic infant formula is available through participating pharmacies, durable medical equipment providers, or other contracted suppliers who bill the plan under the medical benefit. Requests managed under the pharmacy benefit fall under the Medi-Cal Rx program.
• Authorization time frames: Standard PA requests are processed in five days, urgent requests in 72 hours and immediate emergencies can bypass PA to prevent serious disability or life-threatening situations.

Steps for prior authorization

For inpatient –

1. The specialist managing the infant’s care will order therapeutic formula.
2. If needed post-discharge, the specialist should complete and submit the PA request several days before discharge, when possible.

For outpatient –

1. If the infant is already on therapeutic formula and is a new patient, the provider should:

a. Request medical records from the previous prescribing provider.

b. Conduct a comprehensive assessment to confirm medical necessity.

2. Upon determining therapeutic formula is needed, the Medi-Cal fee-for-service provider should follow the PA process below:

a. Establish and document medical necessity in the patient’s records.

b. Complete the Prescription Drug Prior Authorization or Step Therapy Exception Form. Fax it to the health plan’s pharmacy services (fax number: 833-953-3436) with “Attention: Prior Authorization.”

c. Discuss the PA process with the member.

d. Upon approval, contact the member with instructions for obtaining the formula. If the PA is denied, provide further steps such as scheduling follow-up appointments or conducting additional tests to resubmit the request.

Emergency two-week supply

For situations where immediate access to therapeutic formula is required, a one-time emergency two-week supply may be requested.

Steps for the emergency supply:

1. Complete the Prescription Drug Prior Authorization or Step Therapy Exception Form and fax it to 833-953-3436, Attention: Prior Authorization.
2. The two-week supply is available within 24 hours of receiving the authorization request.
3. Write a prescription and explain to caregivers that the two-week supply does not guarantee ongoing approval.
4. To continue the formula after two weeks, submit a new PA request with clinical documentation to the Health Care Services Department or the PPG.

Special considerations

WIC program guidance

• The WIC program does not supply therapeutic formula for Medi-Cal managed care members.
• Health Net's Medi-Cal program covers therapeutic formula when medically necessary. Providers should not refer members to WIC if they are waiting for authorization, facing a denied request, or requiring therapeutic formula.

California Children’s Services (CCS) program

For members under 21 diagnosed with CCS-eligible conditions (e.g., malabsorption, genetic disorders, inborn errors of metabolism), enteral nutrition is covered. CCS approval must be obtained based on medical necessity.

Resources

For additional information regarding enteral nutrition and therapeutic infant formula, visit the Provider Library under Medi-Cal to access specific resources, including:

• Enteral Nutrition.
• Prescription Drug Program (Infant Formula).
• WIC (Formula).
• California Children’s Services (CCS).

For a list of covered products at Med-Cal Rx, select Medi-Cal Rx Contracted Enteral Nutrition Products.

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
 

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

This information applies to Medi-Cal in Fresno, Kings and Madera counties.