Women, Infants and Children* Program

  • Women, Infants and Children (WIC) program exempt formulas are provided based on HCP determination, regardless of the state’s contract for routine products. HCPs can complete the state’s medical documentation form for exempt formulas to ensure their WIC infants receive the infant formula they recommend.

    Click on your state below to view and download any of the following forms:


    • Nutramigen LGG and Nutramigen® LGG® Toddler Medical Documentation Form—Print and sign this form for WIC participants requiring Nutramigen LGG. Your patient will take this form to the WIC office.
    • PurAmino™ and PurAmino™ Toddler Medical Documentation Form—Print and sign this form for WIC participants requiring PurAmino. Your patient will take this form to the WIC office.
    • State Medical Documentation Form—Print, complete and sign this form for patients requiring a Mead Johnson exempt formula. Your patient will take this form to the WIC office.
    • Mead Johnson Approved Products Information—State-specific list of approved Mead Johnson products
  • The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program is the USDA’s supplemental nutrition program. It provides foods, infant formula, nutrition education and referrals to health and other social services to participants at no charge. States are required to have an infant formula rebate contact in place. By federal requirement, the contract brand of infant formulas used in a state is determined through a sealed bid process. The state programs’ contracts cover routine milk and soy infant formulas. The program also provides additional infant formula products which are not covered under the state’s contract and therefore are not rebated. These additional formulas include those the FDA defines as exempt formulas, such as extensive hydrolysates, premature formulas and some other specialty formulas.

    * WIC is a registered service mark of the U.S. Department of Agriculture for USDA’s Special Supplemental Nutrition Program for Women, Infants and Children. No endorsement of any brand or product by the USDA is implied or intended.

    LGG® is a registered trademark of Chr. Hansen A/S.