Prior Authorization

Prescription Prior Authorization Level 3
Individual Request Form
Submission Instructions: Please complete this form and send it to the World Trade Center Health
Program by posting it to the secure SFTP server and then sending an email to
[email protected] indicating the secure server posting of this request. Incomplete forms will
be sent back for more information. Not to be used for formulary additions. DO NOT FILL OUT
WTCHP PROGRAM SECTION.

Requester Information

Request Date

Choose a CCE/NPN

Requester Name

Requester Title/Role

Requester E-mail

Requester Phone

Clinical Director Name

Clinical Director Signature

Request Urgency

Urgency Rationale

Urgent
Routine

Member Information

Member Name

Relevant Certification Condition(s)

Member 911#

Member Date
of Birth

ICD Code

Relevant Certification Condition(s)

ICD Code

Drug Information

Brand Name of Medication Requested:
Generic Name of Medication
Requested:
Is the medication
available generically?

Is this a newly FDA
approved medication?

Is this a newly approved
indication for a previously
approved medication?

Drug Class:

When is this drug indicated during the
normal course of treatment?

1st line
2nd line
Last resort for treatment
Other

If not indicated for the first line therapy,
what medications or therapies are
indicated for use prior to this
medication?
Does this medication require special
monitoring and/or participation in a
patient registration program?
If yes, explain.

Is this an Orphan Drug?

Prescribing Information

What dosage form is
being requested?

Is it a compound medication?

What is the prescribed strength?

What is the prescribed directions?

What is the expected duration of
treatment with this drug?
(maintenance, 14 day course etc)

When is this drug indicated during the
normal course of treatment?

Is this dosage/directions for use FDA
approved for this member's condition?

1st line
2nd line
Last resort for treatment
Other

What medications or therapies are indicated for use before this medication?

Please list currently available formulary medications, if any, which have been tried and failed by
this member. Please include dates the medication was taken.

Did the member experience an adverse event
or drug interaction with preferred medications
that caused a discontinuation of therapy?

If yes, explain:

What is the expected cost of this medication?

Why does the prescribing provider believe this medication is considered medically necessary to
treat this members condition?

Will delay in receipt of this medication result in a unfavorable and/or potentially fatal outcome?

Narrative: Please provide other required information per the formulary guidelines. Please
provide supporting documentation on the safety and effectiveness of this drug (package insert,
Journal citation):

TO BE FILLED OUT BY A WTCHP PROGRAM REVIEWER
Name

WTCHP Program Decision

Credentials

Signature

WTCHP Program Decision Comments