Non-formulary PA3 Form - Airway Medications

Prior Authorization Request Form
Airway Medications
**SENSITIVE BUT UNCLASSIFIED**
This form is to be completed and signed by the CCE/NPN Medical Director and should only be used for prescriptions
to be filled through the World Trade Center Health Program (WTCHP).
The CCE/NPN should upload this completed form into VitalPoint and inform the PBM and the WTCHP of this request
via the SAMS messaging system.
Please provide the following member and prescriber information (please print):
Member Name: ________________________

Prescriber Name:

__________________________

Member ID: ___________________________

Prescriber Address: __________________________

CCE/NPN: ____________________________

__________________________

Requested Medication: __________________

Prescriber Phone #: __________________________

Please complete the following clinical assessment:
1. Is the member certified for the following conditions?

Yes (Asthma)
Go to question 2

Yes (COPD)
Go to question 2

No
Medication not covered

2. Answer the following questions below the applicable medication.
AirDuo, RespiClick
A. Patient has asthma as a certified condition,
AND
Patient requires salmeterol as the LABA component,
AND
Patient requires the lower dose found in AirDuo versus Advair
Diskus or HFA

Yes
Sign and date below

No

OR
B.

Medication not covered

Patient requires fluticasone/salmeterol and cannot manipulate
the Advair Diskus or Advair HFA metered dose inhaler

Arnuity Elipta/Armon Air
A. For existing members, have they failed a trial of Flovent Discus
or HFA with inadequate a response or intolerable side effect or
have a contraindication?

Yes
Sign and date below

Yes
Sign and date below

No

OR
B.

Medication not covered

Is this an incoming new member who is already well controlled
on this medication?

Yes
Sign and date below

Bevespi Aerosphere
A. Does the patient have a COPD certification?
AND
Does the patient experience adverse effects or documented
failure when using a dry powder inhaler and requires a MDI?

Yes
Sign and date below

No
Medication not covered

**SENSITIVE BUT UNCLASSIFIED**
Form continued on next page

Effective 5/9/2018

**SENSITIVE BUT UNCLASSIFIED**

Seebri Neohaler
A. Does the patient have a COPD certification?
AND
B.

Does the patient experience adverse effects or documented
failure of formulary agents:

Yes

No

Sign and date below

Medication not covered

Atrovent
Tudorza
Spiriva or
PA 2 Incruse Ellipta
Striverdi Respimat, Utibron Neohaler
A. Does the patient have a COPD certification?
AND
Does the patient experience adverse effects or documented
failure of formulary agent Anora Ellipta?

TO BE FILLED OUT BY
WTC HEALTH PROGRAM
Decision:

Yes

No

Sign and date below

Medication not covered

By signing below, I certify that the above information is correct and accurate to the best of my knowledge.
__________________________________________
WTCHP (NIOSH) Signature

_______________________________
Date

__________________________________________
CCE/NPN Medical Director (or Designee) Signature

_______________________________
Date

Decision Comments:

Additional information may be attached to this document if needed.

**SENSITIVE BUT UNCLASSIFIED**

Effective 5/9/2018