Non-formular PA3 Form - Antidepressant Medications

Prior Authorization Request Form
Non-formulary Antidepressants
**SENSITIVE BUT UNCLASSIFIED**
This form is to be completed and signed by the CCE Medical Director and should only be used for prescriptions to be
filled through the World Trade Center Health Program (WTCHP).
The CCE 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: ________________________________

__________________________

Requested Medication: __________________

Prescriber Phone #: __________________________

Please complete the following clinical assessment:
Yes

No

1. Is the member being treated for a WTC Health Program covered
mental health condition?

Proceed to question 2

2. Has the member previously responded to the requested nonformulary medication and changing to a formulary medication would
introduce unacceptable clinical risk(s) to the member?

Sign and date below

3. Has the member failed a formulary medication from at least 2
different categories OR has the member failed a formulary
medication from at least 1 category and has a contraindication for at
least 1 other category?

Indicate reasons in box
and sign and date below

Please circle the reason(s) why the member cannot be treated with
the following formulary medications:

Monoamine Oxidase Inhibitor
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline Patch (Emsam)
Tranylcypromine (Parnate)

1
1
1
1

2
2
2
2

3
3
3
3

Serotonin Norepinephrine Reuptake Inhibitors
Duloxetine (Cymbalta)
1
2
3
Venlafaxine (Effexor)
1
2
3
Selective Serotonin Reuptake Inhibitors
Citalopram (Celexa)
1
2
Escitalopram (Lexapro)
1
2
Fluoxetine (Prozac)
1
2
Fluvoxamine (Luvox)
1
2
Paroxetine (Paxil)
1
2
Sertraline (Zoloft)
1
2

TO BE FILLED OUT BY
WTC HEALTH PROGRAM
Decision:

3
3
3
3
3
3

Coverage not approved

Yes

No
Proceed to question 3

Yes

No
Coverage not approved

1. Use of formulary medication(s) is contraindicated.
2. Member has experienced significant adverse effects from
formulary medication(s).
3. Use of formulary medication(s) has resulted in a therapeutic
failure.

Tricyclic Antidepressants
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
Protriptyline (Vivactil)

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

Misc
Bupropion (Wellbutrin, Aplenzin)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Trazodone (Desyrel)
Vilazodone (Vibryd)
Vortioxetine (Trintellix)

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

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