Non-formulary PA3 Form - Antiemetic medications)

Prior Authorization Request Form
Non-formulary Antiemetic
**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.
This form is to be used for these non formulary drugs: Anzemet (dolasetron), Aloxi (palonosetron), Sancuso transdermal
patch (granisetron), Zuplenz oral soluble film (ondansetron), Varubi (rolapitant), Akynzeo (netupitant/palonsetron),
Cesamet (nabilone), Marinol, Syndros (dronabinol), Trimethobenzamide (Tigan).
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:
1. Has the patient previously responded to a non-formulary medication
and changing to a formulary medication would introduce
unacceptable clinical risk(s) to the member?
Has the member filled at least one formulary medications listed
below?
1. Use of formulary medication(s) is contraindicated (e.g., due to a hypersensitivity reaction)
2. Member has experienced or is likely to experience significant adverse effects from formulary medication(s).
3. Use of formulary medication(s) has resulted in a therapeutic failure.

Formulary Drugs
Kytril (granisetron); 1 mg tablet; oral soln
1
Zofran (ondansetron); 4, 8 mg tablet, ODT, oral soln 1
Emend (aprepitant); 40, 80, 125 mg capsule
1

2
2
2

3
3
3

2. Zuplenz request ONLY – the patient requires a non-swallow
dosage form AND has PKU (phenylketonuria) [Zuplenz does not
contain phenylalanine - Zofran ODT contains phenylalanine]

TO BE FILLED OUT BY
WTC HEALTH PROGRAM
Decision:

No

Yes
Sign and date below

Coverage not approved
Proceed to question 2 if
applicable

No

Yes
Sign and date
below

Coverage not approved

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 6/20/2018