Non-formulary PA3 Form - Antipsychotic medications

Prior Authorization Request Form
Non-formulary Antipsychotics
**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 certified condition being treated major depressive disorder?
condition?

Skip to question 4

2. Is the certified condition being treated post-traumatic stress
disorder?

Skip to question 4

3. Is the certified condition being treated related to another mental
health condition?

Skip to question 4

Proceed to question 2

Yes

No
Proceed to question 3

Yes

No
Coverage not approved

If so, please describe the condition: _______________________
4. 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

5. Has the member failed treatment with at least TWO formulary
atypical antipsychotic medications?

Sign and date below

Yes

No
Proceed to question 5

Yes

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

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.

Aripiprazole (Abilify)

1

2

3

Paliperidone (Invega)

1

2

3

Asenapine (Saphris)

1

2

3

Quetiapine (Seroquel)

1

2

3

Latuda (Lurasidone)

1

2

3

Risperidone (Risperdal)

1

2

3

Olanzapine (Zyprexa)

1

2

3

Ziprasidone (Geodon)

1

2

3

TO BE FILLED OUT BY
WTC HEALTH PROGRAM
Decision:

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