PA3 Form (Prior Authorization Level 3) - General

Prescription Prior Authorization Level 3
Individual Request Form
**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. Not to be used for formulary additions.
Member Information
Request Date:

Provider/Requestor Information

Survivor
Responder

Requestor Name:

Requestor Credentials:
Requestor Phone:

Member Name:

Date of Birth:

Requestor Fax:

Member 911#:

CCE/NPN:

Request Email:

Relevant Certified Condition(s) and ICD Code:

Request Urgency:

Routine

Urgent

Urgency Rationale:
Drug Information
Brand Name:

Compound medication?

Generic Name:

Prescribed strength:

Drug Class:

Prescribed directions:

Yes

No

Dosage form/route of administration:
What is the expected duration of treatment with this drug? (Maintenance, 14 day course, etc.)
What is the estimated cost of this medication per month or over the course of treatment?
Is this dosage/directions for the use FDA approved for this member’s condition or recognized as an off-label use in the accept compendia? Yes No
If No – then this request is for “off-label” use. Please provide medical rationale for use, and supporting documentation.
When is this drug indicated during the normal course of treatment?
1st Line

2nd Line

Last resort for treatment

Other

Please list the medications currently and previously used by the member to treat this condition:

Medication

Dosage

Dosing Schedule

Length of Therapy

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

Yes

No

If yes, please explain:
Does this medication require special monitoring and/or participation in a patient registration program?

Yes

No

Please describe the member’s WTC certified condition that will be treated by this medication.
If applicable, please provide any supporting lab test results that may justify the use of the medication.
Has the member taken this medication for this condition before?

Yes

No

If yes, please explain:
Provide any additional medical rationale relevant to this member’s case:

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:

**SENSITIVE BUT UNCLASSIFIED**