Non-formulary PA3 Form - Nucala

Prior Authorization Request Form
Nucala (mepolizumab)
**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. Does member have severe and uncontrolled asthma?

2. Have results of complete blood count (CBC) shown eosinophils
of at least 150 cells/microliter at the initiation of treatment or
eosinophils of at least 300 cells/microliter in the past 12 months?

3. Has the member had an adequate trial and been adherent to a
regimen that includes high-dose inhaled corticosteroids (e.g.,
Flovent®, Pulmicort™), with or without oral corticosteroids, in
combination with any of the following additional controllers?
a.
b.
c.

Yes

No

Go to question 2

Yes

Medication not covered

No

Go to question 3

Yes

Medication not covered

No

Sign and date below

Medication not covered

Long-acting beta agonist (Performomist™, Serevent®)
Leukotriene inhibitor (Singulair®)
Theophylline

OR
Member is intolerant or has contraindications to these agents.

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