Non-formulary PA3 Form - Opioid Abuse Deterrent

Prior Authorization Request Form
Non-formulary Abuse Deterrents
**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.
This form is to be used for these non-formulary drugs: Hysingla ER (hydrocodone), Embeda (morphine sulfate;
naltrexone), Arymo ER (morphine sulfate), MorphaBond XR (morphine sulfate), Xtampza ER (oxycodone), RoxyBond
(oxycodone).
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. Has the member tried and failed at least TWO formulary narcotic
analgesics?

TO BE FILLED OUT BY WTC
HEALTH PROGRAM:
Decision:
Decision Comments:

Yes
Sign and date below

No
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

Additional information may be attached to this document if needed.

**SENSITIVE BUT UNCLASSIFIED**

Effective 10/4/2018