Non-formulary PA3 Form - Injectable Epinephrine (Epi-pen)

Prior Authorization Request Form
Injectable Epinephrine (Epi-Pen) Quantity Limit Override
Current limit 1 (one) package per 90 days
**SENSITIVE BUT UNCLASSIFIED**
This form is to be completed and signed by the prescriber and 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 #: __________________________

Yes
Go to question 2

No
Override not
processed

Has the member’s previous supply been used?

Yes
Sign and date below
Additional refill will
be processed

No
Go to question 3

Is the member’s previous supply expired?

Yes
Sign and date below
Additional refill will be
processed

No
Override not
processed

1.

Does member have severe and uncontrolled
asthma?

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:

**SENSITIVE BUT UNCLASSIFIED**
Additional information may be attached to this document if needed.