Non-formulary PA3 Form - Diabetes Insulin

Prior Authorization Request Form
Non-formulary Diabetes Insulin
**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.
This form is to be used for these non-formulary drugs., Basal Insulins: Tresiba (degludec), Basaglar (glargine). Rapid
Acting Insulins: Ademlog (lispro), Fiasp (aspart), Apidra (glulisine), Afrezza (inhaled human insulin).
Please provide the following member and prescriber information (please print):
Member Name:________________________

Prescriber Name:

__________________________

Member ID:___________________________

Prescriber Address: __________________________

CCE/NPN:____________________________

__________________________

Requested Medication:__________________

Prescriber Phone #: __________________________

All diabetes medications should have the following PA2: Requires certification and its complications secondary to WTC-related
conditions:
Please complete the following clinical assessment:
PA-3 criteria for the following insulins:
Basal Insulins
1. Does the member have a diagnosis Type 1 Diabetes?
2. Has the member tried and failed Lantus?
3. Has the member tried and failed Levemir?

Yes
Proceed to question 2

Yes
Proceed to question 3

Yes
Sign and date below

No
Coverage not approved

No
Coverage not approved

No
Coverage not approved

Rapid Acting Insulins
1. Does the member have a diagnosis Type 1 Diabetes?
2. Has the member tried and failed insulin aspart (Novolog)?
3. Has the Member tried and failed insulin lispro (Humalog)?

Yes
Proceed to question 2

Yes
Proceed to question 3

Yes
Sign and date below

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

No
Coverage not approved

No
Coverage not approved

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