WTC – 6

Medication Request Form

Submission Instructions: Please complete this form to the fullest extent possible and send it to the World Trade Center Health Program at WTCMedCode@csc.com

Requestor:	Date of Request:	Request Urgency:

Urgency Rationale:

Section 1: Medication Request Information

Type of Request:

Generic Name:	Brand Name:

Route of Administration:	Dose Range:

Name of Condition or Condition Category to be Treated:

Suggested Authorization Level and/or Service Limitations (Optional):

Rationale/Benefits of Drug:

(Please identify the medical issue that will be addressed by the addition of this medication, and/or the added benefit that this medication would provide to the WTCHP in relation to similar medications that are already available.)

Section 2: Requested Medication Placement

Requested Formulary Location:

Diagnostic	Standard Treatment	Mental Health	Transplant

Cancer Treatment

Section 3: CCE Comments

Medical Director Comments:

Date Submitted: