Frequently Asked Questions (FAQs)

The World Trade Center (WTC) Health Program is a federal program that provides monitoring and treatment for certified WTC-related health conditions for eligible Responders to the September 11, 2001 attacks in New York City (NYC), the Pentagon in Arlington, Virginia, and the crash site in Shanksville, Pennsylvania. The Program also provides benefits to eligible Survivors who lived, worked, went to school, childcare, or adult day care in the NYC Disaster Area in the days after 9/11, and those who were in the dust or dust cloud on 9/11. In addition, the Program conducts scientific research to better identify, diagnose, and treat physical and mental health conditions related to 9/11 exposures.

On January 2, 2011, President Obama signed the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) into law (Public Law 111-347). The Zadroga Act modified the Public Health Service Act to extend and improve protections and services to individuals directly impacted by September 11, 2001.

The Zadroga Act established or reauthorized the following three programs that help those directly affected by the September 11, 2001, attacks:

• The WTC Health Program;
• The September 11th Victim Compensation Fund; and
• The WTC Health Registry

On December 18, 2015, the President signed legislation to reauthorize the Program, extending it another 75 years, until 2090. In 2019, legislation was signed into law increasing the number of individuals who can be newly enrolled in the WTC Health Program. The Zadroga Act lays out the administrative structure of the WTC Health Program and establishes the criteria for enrollment, certification, health monitoring, and treatment.

The Zadroga Act is federal law and changes to it require an act of Congress. Therefore, the Program cannot make exceptions to requirements set by the Act (for example, the Program cannot enroll someone who does not meet the requirements laid out in the Act).

For more information on the Zadroga Act, visit the Program Laws page.

No, the September 11th Victim Compensation Fund (VCF) is a separate program from the WTC Health Program and is administered by the U.S. Department of Justice.

They’re both part of the James Zadroga 9/11 Health and Compensation Act of 2010 (the Zadroga Act), but the WTC Health Program provides medical monitoring and treatment for Responders and Survivors while the VCF provides financial compensation to individuals (or a personal representative of a deceased individual) who were present at the World Trade Center or in the NYC Exposure Zone (see https://www.vcf.gov/nyc-map-exposure-zone ); the Pentagon crash site; or the Shanksville, Pennsylvania, crash site, at some point between September 11, 2001, and May 30, 2002, and who have since been diagnosed with a 9/11-related physical illness.

The VCF does not compensate for mental health conditions and does not distinguish between responders and survivors. The two programs have different eligibility criteria and application processes. If you’re a member of the WTC Health Program, you are not automatically enrolled in the VCF.

To find out more about the VCF, visit www.vcf.gov or call 1-855-885-1555.

No. There are no application fees, premiums, co-pays, or out-of-pocket costs for members of the WTC Health Program for exams, tests, treatments, medical devices, or medications for medically necessary treatment of certified WTC-related health conditions within the Program network. You need to use the healthcare providers and pharmacies affiliated with the Program for it to cover these costs.

For Responders, the Program directly pays for all monitoring, treatment, and medication costs of a certified WTC-related health condition, except if a Responder has a workers’ compensation claim for the certified condition.

For Survivors, your primary, individual health insurance (private and/or public) pays its share of the cost for your care first, and the Program pays the rest. This is known as Coordination of Benefits and is a process required by the Zadroga Act. For initial health evaluations and annual monitoring exams, the Program pays in full. Learn more about this process on the Coordination of Benefits page.

WTC Health Program members should not receive bills or be asked to pay any copays for treatment of their certified WTC-related health condition(s). However, if you are asked for a copay or do receive a bill by mistake, please call your Clinical Center of Excellence or the Nationwide Provider Network as soon as possible to alert them to the problem.

Note: If your certified condition is work-related and you have a workers' compensation claim for the condition, the Program will pay initially and then seek recoupment from either the workers' compensation carrier or the settlement, where applicable. View Worker’s Compensation FAQs to learn more.

First, you should determine whether you may be eligible for the Program as either a Responder or a Survivor. Then complete an application and include the required supporting documentation. Visit the How to Apply page for more details on the application process.

The Program will evaluate your application to determine whether you meet the eligibility requirements. Once you’re enrolled, the Program sends you a letter explaining how to schedule an initial health evaluation (sometimes called a baseline exam, initial monitoring exam, or initial screening) at one of the Program clinics or in the Nationwide Provider Network (NPN). If your provider determines, based on the evaluation, that you may have a WTC-related health condition substantially likely to be related to your 9/11 exposure, your provider will ask the Program to certify the condition.

Once the condition is certified, you can receive medically necessary treatment for that condition from Program clinics and affiliated providers at no out-of-pocket cost to you. If you need prescription medication or medical devices for your condition, those are also covered.

View condition FAQs to learn more. View certification FAQs to learn more.

Responders worked or volunteered onsite in rescue, recovery, demolition, debris cleanup, or related support services in response to the September 11, 2001, attacks at the World Trade Center or related sites in New York City; the Pentagon in Arlington, Virginia; or the crash site near Shanksville, Pennsylvania.

See the Eligible Groups page for more detailed information on who qualifies as a Responder.

Survivors were in the dust or dust cloud in the New York City Disaster Area on September 11, 2001; or worked, lived, or attended school, childcare, or adult daycare in the New York City Disaster Area for certain timeframes on and or shortly after 9/11. The Zadroga Act does not allow for enrollment of non-responders at either the Pentagon or Shanksville, Pennsylvania sites.

See the Eligible Groups page for more detailed information on who qualifies as a Responder.

You may have a health condition related to your 9/11 exposure and not know it—many people don’t realize that chronic cough, heartburn, or anxiety might be related to their 9/11 exposure. Some conditions, like cancer, can take several years to develop after exposure. WTC Health Program providers are experts at recognizing and treating the kinds of WTC-related health conditions seen in Responders and Survivors.

Once enrolled, benefits counselors at your clinic can work with you to find out what additional benefits you may be eligible for both inside and outside the WTC Health Program. They can help explain those benefits and how to apply for them, and tell you how the Program coordinates with those benefits. Benefits outside the Program could include Workers’ Compensation, the September 11th Victim Compensation Fund (VCF) , disability, cancer care, social services, and treatment for health conditions that are not WTC-related.

You can find out more about benefits counseling in the Member Handbook and from your Program clinic.

Yes. You can choose a designated representative—someone who has your permission to speak and act on your behalf and to see and hear your personal information—for Program administrative matters like enrollment, certification, and appeals.

Legal guardians can also act on behalf of an applicant/member if an original or certified copy of a court order appointing guardianship is provided. Please note that the WTC Health Program does not generally accept Powers of Attorney.

A designated representative is someone you choose who has your permission to speak and act on your behalf and to see and hear your personal information for WTC Health Program administrative matters like enrollment, certification, and appeals. A designated representative cannot make treatment decisions for you.

Your designated representative may be a family member, a friend, or your attorney. However, you can have only one designated representative at a time. You can change representatives in writing at any time. Once you choose a designated representative, everything the Program sends to you may also be sent to your representative. Please note that the WTC Health Program does not generally accept Powers of Attorney for administrative matters.

To learn more about designated representatives and how to designate one, see the Designated Representative page.

The WTC Health Program does not generally accept Powers of Attorney for administrative matters. This includes signing and/or submitting an application on an individual’s behalf, signing Designated Representative forms on an individual’s behalf, and otherwise interacting with the WTC Health Program on an individual’s behalf.

However, each applicant/member can appoint a designated representative to act on their behalf and represent their administrative interests in the WTC Health Program. Legal guardians can also act on behalf of an applicant/member if an original or certified copy of a court order appointing guardianship is provided.

To learn more about designated representatives and how to designate one, see the Designated Representative page.

The WTC Health Program research program plays a vital role in the treatment of your condition and the Program’s ability to add a condition to the List of WTC-Related Health Conditions.

For members in the NY metropolitan area, when you come in for an exam, you will be asked if the CCE can add your medical information to the data which researchers are using to understand 9/11 health effects.

Participation is optional and any information collected is maintained in accordance with strict requirements for privacy and confidentiality. You will receive your exam and continue to receive treatment, even if you do not agree to share medical information for research purposes.

You’re enrolled in the Program if:

• You applied to the WTC Health Program and received an acceptance letter; and/or
• You were previously enrolled in the WTC Medical Monitoring and Treatment Program (MMTP) as an FDNY member (active or retired), a New York City responder, or a New York City volunteer. The WTC Health Program replaced the MMTP in July 2011; or
• You were enrolled in the WTC Environmental Health Center Community Program. The WTC Health Program replaced the WTC Environmental Health Center Community Program in July 2011.

If you’re not sure if you are enrolled, you can call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

You can apply through the Program’s online application system, OASIS, or you can download an application form to print out and mail or fax. You also need to gather and send required supporting documentation with your application. We cannot process your application unless we also have your required supporting documentation.

Application forms are available in English, Español, Polskie, and 中文. The OASIS online application is currently available only in English.

You can also call the Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), and ask for an application to be mailed or faxed to you.

You should apply only once, either online or by mail/fax.

For more information, see the How to Apply page.

If you are applying as a Responder, you need to provide documentation that shows you worked at one or more of the World Trade Center sites, the Pentagon, or the Shanksville, Pennsylvania site. The documents must show all of the following information:

• The type of work you performed (activity);
• The address and/or street name of where you worked (location);
• The time period you worked at each location (date range); and
• How many hours per day, week, or month you worked at each location.

If you are applying as a Survivor, you need to provide documentation that shows one or more of the following:

• Address of your home, workplace, school, daycare center, or adult daycare center and dates of residence or attendance;
• Proof of presence within the NYC Disaster Area and confirmation of exposure to the dust or dust cloud on September 11, 2001; or
• Proof of eligibility to receive a residential grant from Lower Manhattan Development Corporation (LMDC)
• Residential Grant Program or proof of your employer receiving a LMDC grant.

For examples of supporting documentation, see the Required Supporting Documentation page.

If you have questions about your required supporting documentation, call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

If you can’t get copies of your official supporting documentation, you can submit a letter written by someone who can confirm the details of your eligibility. This is called a third-party attestation.

If you can’t find official supporting documentation or someone to write a third-party attestation, you can personally write a letter that includes the required eligibility information. This is known as a first-party attestation. Along with the first-party attestation, you must also include details about:

• What you did to try to get documentation, and
• Why you can't include it.

Both types of attestations must contain the required specific information about your activities and location and be signed by the writer as truthful under penalty of law. You can find more information about attestations on the Required Supporting Documentation page.

If your current name does not match what is on your supporting documentation, you must also send in documentation of your name change (such as a copy of your marriage certificate, divorce decree, adoption decree, or court order) with the rest of your supporting documentation.

If you have included all the required information on your application and sent all the necessary supporting documentation with it, it will generally take a few weeks to review and process. Every application is different, however, and some reviews may take longer.

If your application is missing information, your application review will be delayed or suspended. If that happens, a WTC Health Program enrollment specialist will contact you by phone, email, or mail to help you complete your application.

Call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), to check the status of your application.

If your enrollment is denied, we will send you a letter explaining why it has been denied. You have the right to appeal this decision. Please see the Appeals section of this FAQ for more details.

Your enrollment classification is whether you are enrolled as a Responder or Survivor in the Program. If you receive your enrollment acceptance letter and you feel the classification is incorrect, call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern). The helpline representative will tell you what you need to do to request a change in your classification.

If your member contact information (such as your address or phone number) has changed, call both your Clinical Center of Excellence (CCE) or Nationwide Provider Network (NPN) clinic and the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), as soon as possible to update your information.

If you have moved away from your clinic and need to transfer to another clinic closer to your new residence, please see Can I change clinics? in this FAQ for information on how to transfer.

In the New York metropolitan area, there are several Clinical Centers of Excellence (CCEs) specializing in either Responder or Survivor care. Outside the New York metropolitan area, both Responders and Survivors can go to a provider closer to your home through the Nationwide Provider Network (NPN).

If you live in the New York metropolitan area, your enrollment letter will explain which clinics you can go to for your evaluation and any necessary treatment. If you live outside the New York metropolitan area, you’ll get a welcome packet from Managed Care Advisors (MCA)-Sedgwick, the contractor that administers the NPN. The packet will explain the next steps in finding a Program-affiliated provider near you.

Please note: The WTC Health Program only covers medically necessary healthcare services within the United States and its territories, including the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, American Samoa, and the Trust Territory of the Pacific Islands. The WTC Health Program does not cover medical care, pharmacy products, or supplies received outside of the United States or its territories.

Every WTC Health Program member is assigned an individual member ID number. When you are enrolled, your member number will be on your welcome letter. Keep this number handy as you may be asked for it when calling the WTC Health Program call center or when talking with your clinic.

If your Program clinic is one of the Clinical Centers of Excellence in the New York metropolitan area, you don’t need a coverage card and won’t receive one. If you’re outside the New York metropolitan area, you’ll receive a NPN Member ID card from Managed Care Advisors (MCA)-Sedgwick, the Nationwide Provider Network administrator.

If you have a certified WTC-related health condition, you will receive a pharmacy benefits card from Express Scripts, the Program’s Pharmacy Benefits Manager.

View Pharmacy Benefits FAQs to learn more.

Call your CCE/NPN directly for scheduling or questions about appointments. The WTC Health Program helpline doesn’t have information about appointments and can’t schedule them for you.

You can find contact information for each clinic on the Find a Clinic page.

Your first appointment—known as your initial health evaluation or baseline monitoring exam—is to check for possible WTC-related health conditions. Your WTC Health Program provider will run tests and gather information about your health.

The evaluation will take about two to four hours. Your provider will talk with you after the evaluation about the initial results, and you’ll get a final report later with the results of your lab tests.

At your initial health evaluation, you will complete:

• Questionnaires about your medical history and physical and mental health. If your initial evaluation is at an NPN clinic, your NPN case manager will call you before your appointment to get your medical history;
• An assessment of your 9/11 exposure;
• Blood tests;
• A physical exam;
• Breathing tests (spirometry/pulmonary function testing); and
• A vital signs check (blood pressure, body temperature, respiration rate, and heart rate).

If you meet certain guidelines and your doctor thinks it is medically necessary, you may also have:

• A chest X-ray;
• An EKG;
• Urine testing.

If the evaluation suggests you may have a WTC-related health condition, the condition will have to be certified before the Program can cover treatment (see What is certification? in this FAQ for more information).

To get the most out of your evaluation:

• Review the member handbook to learn about your Program benefits, rights, and responsibilities;
• Complete any paperwork provided by your Program clinic prior to your first visit;
• Write down a list of symptoms you are experiencing, even those that you think might not be related to your 9/11 exposures. Symptoms may include trouble sleeping, persistent cough, runny nose, etc.;
• Write down a list of questions you would like to ask the doctor, mental health provider, or benefits counselor;
• Write down a list of any medications you are currently taking;
• Bring your medical records and any workers’ compensation or line-of-duty injury paperwork with you; and
• Be prepared to talk about your exposure, work history (if applicable), and your current symptoms.
• Survivors: present your primary insurance card at ALL appointments.

Your Program provider will need a HIPAA Authorization to Disclose Health Information form from you before they can release copies of your medical records. Please contact your CCE/NPN to get this form and find out how to return the completed form to them.

You can find contact information for each clinic on the Find a Clinic page.

Yes, but different clinics see different types of members. Responders need to go to Responder clinics, and Survivors need to go to Survivor clinics. You can find the right kind of clinic for you on the Find a Clinic page.

To transfer clinics, contact your current CCE or NPN. That clinic will start the transfer process. You will need to sign a medical release form so your old clinic can send your records to the new one.

You can choose to transfer to a new clinic once every 12 months. If you move, you can transfer to a new clinic immediately even if you transferred within the last 12 months. If you have special circumstances that mean you need to transfer more than once in 12 months, contact your clinic and explain the circumstances.

Learn more about the transfer policy and process on the Transferring Clinics page.

No. To maintain continuity of care, you must receive your Program health benefits through one Program clinic (or the NPN) at a time.

For the WTC Health Program to cover your treatment, your condition must be certified, and you must be treated by a provider affiliated with the Program. If your current doctor is affiliated with the Program, you can continue seeing the same doctor for your certified condition.

If your current doctor is not affiliated with the Program, they may be eligible to become a Program doctor. Ask your doctor to contact your Program clinic to discuss the requirements.

By law, the Program covers treatment for only specific physical and mental health conditions related to 9/11 exposures. The List of WTC-Related Health Conditions may be updated through rulemaking based on available science. Your provider will work with you to find out if your health condition or conditions are covered. There are five categories of conditions that the Program covers:

There are five categories of conditions that the Program covers:

• Acute traumatic injuries (like burns, sprains, and fractures)
• Aerodigestive (airways and digestive) disorders (like asthma, GERD, and sleep apnea)
• All cancers
• Mental health conditions (like PTSD, depression, and substance abuse)
• Musculoskeletal disorders (like carpal tunnel syndrome and low back pain)

For more detailed information on the conditions covered under each category, please see the Covered Conditions page of the Program’s website. Please note, however, that not every condition falling under these categories is covered by the Program. Please see the Program Regulation at 42 C.F.R. § 88.15 for the official List of WTC-Related Health Conditions (List).

In order for the Program to cover treatment for your condition, your condition has to be on the List and also has to be certified by the Program as a WTC-related health condition. See What is certification? for more details.

The WTC Health Program covers medically necessary monitoring and treatment for certified WTC-related health conditions. The Program also covers medically associated health conditions, which are conditions that result directly from the treatment or progression of a certified condition. For example, the Program does not cover routine dental care; however, if a member has a certified WTC-related head and neck cancer and the Program determines that treatment for that cancer has resulted in a dental condition, the Program may certify the dental condition as a medically associated condition and cover medically necessary dental procedures to treat the certified medically associated dental condition.

“Medically necessary” means the treatment has been shown to manage, improve, or cure your health condition or an illness caused by your condition.

The Program covers medically necessary treatment for certified conditions when such treatment complies with all Program policies, procedures, and medical protocols. There may be quantity or frequency limits for some treatments.

The Program can cover treatment only for health conditions on the List of WTC-Related Health Conditions (List) that are also certified as related to your specific 9/11 exposures. If your condition is not on the List, or if the type of health condition you have is on the List but does not meet the requirements for certification, your provider will refer you to a benefits counselor. The counselor can help you find options for treatment of your condition outside the Program.

The WTC Health Program will pay for medically necessary treatment of certified conditions. The Program can certify your condition if:

• Your health condition is included on the List of WTC-Related Health Conditions;
• Your 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing the health condition; and
• Your health condition and 9/11 exposures meet WTC Health Program policies and criteria for certification, such as maximum time intervals, minimum latency requirements, or any additional requirements.

If your WTC Health Program doctor determines that you have a health condition that meets all of the criteria above, your CCE or the NPN will complete paperwork signed by your Program doctor (called the WTC-3 Certification Package) to request that the Program certify your health condition.

The Program will review the WTC-3 Certification Package submitted by your CCE or the NPN to decide if your health condition can be certified. The Program will certify your health condition if it finds that your health condition and exposure meet the above criteria.

To learn more about the certification policies and certification criteria, visit the WTC Health Program Policies and Procedures page.

The WTC Health Program will notify you in writing if your condition has been certified or denied certification. Your CCE or NPN will also be sent notification of the decision.

Call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), to check the status.

You’re eligible for treatment in the WTC Health Program as soon as your condition has been certified. Your provider will work with you to set up a treatment schedule.

If your CCE or NPN doctor submits a certification request and the WTC Health Program denies certification of your health condition, you have the right to appeal that decision. Please see the Appeals section for more information. You will be informed of the denial in writing and receive information about how to appeal the denial at that time.

View Appeals FAQs to learn more.

If your CCE or NPN provider declines to submit your health condition to the Program for certification, you may be eligible for a secondary medical review. A secondary medical review is a review of your case by the CCE/NPN Clinical Director or a designee. This designee may be a WTC Health Program doctor at another CCE.

You may request a secondary medical review when, for example, you disagree with the CCE/NPN doctor regarding the characterization of your exposure, diagnosis, onset of symptoms date(s), or intensity of exposure in relation to aggravating, contributing to, or causing your health condition.

However, you may not request a secondary medical review when your health condition does not meet Program policy or certification criteria. Disagreement with Program policy is not a valid reason for secondary review.

If your condition is not submitted to the Program for certification because it is not on the List of WTC-Related Health Conditions, you can petition to have your health condition added. Learn more about petition process at the Petition page.

If you are not eligible for a secondary medical review and still have concerns regarding your health condition and certification, you may write to the Administrator of the WTC Health Program at:

CDC/NIOSH
ATTN: World Trade Center Health Program
400 7th Street SW, Suite 5W
Washington, DC 20024

The Program only provides treatment for the specific conditions on the List of WTC-Related Health Conditions established by the Zadroga Act and Program regulations. However, the Administrator may add new health conditions to the List through the rulemaking process.

For example, a condition may be added if the Administrator finds there is enough scientific evidence to link a health condition to 9/11 exposures. This might happen if research shows that a health condition is more likely to occur in individuals with 9/11 exposure than in individuals without 9/11 exposure.

You may have a condition that you believe is the result of your 9/11 exposure but is not included on the List. If this is the case, you may petition the Administrator to add a health condition to the List. In order to be considered, a petition must be sent in writing to the Administrator, and include the following:

• An explicit statement of an intent to petition the Administrator to add a health condition to the List of WTC-Related Health Conditions;
• Name, contact information, and signature of the interested party submitting the petition;
• Name and description of the health conditions(s) to be added; and
• Reasons for adding the health conditions(s), including the medical basis for the association between 9/11 exposure and the health condition(s) to be added.

Please see visit the Petitions page for more information on submitting a petition to add health conditions to the List.

The Program pays for all medically necessary treatment for your certified WTC-related health condition(s), as well as any certified medically associated health condition(s), as long as treatment is provided by a WTC Health Program affiliated provider. All Program treatment services must be authorized by your Program provider, and in some cases the CCE or NPN Clinical Director and the Program. All treatment must follow Program guidelines. To learn more about treatment in the Program, see the Treatment section of the Member Handbook.

Yes. Members eligible for medical monitoring within the WTC Health Program are strongly encouraged to participate in regular monitoring exams for the following two reasons:

1. The exam may detect changes in body function that you are not aware of and that can be corrected or slowed with early intervention; and
   
2. While the main focus of the WTC Health Program is to assess your health, the information that is learned about 9/11 responders is extremely valuable in understanding how to protect workers in future emergency or disaster operations.
   

The Program covers all cancers. Further description of the cancers covered by the Program may be found on the Program’s Covered Conditions webpage. The official list of WTC-related cancers can be found in the Program’s regulation at 42 C.F.R. § 88.15, List of WTC-Related Health Conditions in the cancer section. If you have cancer, speak to your CCE or NPN doctor to find out if your cancer may be related to your 9/11 exposure. In order for your cancer to be certified it must meet certain criteria like cancer latency periods. Visit the cancer latency section of the member handbook to learn more about cancer latency periods.

To learn more about certification visit the Certification section of this FAQ.

No. The inclusion of your cancer on the List of WTC-Related Health Conditions does not mean that your cancer will automatically be covered by the Program. Your Program doctor must also find that your 9/11 exposures are substantially likely to have been a significant factor in causing or contributing to your cancer and request certification of your cancer from the Program. If your cancer is certified, then you are eligible for treatment coverage in the Program.

In order for a WTC Health Program member to obtain coverage for treatment of any health condition on the List of WTC-Related Health Conditions (List), including any type of cancer added to the List, the condition must first be certified by the Program.

Once certified, all care must be rendered by a provider affiliated with the Program. If your current doctor is affiliated with the Program, then you will be able to continue seeing your doctor. If your current provider is not affiliated, ask the provider to contact your CCE or the NPN to discuss becoming a WTC Health Program provider.

No. The Program will not reimburse members or healthcare providers for the costs of cancer treatments received before most cancer coverage began in the Program (October 2012), or uterine cancer (January 2023), or before certification.

However, you may be able to receive compensation through the September 11th Victim Compensation Fund (VCF) for past cancer treatment costs. The VCF is administered by the Department of Justice, and enrollment in that program is separate from the WTC Health Program.

For information regarding the VCF, please visit https://www.vcf.gov/ or call the VCF toll-free at 1-855-885-1555.

If you are a member of the WTC Health Program:

Contact your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN) to schedule an appointment so that you can begin the cancer certification process as soon as possible. If you do not know which CCE/NPN you are with, please contact the Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

If you are not a member of the WTC Health Program:

Please visit our How to Apply page for information about the application process. You can also contact the Program at 1-888-982-4748 for information on how to apply.

If you are a member of the WTC Health Program:

Contact your CCE or NPN to schedule an appointment to review your medical history. Your doctor will determine if the cancer certification process should be started in case you need treatment again in the future. If you do not know which CCE/NPN you are with, please contact the Program helpline at 1-888-982-4748.

If you are not a member of the WTC Health Program:

Please visit our How to Apply page for information about the application process. You can also contact the Program at 1-888-982-4748 for information on how to apply.

If you are a member of the WTC Health Program:

It is important that you continue to go to your annual monitoring exams so that your health can be checked. If a doctor finds that you have cancer, or any other listed WTC-related health condition, during your annual monitoring exam, the doctor will determine whether your health condition may be related to your 9/11 exposure. If your Program provider determines your cancer is related to your 9/11 exposures, your provider will request certification of that condition(s) as soon as possible so that you can get the treatment you need.

At any point in time, if you find out you have cancer from another healthcare provider, contact your CCE or NPN as soon as possible so that your doctor can determine if the certification process should be started.

If you are not a member of the WTC Health Program:

If you are eligible as a Responder, you should apply and begin your annual monitoring exams so that your health can be checked yearly to see if you develop any WTC-related health conditions, including cancer.

If you are eligible as a Survivor and develop a condition (or symptoms of a condition) on the List of WTC-Related Health Conditions, including cancer, you should then apply to the WTC Health Program.

For more information, see the How to Apply page.

The Program covers medically necessary prescription medications used to treat certified WTC-related health conditions. Prescriptions covered by the Program must be prescribed by a Program-affiliated provider and be on the Program’s pharmacy formulary—a list of medications approved for use by the Program.

Many covered prescriptions will not need any authorizations by your World Trade Center Health Program provider. On occasion, some medications may require prior authorization. Your Program provider can submit a request to Express Scripts for this approval.

If a medication is denied for coverage through the WTC Health Program and you would still like to use it, you will have to use your primary health insurance or pay out of pocket.

For Survivors: In some cases, coordination of benefits may require two prior authorizations—one for your primary insurance plan and one for the WTC Health Program. Your Program provider will need to complete both prior authorizations in this case.

If your prescription is denied due to a missing prior authorization, please check with your Program provider to make sure that all prior authorizations are completed and approved. If you have questions about prior authorizations, please contact your CCE, NPN, or call Express Scripts at 1-800-935-7179.

Responder and Survivor members can choose from several options to fill WTC-related prescriptions through Express Scripts, the Pharmacy Benefit Manager for the WTC Health Program. These options may look different depending on whether you are enrolled as a Responder or a Survivor member. This includes filling prescriptions at a retail pharmacy or through home delivery. Express Scripts has a large network of pharmacies to provide all members with their WTC-related medication(s).

You can find a pharmacy near you using the Express Scripts pharmacy locator in the Express Scripts Member Portal online. If you have not set up your Express Scripts account, you can register here . Please see below for information about filling your prescriptions depending on your situation.

For more information about filling your WTC-related prescriptions, or other pharmacy related questions, please call Express Scripts at 1-800-935-7179.

Responders

• Retail: Responders can get up to a 90-day supply of their WTC-related long-term medication(s) at Walgreens/Duane Reade pharmacies and a 30-day supply at any other retail pharmacy in the Express Scripts network.
• Home Delivery: Responders can get up to a 90-day supply of their WTC-related long-term medication(s) delivered through Express Scripts Home Delivery Pharmacy.
• Specialty: Responders can get up to a 30-day supply of their specialty medications. Responders must fill all specialty medications covered by the WTC Health Program through Accredo, an Express Scripts specialty pharmacy. To fill prescriptions online, track shipments and access your plan information, visit the Accredo website or call 1-855-540-1780 with any questions.

Survivors
As required by the James Zadroga 9/11 Health and Compensation Act of 2010, a process called coordination of benefits is required to fill WTC-related prescriptions for Survivors. Visit the Coordination of Benefits page for more information.

• Retail: Survivors can get up to a 90-day supply of WTC-related long-term medication(s) at retail pharmacies that are both a part of the Express Scripts network and in-network for their primary insurance.
• Home Delivery: Survivors can get up to a 90-day supply through a home delivery pharmacy that is in-network for your primary health insurance and in Express Script’s network. If you have Express Scripts as your primary insurance, you can use the Express Scripts Home Delivery Pharmacy.
• The Express Scripts network includes CVS/Caremark and Optum home delivery pharmacies for Survivors. If CVS/Caremark and Optum home delivery pharmacies are in network for your primary insurance, you can have your WTC-related prescriptions delivered through them at no cost.
• Specialty: Survivors can receive up to a 30-day supply of specialty medications covered by the WTC Health Program at any retail or specialty pharmacy that are in-network with their primary insurance and in the Express Scripts pharmacy network. For more information, visit the Pharmacy Benefits page.

All members with a certified health condition(s) receive a WTC Health Program Prescription ID card from Express Scripts in the mail. If you have a certified condition and have not received this ID card, please call Express Scripts at 1-800-935-7179.

The Program covers the cost of medications approved to treat your certified WTC-related health condition(s), whether you get them from your local in-network pharmacy or by home delivery. This means that you should not pay anything for your WTC-related medications.

Please make sure to tell your pharmacy which prescriptions they should bill to the WTC Health Program. The WTC Health Program only covers prescriptions needed to treat your certified WTC-related health conditions. All other prescriptions must be billed to your primary insurance.

Important Information about Coordination of Benefits: For Survivors, coordination of benefits is required so that the WTC Health Program can pay for prescriptions to treat your certified WTC-related health condition(s).

Coordination of benefits is a requirement for Survivors according to the James Zadroga 9/11 Health and Compensation Act of 2010. It sets the order in which different payors (e.g., private insurance, public insurance, the WTC Health Program) pay their share of costs for treatment of a Survivor’s certified WTC-related health condition.

Survivors should follow the steps on the Coordination of Benefits page to ensure that WTC-related medications are billed properly.

The Program covers all WTC-related prescriptions prescribed by a Program provider for certified WTC-related conditions. The best way to receive all covered prescriptions is to have them processed at the pharmacy. You should not pay for any WTC Health Program prescriptions out-of-pocket.

However, sometimes billing can be a complicated process in the Program. If there are issues and you decide to pay out-of-pocket for a prescription that should be covered under the WTC Health Program, you can submit a Direct Claims form with Express Scripts for reimbursement. You can do that in one of two ways:

• Online through the Express Scripts Member Portal . (If you do not have a member portal set up, please register .)
• Through the mail by printing this form [PDF, 2 pages, 1.2 MB] , filling it out, and mailing it in. You can also contact Express Scripts by calling 1-800-935-7179 to ask for a form in the mail. The direct claims form is also available in Spanish [PDF, 2 pages, 462 KB]

All prescriptions that you submit a Direct Claims form for must meet all program requirements for coverage to be reimbursed.

Please note that reimbursement is through Express Scripts. The WTC Health Program is not a part of this process and cannot guarantee reimbursement. For questions about this process, please contact Express Scripts at 1-800-935-7179.

The WTC Health Program understands that medication can play an important role in our members’ health and well-being. Though uncommon, it is possible that you could experience issues when filling a WTC-related prescription. If this happens the information below may help you take the appropriate steps to resolve the issue.

Reasons your prescription might be rejected
There is a possibility that you may experience other issues as well. Here are brief descriptions of other known issues and their solutions.

• If you need a prior authorization, contact your Program provider (doctor, physician assistant, etc.) who prescribed the medication and ask them to submit the prior authorization for you.
• If the pharmacy gets a rejection for your prescription that says, “prescriber is not covered” or “provider not in network,” contact your Clinical Center of Excellence or Nationwide Provider Network and let them know.
• If you or your pharmacist do not know why your prescription cannot be filled, contact Express Scripts at 1-800-935-7179.
• If you are a Survivor member and you receive a notification to “Submit Bill to Other Processor or Primary Payer,” give the pharmacy your primary insurance information and let them know that the WTC Health Program is the payor of last resort. This is required for Coordination of Benefits to cover your medications through the WTC Health Program. Find out more information about this process on the Coordination of Benefits page. For more information contact Express Scripts at 1-800-935-7179.

You or your designated representative may appeal the following three types of decisions made by the Program:

• Enrollment denial – includes denial of enrollment in the Program or disenrollment.
• Certification denial – includes denial of certification of a health condition as a WTC-related health condition, denial of certification of a health condition as a medically associated health condition, or decertification of a WTC-related health condition.
• Treatment denial - includes denial of treatment authorization for a certified health condition based on a finding that the treatment is not medically necessary.

Not all appeal requests can be considered. An appeal will be considered invalid if it challenges:

• Enrollment criteria established by the James Zadroga 9/11 Health and Compensation Act (Zadroga Act) or WTC Health Program regulations;
• Certification requirements established by the Zadroga Act;
• A WTC Health Program policy that has been established by the Administrator and is applicable to all Program applications and/or members; or
• The exclusion or absence of a health condition from the List of WTC-Related Health Conditions (List).

Criteria and requirements in the Zadroga Act are established by law and may only be changed by the U.S. Congress amending the Act. Criteria within the WTC Health Program’s regulations are established through rulemaking and may only be changed by the Program revising the regulations. Health conditions may only be added to the List through a petition process. More information on how to add a condition available on the Petitions page.

Your appeal may, however, challenge the Program’s application of enrollment, certification, or treatment authorization criteria to your individual enrollment, certification, or treatment decision. For example, an appeal request could argue that the Program incorrectly determined the number of hours the individual worked or volunteered during a covered time period.

More information on what may and may not be appealed is available on the Appeals page.

If you would like to appeal an enrollment, certification, or treatment denial, you must mail or fax a written letter requesting an appeal to the Program’s appeals coordinator postmarked within 120 calendar days from the date of your denial/disenrollment/decertification letter from the Administrator.

Your appeal letter must:

• Be made in writing and signed;
• Identify the name, address, and contact information of the member and designated representative (if applicable);
• Describe the decision being appealed and state the reasons why you believe the decision was incorrect and should be reversed; and
• Provide a basis for the appeal that is sufficiently detailed and supported by information to permit a review of the appeal. An appeal request may include relevant new information not previously considered by the WTC Health Program.

The description may include:

• Scientific or medical information correcting factual errors that may have been submitted to the Program by the CCE or NPN;
• Information showing that the Program did not correctly follow or apply relevant Program policies or procedures;
• Any information showing that the Program’s decision was not reasonable given the facts of the case; or
• A request to designate a representative.

Your appeal letter should be mailed or faxed to:

Appeals Coordinator WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144
Fax: 1-877-646-5308

For certification denial, decertification, or treatment authorization denial appeals, your appeal request may also include a request for you or your designated representative to make a 15-minute oral statement by telephone.

For more information on filing an appeal visit the Appeals page.

Where your health condition it work-related, the James Zadroga 9/11 Health and Compensation Act requires the WTC Health Program to recoup (recover) costs from workers’ compensation insurers since these insurers have primary responsibility for your healthcare expenses.

If you receive a lump-sum settlement from workers’ compensation for a health condition that would be covered by the Program, you will need to set some of that money aside for future medical expenses in the Program. The Program must approve the amount of this set-aside. The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

The Program has to approve all lump-sum workers’ compensation agreements settled on or after October 1, 2013.

If your settlement agreement releases your employer or insurer from future payments towards health conditions that are covered by the Program, and workers’ compensation would otherwise have paid for those conditions, then the Program must approve the amount of money you set aside to pay for future medical expenses before you agree to the settlement. The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

You do not need Program approval for any settlements filed with workers’ compensation before October 1, 2013, even if workers’ compensation approved the settlement after that date.

You need to set aside enough to pay for the reasonably anticipated costs of medical treatment and medications for your covered conditions. Since Congress has funded the WTC Health Program through 2090, you should set aside enough to pay for future medical expenses for your health conditions covered by the Program through 2090, taking into account your anticipated lifetime. You should use the reimbursement rates under your state’s workers’ compensation law to calculate those costs.

You do not have to set aside money for screenings, monitoring exams, or diagnostic testing provided by the Program.

The Centers for Medicare and Medicaid Services (CMS) have their own requirements for lump-sum settlements. To find out if you have comply with CMS requirements as well as WTC Health Program requirements, visit the Workers’ Compensation Medicare Set Aside Arrangements page on CMS’ website.

You or your designated representative need to submit a copy of the proposed settlement agreement to the Program. The proposed agreement has to show:

• Your (the claimant’s) name, address, and date of birth;
• The Workers’ Compensation Board claim number;
• A description of the conditions covered by workers’ compensation, and whether the Workers’ Compensation Board has ordered the carrier (the insurance company) to pay medical benefits (or whether the carrier’s responsibility for medical benefits is still in dispute);
• A statement about any proposals to set aside money from your lump-sum settlement, including the amount you plan to set aside;
• An explanation of how you calculated your future medical and pharmaceutical expenses. If the amount is based on an actuarial estimate from an outside expert, send the expert’s report too;
• A copy of the CMS approval of any Medicare set-aside, if CMS has reviewed the settlement; and
• The name and address of the custodian for the set-aside funds. The custodian is the individual or entity who will pay any medical expenses on your (the claimant’s) behalf. You can be the custodian for your own fund, or you can choose someone else to manage the account.

Send all the information above to the WTC Health Program at wtchp.recoup@cdc.gov.

The Program will send a letter telling you whether the Program agrees that the amount set aside for future medical expenses is reasonable, or whether you do not have to set aside any money from your lump-sum settlement.

The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

If you don’t get the Program’s approval for a set-aside amount to pay for a health condition covered by the WTC Health Program from your lump-sum settlement, you may be legally responsible for future medical expenses in the Program. The Zadroga Act requires the Program to recoup (recover) costs for conditions that are covered under other programs, like Workers’ Compensation. If you receive a settlement that releases your workers’ compensation insurer or employer from legal responsibility for future medical expenses, and the Program has not approved the settlement, the Program may need to recoup those costs directly from you.

You will not have to pay for any medical expenses within the WTC Health Program beyond the set-aside amount, as long as the Program approved the amount of money set aside for future medical expenses and you created a set-aside account with the approved amount.

The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved. If your medical expenses are more than the amount in your approved set-aside agreement, the Program will pay those extra expenses.