Us Family Health Plan Pharmacy Program Medical Necessity Form For Nucynta (Tapentadol) Page 2

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Pharmacy Program Medical Necessity Form for

Nucynta (tapentadol)

This form applies to the US Family Health Plan Mail Order Pharmacy and the US Family Health Plan Retail Pharmacy programs. This form must be completed and signed by

the prescriber.

 Nucynta (tapentadol) is a Schedule II high potency opioid analgesic indicated for short-term therapy in the relief of moderate to severe acute pain.

Nucynta is non-formulary, but available to most beneficiaries at the non-formulary cost share. Opioid analgesics on the DoD Uniform Formulary

include Opana (oxymorphone immediate-release) and multiple generics: codeine, hydromorphone, levorphanol, meperidine, methadone, morphine

sulfate immediate-release, and oxycodone immediate-release.

 The purpose of this form is to provide information that will be used to determine if the use of Nucynta instead of a formulary medication is medically

necessary. If Nucynta is determined to be medically necessary, non-Active duty beneficiaries may obtain it at the formulary cost share.

• The provider may call:

or the completed form may be faxed to:

• The patient may attach the completed form to the prescription and mail

it to: ATTN: Pharmacy, 77 Warren St, Brighton, MA 02135

Step

Please complete patient and physician information

(please print)

Patient Name:

Physician Name:

Address:

Sponsor ID #