Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form (Page 3 of 3) in pdf

STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES

TELEPHONE: 1-866-409-8386 FAX: 1-866-759-4110 OR (860) 269-2035

CT Medical Assistance Program

Long Acting Sustained Release Opioid Prior Authorization (PA) Request Form

To Be Completed By Prescriber

Prescriber Information

Patient Information

Prescriber’s NPI:

Patient Medicaid ID Number:

Prescriber Name:

Patient Name:

Phone #: (

)

Patient DOB:

Fax #: (

)

Primary ICD Diagnosis Code:

Prescription Information

Drug Requested:

Dose/frequency:

□ New therapy

□ Continuation

Expected Duration:

This form must be completed by the prescribing provider. If the form is missing information, the PA will not

be processed. Please fax the completed form to the Hewlett Packard Enterprise Pharmacy PA Assistance

Center at the number above for evaluation & processing.

Clinical Information

□ Yes

□ No

Is the patient 12 years of age or older?

□ Yes

□ No

Does the patient have a diagnosis of cancer?

Is the patient under the care of an Oncologist or pain specialist who is experienced in the use of

Schedule II opioids to treat cancer pain?

□ Yes

□ No

Is the patient free from all of the following contraindications: hypersensitivity to opiates,

hypoxia/hypercarbia, severe asthma or chronic obstructive pulmonary disease, or paralytic ileus?

□ Yes

□ No

□ Yes

□ No

The patient needs an ongoing, continuous course of therapy and not on an as needed basis.

*If you answered ‘NO’ to any of the questions above, this request must be reviewed by the Medical Director for consideration.

Please provide additional information relating to the medical necessity (see Conn. Gen. Stat. § 17b-259b(a)) of a Long Acting

Sustained Release Opioid for this patient. Submit request, via fax, to 860-424-4822.

___________________________________________________________________________________________________

If the medication being requested is a Non-Preferred Drug, one of the following reasons for not using a Preferred

Drug must be indicated:

□

Preferred Long Acting Opiates:

Intolerance to preferred agents

□

Adverse reaction to preferred agent

Fentanyl (12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr,

□

Inadequate response to preferred agents

100 mcg/hr), Hysingla ER, Methadone, Morphine ER

□

Absence of appropriate formulations

Tablet, Tramadol ER (generic Ultram ER)

□

Medically necessary/medically appropriate

I certify that documentation is maintained in my files and the information given is true and accurate for the medication requested, subject to penalty under section 17b-99 of

the Connecticut General Statutes and sections 17-83k-1-13 and 4a-7, inclusive, of the Regulations of Connecticut State Agencies. I certify that the client is under my

clinic’s/practice’s ongoing care.

I certify that I am a practitioner and hold a current, unrestricted license that allows me to prescribe medication and that I am

enrolled in the CT Medical Assistance Program.

Prescriber Signature: ____________________________________________Date:_________________

This form (and attachments) contains protected health information (PHI) for Hewlett Packard Enterprise and is covered by the Electronic Communications Privacy Act, 18

U.S.C. § 2510-2521 and the Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, which is intended only for the use of prior

authorization. Any unintended recipient is hereby notified that the information is privileged and confidential, and any use, disclosure, or reproduction of this information is

prohibited. Any unintended recipient should contact Hewlett Packard Enterprise by telephone at (860) 255-3900 or by e-mail immediately and destroy the original message.

Long Acting Opioid PA Form 11/2016

Long Acting Sustained Release Opioid Prior Authorization (Pa) Request Form Page 3

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